Failure to Follow and Communicate Hospital Warfarin Orders
Penalty
Summary
The facility failed to ensure that a physician's order for Warfarin medication from the hospital was followed and accurately communicated to the facility's physician for a resident admitted with diagnoses including falls and atrial fibrillation. Upon admission, the resident had a hospital order to hold Warfarin due to a critically high INR level, with instructions for a repeat blood test on the following Monday. However, the facility administered a total of 9 mg of Warfarin to the resident on the evening of admission, based on an outdated order from March 2022, rather than following the most recent hospital instructions to hold the medication. Review of clinical records and staff interviews revealed that the admitting nurse did not communicate the hospital's hold order to the facility's NP, who then ordered the outdated Warfarin dose. As a result, the resident experienced an elevated INR and was subsequently sent to the emergency room, where further complications including multiple falls, possible rib fractures, and a hematoma were documented. The deficiency was attributed to the breakdown in communication and failure to verify and implement the current physician's orders from the hospital.