Failure to Reorder and Administer Anticoagulant as Prescribed
Penalty
Summary
The facility failed to ensure that licensed nurses administered a significant medication as ordered for one resident when they did not reorder the medication before the supply ran out. The resident was admitted with diagnoses including wedge compression fracture, chronic pulmonary embolism, atrial fibrillation, and muscle weakness, and had a physician’s order for rivaroxaban 15 mg orally once daily for thromboembolism related to chronic atrial fibrillation. Review of the October 2025 Medication Administration Record showed that on 10/15/25 the rivaroxaban dose was marked with the number 8, which staff stated indicated the medication was not available to be administered that day. During interviews, a licensed nurse reported that on 10/15/25 she did not administer the rivaroxaban because the supply had run out and, if the medication was not available in the emergency medication supply kit, the resident had to wait until the next day for the pharmacy delivery. The DON explained that the medication bubble pack background turned blue at medication number 4 to indicate the supply was low and needed to be reordered, and that nurses were responsible for reordering medications when the supply became low. Facility pharmacy policy required medications to be reordered five days in advance of need to ensure an adequate supply, and the general medication administration policy required medications to be administered safely, in a timely manner, and as prescribed. These policies were not followed, resulting in the missed dose of rivaroxaban on 10/15/25.
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