F0760

D

Failure to Reconcile Admission Orders Resulting in Missed Warfarin Doses

Springfield, Illinois Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

A cognitively intact resident with multiple significant diagnoses, including aortic valve replacement, pulmonary emboli, atrial fibrillation, atherosclerotic heart disease, diabetes mellitus type 2, lung cancer, BPH, depression, and COPD, was admitted on 12/15/25 with orders for Warfarin (Coumadin). The resident’s care plan documented anticoagulant use and risk for bleeding, and the MDS showed the resident required partial to moderate assistance with ADLs. Despite having Warfarin on the admission medication list and on all discharge instructions, there was no Warfarin order entered into the facility’s system prior to 12/20/25, and the resident went five days without receiving the ordered anticoagulant.

On 12/20/25 at 8:50 PM, during a chart audit, nursing staff identified that Coumadin appeared on all discharge instructions but had not been entered as an active order, and multiple different doses of the resident’s Coumadin were found in the medication room. An on‑call physician was contacted, and new orders were obtained for Warfarin 10 mg once, followed by 5 mg the next day and repeat INR testing. The resident’s INR on 12/20/25 was 1.1, with subsequent INRs of 1.7 on 12/22/25, 2.2 on 12/23/25, 4.0 on 12/30/25, and 1.9 on 1/2/26. The facility’s documentation notes that the resident had Warfarin orders upon admission that were not entered, resulting in the missed doses.

Interviews with facility staff revealed that the admission process was not followed as required. The DON stated that an admission audit, which should be completed within 24 hours of arrival to verify that all physician orders are entered, was not done until five days after the resident’s admission. Nursing staff reported that, at admission, nurses are to fax all physician orders to the pharmacy for entry into the EMR and then double‑check by acknowledging each medication, but in this case, the medication list faxed prior to admission was used instead of reconciling it with the updated orders that arrived with the resident. The facility’s own policies on medication reconciliation and admission assessment require reconciling the medication history, admitting orders, previous MAR, and discharge summary, and contacting the physician if discrepancies are found, but the two sets of orders for this resident were not reconciled, leading to the Warfarin omission.