Medication Administration and Discharge Medication Errors Involving Anticoagulant Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered and that a discharged resident was sent home with the correct medications. Resident B, admitted with diagnoses including a right lower leg fracture and requiring substantial to maximal assistance with toileting, showering, and transfers, had a physician’s order for enoxaparin 30 mg/0.3 mL subcutaneously from early September until the order was discontinued on 9/19/25. Review of the MAR showed that enoxaparin doses were not given on multiple days, documented as unavailable or awaiting delivery on three dates, and left blank with no explanatory note on another date. An Emergency Drug Kit (EDK) in the facility contained enoxaparin 30 mg/0.3 mL syringes, and staff reported the EDK was kept stocked and could be restocked by the pharmacy within a day if running low. The deficiency also includes an error at discharge in which Resident B was sent home with medications belonging to another resident. An incident form indicated that when Resident B was discharged, medications for a different resident were included among the discharge medications. The discharge progress note documented that the resident was discharged home with all medications and was signed by one LPN. Facility staff reported that the process for discharging residents with medications required two nurses to verify the medications and sign the discharge summary form, but the discharge summary for this resident contained only one nurse’s signature along with the representative’s signature. The facility’s current medication administration competency form stated that medications should be administered as ordered.
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