Missed High-Risk Warfarin Doses for Anticoagulation Therapy
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from significant medication errors involving the anticoagulant warfarin. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, generalized muscle weakness, need for assistance with personal care, and chronic migraine without aura. Physician orders showed multiple adjustments to the resident’s warfarin regimen over time, including varying dosages and schedules (daily dosing, then specific days of the week, and later a fixed daily dose) for treatment of cerebral infarction affecting the left dominant side. Record review of the January 2026 MAR revealed that three ordered doses of warfarin were not administered on 01/18/26, 01/19/26, and 01/21/26. During an interview, the DON confirmed that these warfarin doses were missed and acknowledged that warfarin is a high-risk medication that should be administered as ordered. The DON also stated she had not been aware that the resident had missed any warfarin doses and reported that her expectation is that nurses notify her and the pharmacy if a medication is not available.
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