Late Administration of Anticoagulant by Registry Nurse Without Documentation
Penalty
Summary
The deficiency involved the facility’s failure to ensure a prescribed anticoagulant was administered within the facility’s established time frame and in accordance with professional standards of practice. A resident with a history of venous thrombosis and embolism, and with intact cognition as evidenced by a BIMS score of 14/15, was ordered Xarelto 20 mg daily at 5:00 PM. On the evening in question, the resident reported that a registry nurse assigned to her was unable to find her Xarelto, and that it took some time before the medication was administered. Review of the EMAR and Medication Audit Report showed that the Xarelto dose scheduled for 5:00 PM was actually administered at 6:43 PM, which exceeded the facility’s acceptable administration window of one hour before or after the scheduled time. Record review from 2/19/26 to 2/24/26 revealed no documentation explaining the reason for the delayed administration of Xarelto on that date. During interviews, the DON and Infection Preventionist confirmed that the administration time was 43 minutes beyond the acceptable window and acknowledged there was no documentation of the cause of the delay. Both indicated it was likely the registry nurse did not know where to locate the medication. Facility policies required medications to be administered in accordance with physician orders and within one hour before or after the scheduled time, required registry staff to be oriented and competent in facility-specific medication administration procedures, and defined medication errors to include omissions of vital medications, with prompt physician notification and documentation of the error and subsequent orders. Policies also required medications to be stored safely, securely, and properly, with access limited to authorized staff. These requirements were not met in this incident, as the anticoagulant was administered late, the reason for the delay was not documented, and there was no documented notification of the physician or pharmacy.
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