Failure to Follow Physician Orders for Anticoagulation and UTI Treatment
Penalty
Summary
Surveyors identified a failure to follow practitioner orders for a resident admitted with acute on chronic diastolic congestive heart failure. The resident’s care plan included interventions to administer medications per MD order and to consult the pharmacist for monthly and PRN medication reviews, including medications with black box warnings. On admission, a future lab order was entered for an INR draw, and on 2/13 a urinalysis was ordered. The hospital lab urinalysis collected on 2/13 and finalized on 2/15 included physician-directed medication changes: initiation of Macrobid 100 mg PO BID for 7 days and a decrease in the resident’s warfarin dose by half while on the antibiotic, with an electronic physician signature. These medication orders were not implemented as directed. Progress notes showed that an INR was drawn on 2/16 and that staff called the physician’s office on 2/17 for recommendations, but there was no documentation of follow-up on the Macrobid order from the 2/15 urinalysis report. On 2/18, the resident tested positive for COVID and was started on Paxlovid. The order recap showed multiple warfarin dose changes over the subsequent days, including a change from 5 mg daily to 4 mg daily, then to 3 mg daily, and an order for vitamin K after an INR of 7.3 was obtained on 2/23, along with instructions to hold warfarin for two days and recheck the INR. The record also showed a delayed urinalysis order on 2/23, despite the original urinalysis order dated 2/13 and the earlier lab results with treatment recommendations. The resident experienced nosebleeds over a weekend and, on 2/23, was documented as feeling dizzy, lightheaded, nauseated, with two episodes of emesis and a tympanic temperature of 95°F, leading to an order to send the resident to the emergency room. There was no documentation of pharmacy review or communication regarding the interaction between Paxlovid and warfarin, despite reference information advising frequent INR checks and anticoagulant dose adjustments when warfarin is co-administered with ritonavir-containing therapy. In an interview, the DON stated there was no facility policy on taking or following physician orders and that the facility relied on general standards of practice. The DON acknowledged not knowing why the Macrobid order from the 2/15 urinalysis result was not followed and could not explain why the antibiotic for the positive UTI was not initiated per physician orders.
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