Missed Warfarin Doses and PT/INR Monitoring Due to Order Entry Error
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was free from significant medication errors related to warfarin therapy and required PT/INR monitoring. The resident had diagnoses including chronic embolism and thrombosis of unspecified deep veins of the left lower extremity and dementia. A physician order entered by an employee on February 24, 2026, directed that the resident receive warfarin 2.5 mg at bedtime starting February 25, 2026, with a PT/INR recheck scheduled for March 11, 2026. The Medication Administration Record showed that the resident received warfarin from February 25 through March 10, 2026, but did not receive any warfarin from March 11 through March 17, 2026. The clinical record contained no evidence that the ordered PT/INR was completed on March 11, 2026. A progress note on March 18, 2026, documented that a registered nurse discussed concerns about the resident’s PT/INR and missed warfarin doses with night shift staff and informed the resident’s physician, who was present in the facility. A physician progress note later that day indicated that staff had noted the resident missed a few days of warfarin and that an order for a stat PT/INR was given, with the resident restarted on her previous warfarin dose and a new order to recheck PT/INR in a week. The resident’s March 2026 Medication Administration Record showed that warfarin administration resumed on March 18, 2026, and the Treatment Administration Record showed a scheduled PT/INR lab draw for March 24, 2026. During an interview, the Regional Director of Clinical Services confirmed that the employee who entered the original orders had signed off on the lab order in a way that prevented it from populating on the resident’s record and had also set the medication order to stop on the date the lab was ordered, resulting in the resident not receiving the ordered lab test or warfarin doses during the identified period.
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