Failure to Administer Anticoagulant as Ordered and Notify MD When Medication Unavailable
Penalty
Summary
The deficiency involves the facility’s failure to administer a prescribed anticoagulant medication, Eliquis, as ordered for a resident with a history of right hip prosthesis infection and injury of the right iliac vein. The resident was admitted with an order for Eliquis 5 mg, two tablets by mouth twice daily for DVT. The electronic MAR showed that on one evening the medication status was documented as “Pending delivery,” and on another evening it was documented as “Medication not available,” resulting in missed scheduled doses. The facility’s own medication administration policy required that medications be administered in accordance with prescriber orders, including any required time frame. Nursing documentation indicated that, in the early morning hours, the resident called 911 from her room, reporting to the nurse and the 911 operator that she had not received her Eliquis for days for DVT and was experiencing pain in her right lower limb. A nurse practitioner progress note later documented that the resident complained of leg pain, was worried she might have missed her Eliquis dose, and called 911 to be taken to the emergency room. A subsequent nurse practitioner discharge summary noted that during a recent hospital visit the resident was given Eliquis for DVT. Interviews with multiple licensed nurses revealed that when medications are not available, staff are expected to check with the pharmacy, search medication rooms and carts, and, if still unavailable, notify the physician for further direction or possible order adjustments. One nurse stated uncertainty about the availability of oral medications in the e-kit and described that staff might obtain medication from another resident with the same medication until delivery. Another nurse reported being unable to locate documentation that the physician had been notified about the missed Eliquis doses. The DON stated that the Eliquis had been delivered by the pharmacy on the day of admission prior to the scheduled administration time and that staff should have notified the physician when the medication was not administered, emphasizing that the resident had a confirmed DVT diagnosis and that the medication should have been administered as ordered.
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