Failure to Monitor and Adjust Anticoagulant Therapy Leads to Resident's Death
Summary
The facility failed to adhere to physician orders for a resident's anticoagulant medication, Warfarin, resulting in the resident receiving an incorrect dosage for 24 days. The resident was supposed to have their Warfarin dosage decreased from 3mg to 2.5mg, but this adjustment was not made. Additionally, the facility did not conduct the necessary PT/INR tests to monitor the resident's blood clotting time as recommended by the drug manufacturer guidelines. This oversight led to the resident's PT/INR levels reaching critical levels, causing internal bleeding. The resident, who had a complex medical history including conditions such as Transient Cerebral Ischemic Attack, Non-Rheumatic Aortic Valve Stenosis, and the presence of a prosthetic heart valve, was at significant risk due to the facility's failure to monitor and adjust the anticoagulant therapy appropriately. The resident's PT/INR levels were consistently out of range, and despite this, the facility continued to administer the incorrect dosage of Warfarin. The lack of proper monitoring and adjustment of the medication dosage resulted in the resident experiencing Warfarin toxicity. Ultimately, the resident was sent to the hospital with Warfarin toxicity and was admitted with lethal bleeding. The hospital notes indicated severe complications, including a left hemothorax and alveolar hemorrhage. The resident's condition deteriorated, leading to their death, which was documented as being caused by cardiopulmonary arrest with acute respiratory failure and a left hemothorax. Interviews with facility staff, including the Director of Nursing and the Medical Director, confirmed that the facility did not follow the correct Warfarin order and failed to monitor the resident's labs as required.
Removal Plan
- All licensed and direct care staff was educated on Administration Procedures for All Medications including but not limited to: medications are administered in accordance with physician order, and physician notification including monitoring and adverse reactions.
- All licensed and direct care staff was educated on referencing and following drug manufacturing guidelines for monitoring of drug side effects, labs, and possible adverse reactions.
- All licensed staff was educated on utilizing the Coumadin Tracking Log to ensure medication dosage, order, and follow-up PT/INR are reviewed and to ensure physician's orders are carried out.
- All licensed and direct care staff was educated on anticoagulant administration, effects, precautions, and monitoring.
- All licensed staff was educated on the facility process to monitor/review/follow-up/coordinate and administer safe use of anticoagulant medications.
- An impromptu QAPI meeting was held with the medical director and staff IDT to discuss deficiency and facility action plan.
- The facility will audit the Coumadin Tracking Log and review resident charts to ensure anticoagulant medication orders were followed, monitoring for anticoagulant side effects, the physician was notified of changes in condition(s) of residents, and that abnormal lab results were reported to the physician. A QA tool will be completed to verify this practice has occurred. There will be oversight of the QA tool by the RNC.
- The facility will audit all residents currently receiving an anticoagulant to ensure physician orders are being followed, and monitoring is in place including monitoring side effects, labs, and adverse reactions. A QA tool will be completed to verify this practice has occurred. There will be oversight of the QA tool by the RNC.
- Nursing Management will audit all newly admitted and readmitted residents to ensure residents receiving anticoagulant medication are being monitored for side effects and adverse reactions, laboratory orders are in place, and the physician is notified of any change in condition. A QA tool will be completed to verify this practice has occurred. There will be oversight of the QA tool by the RNC.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with hypertension, CHF, and CAD had repeated episodes of markedly elevated BP that met parameters for PRN Clonidine, yet nursing staff did not administer the medication or document any clinical rationale for withholding it. The same resident also received Isosorbide Mononitrate despite ordered hold parameters requiring the drug to be withheld when systolic BP was below a specified threshold, with no justification documented. Nursing staff interviews revealed lack of awareness of the PRN order and the hold parameters, while the resident, with moderately impaired cognition, reported being on BP medications and experiencing headaches and dizziness at times.
A resident with hemiplegia and hemiparesis following a cerebral infarction was given another patient’s medications when a nurse failed to follow established medication administration procedures. The resident’s EHR documented that the Unit Manager was notified of a med error and that the resident received multiple medications not prescribed for him, including Tylenol, furosemide, spironolactone, olanzapine, Entresto, Brilinta, metoprolol, aspirin, ticagrelor, venlafaxine, and gabapentin. The DON stated that RNs are trained to use two identifiers and follow the facility’s Medication Administration policy, which requires verifying the resident by photo in the MAR and matching the medication source to the MAR for name, drug, dose, route, and time, but these steps were not followed in this instance.
An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A resident received an incorrect higher dose of Divalproex DR after the pharmacy dispensed 500 mg tablets labeled to be given multiple times daily, which did not match the physician’s order for 250 mg tablets. Nursing staff did not detect the discrepancy between the MAR and the medication card despite facility policy and expectations to verify the right dose and ensure orders matched dispensed medications. Over time, the resident developed weakness and altered mental status, was sent to the hospital at the family’s request, and was found to have an elevated valproic acid level, with hospital documentation indicating motor weakness was possibly medication-induced.
A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
A resident with ESRD on thrice-weekly dialysis, along with DM2, A-fib, COPD, and CHF and moderate cognitive impairment, did not receive scheduled morning medications, including metoprolol and linagliptin, while away at dialysis. The MAR documented that the 9 AM metoprolol dose was not given because the resident was away from the facility without medications, and a progress note confirmed that morning medications were not administered due to the dialysis appointment. The DON later confirmed these omissions and identified them as medication errors.
Failure to Follow Antihypertensive and Vasodilator Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for antihypertensive and vasodilator medications for a resident with hypertension, congestive heart failure, and coronary artery disease. The resident had an order dated 12/13/25 for Clonidine 0.2 mg every 12 hours as needed for systolic blood pressure greater than 180 or diastolic blood pressure greater than 90. The Medication Administration Records (MARs) for December 2025 and January 2026 showed multiple instances of significantly elevated blood pressures, including readings such as 248/100, 210/87, 235/101, 231/90, 187/88, and 212/87, documented by nursing staff. Despite these readings meeting the ordered parameters for as-needed Clonidine, there was no documentation that Clonidine was administered on those dates, nor was there any documented clinical rationale for withholding the medication in the nursing progress notes. Interviews with nursing staff revealed a lack of awareness and follow-through regarding the as-needed Clonidine order. One nurse stated she had not been assigned to the resident for a while prior to recording the elevated blood pressures, and another nurse reported she was not aware that the resident had an order for as-needed Clonidine for elevated blood pressure. When later contacted, that nurse declined to comment further on the medication issue that occurred in January. The Nurse Practitioner confirmed that the as-needed Clonidine was ordered for a reason and that the blood pressure parameters should have been followed, with the medication administered when indicated. The facility also failed to follow hold parameters for Isosorbide Mononitrate extended release 60 mg, ordered on 4/6/26 to be given once daily for angina with instructions to hold the medication if systolic blood pressure was less than 120. The April 2026 MAR showed that the medication was administered on multiple occasions when the resident’s systolic blood pressure was below 120, including readings of 112/76, 118/70, and 118/75, with no documentation or clinical justification in the nursing progress notes for giving the medication despite the hold parameters. A nurse involved stated she had not held the Isosorbide Mononitrate and did not realize the medication had hold parameters, explaining that the hold parameters were not noticeable on the electronic MAR and were therefore overlooked. The resident, who had moderately impaired cognition per a quarterly MDS, reported being on blood pressure medications but did not know which ones or their schedule, and described experiencing headaches and dizziness at times. The Nurse Practitioner and the DON both stated that ordered parameters for these medications should have been followed by the nursing staff.
Medication Error Involving Administration of Another Resident’s Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a nurse administered another resident’s medications. The affected resident is an adult male with hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, receiving Intermediate Care Facility level of care. A complaint was filed with the Office of Health Care Assurance alleging that the resident had been given another patient’s medications. Review of the resident’s electronic health record showed a progress note documenting that the Unit Manager was notified that a nurse made a medication error and that the resident was given another patient’s medications. The record specified that the resident received multiple medications not prescribed for him, including Tylenol, furosemide, spironolactone, olanzapine, Entresto, Brilinta, metoprolol, aspirin, ticagrelor, venlafaxine, and gabapentin. During an interview, the DON confirmed that RNs are trained and instructed to identify residents using two identifiers (name and date of birth) at all times. Review of the facility’s “Medication Administration” policy, revised 03/01/26, showed that staff are instructed to identify the resident by photo in the MAR, review the MAR to identify the medication to be administered, and compare the medication source to verify resident name, medication name, form, dose, route, and time. Despite these policies and training, the nurse did not follow the required resident identification and medication verification steps, resulting in the administration of another resident’s medications.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Significant Medication Error From Incorrect Divalproex Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to incorrect dosing of Divalproex DR. Clinical record review showed that the resident was being seen repeatedly by advanced practice providers in June for muscle weakness and weakness. A nurse practitioner documented on 6/23/25 that the resident’s weakness was found to be due to an incorrect medication dose being dispensed, noting a 500 mg dose instead of the ordered 250 mg. The physician’s order specified Divalproex DR 250 mg tablets, but the medication dispensed and administered was Divalproex DR 500 mg. Pharmacy records and interviews confirmed that on 5/18/25, the pharmacy dispensed 150 tablets of Divalproex DR 500 mg with a label instructing staff to give two tablets in the morning and three at bedtime, which did not match the physician’s order for 250 mg tablets. Nursing staff interviews indicated that nurses were expected to follow the facility’s medication administration policy, including verifying the right resident, right medication, right dose, and ensuring the medication card matched the MAR. The DON and multiple LPNs stated that if the pharmacy sent the wrong medication or if the milligrams did not match the MAR, nurses were expected to identify and correct the discrepancy, but this did not occur in this case. On 6/20/25, the resident was assessed by an LPN who initially stated she did not observe changes in condition, but her documentation reflected that the resident had altered mental status, and the resident’s mother requested hospital transfer. At the hospital, the discharge summary indicated that the resident’s motor weakness was possibly medication-induced, and lab results showed a valproic acid level of 115, above the normal range of 50–100. A physician assistant interviewed later confirmed that increased doses of Divalproex DR can cause drowsiness, muscle weakness, skin reactions, somnolence, nausea, and vomiting. These findings collectively demonstrate that the resident received an incorrect, higher dose of Divalproex DR over time, constituting a significant medication error that resulted in harm.
Missed Antibiotic Doses Not Reported to Provider
Penalty
Summary
The facility failed to ensure that Resident ID #17 was free from significant medication errors when the resident missed 6 doses of a prescribed antibiotic. The resident was admitted in April 2026 with diagnoses including surgical aftercare and complication of surgical and medical care, and had a physician order dated 4/3/2026 for Cefadroxil 500 mg by mouth twice daily for 14 days. Review of the April 2026 MAR showed missed doses on 4/3 at 8:00 PM, 4/6 at 8:00 PM, 4/11 at 8:00 PM, 4/12 at 8:00 AM, 4/14 at 8:00 PM, and 4/17 at 8:00 AM. The record did not show that the provider was notified of the missed antibiotic doses. During interview, the RN acknowledged the 6 missed doses and stated they should have been reported to the provider. The Medical Director stated she was unaware of the missed doses and said she would have extended the antibiotic course if she had known. The DON also acknowledged the missed doses and stated she would expect the provider to be informed if a resident misses any dose of an antibiotic.
Failure to Administer Ordered Medications During Dialysis Absence
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when required medications were not administered as ordered while the resident was away from the facility for dialysis. The resident had multiple serious diagnoses, including end stage renal disease requiring dialysis, type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, and was assessed with moderate cognitive impairment. The resident required extensive assistance with most activities of daily living and was receiving dialysis services three times weekly. The comprehensive care plan documented scheduled dialysis on Monday, Wednesday, and Friday. On a documented dialysis day, the resident did not receive the scheduled 9 AM dose of metoprolol tartrate 25 mg because the resident was away from the facility without medications. The medication administration record showed a code indicating the medication was not given due to the resident being away, and a progress note stated that morning medications were not administered because the resident was at dialysis that morning. Later, the physician ordered metoprolol to be given after the resident’s heart rate was found to be 116. In an interview, the DON confirmed that the resident did not receive metoprolol and linagliptin on that date and acknowledged that the omission constituted a medication error.
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