In this self reported incident and partial extended survey investigation it was determined that the facility failed to ensure resident safety by keeping the resident free from unnecessary drugs. In this survey report the facility was determined to have failed to immediately monitor and assess one resident on anticoagulant therapy (Coumadin) when the resident had critical laboratory results indicative of decreased blood clotting ability.
In addition, the facility failed to clarify the anticoagulant medication orders and continued to administer the routine Coumadin dose despite the critical laboratory results. This resulted in Immediate Jeopardy when one of four sampled residents on Coumadin therapy was placed at risk of hemorrhage or death.
On 05/19/10, the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 04/26/10 when Laboratory Technician verbally notified Licensed Practical Nurse of critical test results for Resident: prothrombin time (PT) 95.7 seconds and International Normalized Ratio (INR) greater than 10. These results indicated high risk for bleeding from Coumadin therapy. Additionally, the laboratory sent a facsimile (fax) result to the facility on 04/26/10, which was received by a Registered Nurse (RN). The LPN and RN failed to assess and monitor Resident for bleeding and immediately notify the physician.
Additionally the LPN continued to administer Coumadin 5 milligrams (mg) to Resident on 04/26/10. On 04/27/10, the laboratory reported persistent and increased critical test results: PT was 116 seconds, INR was greater than 10 and Resident continued at high risk for bleeding. The Immediate Jeopardy was removed on 05/03/10. The facility was cited at a J level. References used in the citation included: of Laboratory Diagnostic Tests with Nursing Implications and Nursing 2010 Drug Handbook.
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1. Have a lab book on each unit.
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3. 11-7 checks it nightly and fills out the requisition form.
4. The lab is drawn in the am.
5. The completed lab slips go with the nursing report book.
6. All critical lab results are called into the unit nurse.
7. The unit nurse needs to call the physician with critical lab results. Non-critical abnormal labs can be faxed to the physician asap.
8. Call the physician's office to let them know labs were faxed.
9. Write actions taken on actual lab, i.e. called/faxed to physician, date and time.
10. Wait a few hrs or so for the physician to call back. Set a time alert to call physician back before the office closes.
11. After speaking with physician, note there were new orders or not on the lab.
12. Also should be placed on report and of course a nurses note should be written.
13. Use of a coumadin protocol and flow sheet might help you manage the PT/INR doses.
14. Start with an INR; start with the last known one whether from the hospital or the facility and the dose of Coumadin the resident was on, then date next PT/INR due and the results and then changes.
15. Some facilities follow a Coumadin protocol that has been approved by Medical Director and/or resident physician.
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We have PT/INR machines in-house this way we get real time testing and can call the doctor immediately with the results. It helps with reducing the risks of errors.
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