ISDH IJ/SSQC Update

The ISDH cited one tag in October that was at the IJ and SSQC level.  That tag, F329, was cited for failure to ensure an anticoagulant that had been discontinued per the physicians order was actually discontinued, and that accurate documentation of MARs and Physician Order Sheets were accurately reflecting physician orders.  The resident had been placed on Coumadin therapy, with corresponding orders for P/INR tests, to manage deep vein thrombosis as of April 21, 2014.  The physician discontinued the medication regimen on May 12, 2014 and the medication was not administered in May thereafter.  In June the Physician Order Sheet included an order for Coumadin for the resident, however the RN in charge of checking orders caught the error and crossed it off per the physician’s order.  In July, August and September the Physician Order Sheet contained the same order for Coumadin, but in each of these months the nurse did not catch the error and according to the MARs the Coumadin was administered.  The error was caught in September when the DON was reviewing lab results, at which time the resident was experiencing critically high PN/INR values resulting in administration of Vitamin K and ongoing monitoring for bleeding issues.  Investigation at the facility found that Coumadin flow sheets were not being maintained in July and August, and the pharmacy indicated that they reported no discontinuation orders for this medication.  The IJ was lifted when new staff was assigned to review Physician Order Sheets, random audits were performed for the sheets, and all staff were in-serviced concerning Physician Orders Sheets and monitoring for effects of medication.

Please click here to access the October 2567 and the IJ/SSQC 2014 Summary.