HospitalInspections.org

Based on interviews and documentation review, it was determined the Hospital had not (yet) implemented its corrective action plan related to the 6/2/10 panic alert value.

Findings included:

Medical record review indicated the Patient with a history of advanced nonsmall cell lung cancer, coronary artery disease, ischemic cardiomyopathy, congestive heart failure, atrial fibrillation and dementia had been treated in the past with Coumadin. On 6/2/10 the Patient was called at home because of a panic alert value INR of 8.46 and was told to hold the Coumadin.

On 6/3/10 the Patient was told to go to the ED by his Oncologist because of pain. Medication reconciliation was performed in the ED which indicated a list of 16 current medications provided by family and did not include Coumadin.

Review of the Hospital's policies and procedures regarding medication reconciliation indicated that patient admitted through the ED will have list of current medications documented. The policy and procedure also indicated the admitting nurse will document on the form.

The Patient was admitted and the admitting nurse reviewed the current list of medications provided by the family that indicated the Coumadin had been on hold. Also there was no follow up as to why it was on hold. The Patient was treated with blood transfusion and pain medication. The Patient was prescribed and administered Enoxaparin for DVT prophylaxis. On 6/5/10 the Patient became unresponsive and a head CT scan showed a massive intracranial hemorrhage and the Patient's INR was 12.38.

At the time of the visit the Hospital had not yet completed its internal investigation regarding the incident. The Hospital had not yet implemented a corrective action plan to prevent a like incident from occurring again.