HospitalInspections.org

Based on interview of staff, record review and review of facility policy and procedures, the facility failed to assess 1 of 10 sampled patient records (Patient 6) lab result and notify the physician that the lab result was out of the desired range for Patient 6 prior to administering an anticoagulant medication (blood thinner) - Warfarin. The facility census at the time of entrance on 10/13/16 was 37. This failure has the potential to effect patients admitted to the facility receiving blood thinner medication.

Findings are:

A. A review of Patient 6's medical record admitted on 10/10/16 to the Behavioral Health Unit in the hospital revealed the following diagnoses:
-Bipolar disorder, (a disorder that causes extreme mood swings) current episode manic (heightened feeling of energy, invincible and sleep very little) severe with psychotic features
-Neuroleptic induced parkinsonism (medication induced movement disorder)
-Unspecified neurocognitive disorder (irreversible and progressive dementia)
-Chronic kidney disease
-anemia (blood lacks red blood cells to carry oxygen to the body's tissues)
-Benign prostatic hypertrophy (an enlarged prostate)
-venous thromboembolism (blood clot in the vein) - on chronic anticoagulation (blood thinner)

A review of Patient 6's progress note revealed:
-Dr. A (family practice physician) on 10/12/16 at 7:21 AM revealed, Venous thromboembolism - "on chronic anticoagulation, INR (International normalized ratio- a lab test done to check how long it takes your blood to clot while on Warfarin) yesterday was 2.3, today it is pending. Goal INR is 2-3. I will continue to follow medically with psychiatry (mental health physician) and nephrology (kidney physician)."
-Dr. B (Psychiatrist) on 10/13/16 at 15:59 (3:59 PM) revealed, Venous thromboembolism - "INR is greater than 3. Grateful for primary care who is managing this."
-Dr. A on 10/14/16 at 10:01 AM revealed, "INR =ok"
-Dr. A on 10/17/16 at 6:54 AM revealed, "It appeared that the hospitalists did not follow (gender) in the behavioral medicine unit over the weekend even though (gender) is on my list. (Gender) INR today is 3.6 which is too high. We'll hold (gender) warfarin. No other medical issue reported..." Venous thromboembolism - "Supratherapeutic INR" "Hold warfarin today."
-Dr. A on 10/18/16 at 7:02 AM revealed, "(Gender) INR is 4.7. (Gender) warfarin was held yesterday and will hold it again now. (Gender's) not having any active bleeding so I won't administer any vitamin K (medication given to reverse the effect of warfarin)." Venous thromboembolism - "Supratherapeutic INR"


Review of the daily INR's for Patient 6 revealed:
-10/11/16 - 2.4 received 8 mg (milligram) warfarin
-10/12/16 - 2.2 received 4 mg warfarin
-10/13/16 - 3.1 received 4 mg warfarin
-10/14/16 - 2.9 received 8 mg warfarin
-10/15/16 - 3.3 received 4 mg warfarin
-10/16/16 - 3.6 received 4 mg warfarin
-10/17/16 - 4.7 WARFARIN HELD
-10/18/16 - 5.1 WARFARIN HELD (Critical High range > 5.0) Vitamin K 2.5 mg given one time per mouth for critical INR
Patient therapeutic INR goal 2-3

D. Interview with the Behavioral Health Manager on 10/18/16 at 2:48 PM verified:
-Patient 6 was not seen by a medical physician over the weekend (10/15 & 10/16/16). The Hospitalist did not see Patient 6 and (Dr. A) was off over the weekend.
-That no physician reviewed the daily INR results (10/15/16 3.3 & 10/16/16 3.6 - both out of the patients therapeutic INR goal of 2-3)
-The patient was seen by psychiatry, but the psychiatrist do not manage the medical issues of the patients they manage the psychiatric issues.

An interview with the Vice President, Chief Nurse Executive on 10/18/16 at 5:00 PM verified that (Patient 6) was not on the Hospitalist list over the weekend. The Hospitalist have a Nurse Practitioner come to the hospital on Friday and review the patients and make the list for the Hospitalist to see over the weekend. The physicians (internal specialist and family practice) have indicated a perpetual turn over of their patients to the Hospitalist for the weekend so not a formal hand off.
The Vice President, Chief Nurse Executive indicated that usually those on Behavioral Health Unit do not have the medical need, and the Psychiatrist are the main attending physician. On the other floors it is the Lead Nurse responsibility to check that the physician has made rounds, on the Behavioral Health Unit there isn't a nurse that is identified as a Lead Nurse. "This is a process that needs to be looked at."

An interview with Registered Nurse (RN) H on 10/20/16 at 11:00 AM revealed, "If the INR is out of the therapuetic range then we are to call the physician before giving the medication (warfarin)."

Review of the HIGH ALERT MEDICATION policy dated January 2015 revealed the following HIGH ALERT MEDICATION:
-Anticoagulants - the risk of bleeding is common and could result in extra monitoring, possiple additional treatment, prolonged hospitalization, or in severe cases, may be fatal.
A) RN's may administer all routes of all anticoagulants, and LPN's (licensed practical nurses) may administer oral and subcutaneous anticoagulants after proper inservice education.
B) Daily doses of oral anticoagulants are to be given at 12 noon unless otherwise specified by the prescriber.
1) If blood coagulation studies are ordered, the dose is to be held until lab results are available.
2) The Pyxis Medstation (medication dispensing machine) will prompt the nurse to check the PT/INR before removing each dose of warfarin.
3) When charting the dose of warfarin, the nurse will also chart the current PT/INR on the emar (electronic medication record).