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Based on medical record review and interviews it was determined the facility failed to ensure medications were administered per physician order for one (#7) of ten sampled patients.

Findings included:

Review of the medical record for Patient #7 revealed the patient was admitted on 05/13/2017 at 6:17 a.m. Review of physician orders dated 05/13/2017 revealed an order for Heparin 5,000 unit injection subcutaneously every 12 hours to prevention of a deep vein thrombosis (blood clots) to start on 05/13/2017 at 9:00 p.m.

Review of the medication administration record (MAR) for heparin 5,000 units every 12 hours revealed Patient #7 failed to receive seven of the eight doses of heparin to prevent blood clots as follows:
05/13/2017 at 8:41 p.m.-Not Given: Refused by Patient. There was no documentation of physician notification.
05/14/2017 at 8:03 p.m.-Not Given: Refused by Patient. There was no documentation of physician notification.
05/15/2017 at 7:57 a.m. and 8:46 p.m.-Not Given: Refused by Patient. There was no documentation of physician notification.
05/16/2017 at 9:00 a.m. and 9:13 p.m.-Not Given: Refused by Patient. There was no documentation of physician notification.
05/17/2017 at 9:00 a.m.-Not Given: Refused by Patient. There was no documentation of physician notification.

A complete review of the medical record failed to document the physician was made aware of the patient's refusal to take the heparin or that the patient received education related to the risks and benefits of receiving and not receiving heparin for the prevention of blood clots. A complete review of physician documentation in the medical record failed to reveal the physician was aware of the patient's refusal to take the heparin.

On 06/19/2017 at approximately 1:30 p.m. an interview with the facility's Risk Manager and Director of Quality Management confirmed the above findings.