DENVER, CO-SLOAN’S LAKE REHABILITATION CENTER

Resident #87 was admitted to the facility following a surgical procedure. Upon admission, the resident had a physician’s orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did not receive the anticoagulant medication between 3/3/21 (admitted ) and 3/9/21, representing 12 missed doses. Although the medication was not received from the pharmacy until 3/9/21, it was recorded on the MAR as given on several occasions.

Serious harm was likely to occur as the resident was at greatest risk for developing a blood clot by not receiving the anticoagulant medication post surgery. The facility did not do anything or was not even aware of the extent of the error until it was brought up during the recent recertification survey.

The March 2021 Medication Administration Record (MAR), revealed the [MEDICATION(S)] medication was administered (marked with a check mark) on the following date and times even though the medication was not in the facility to administer to the resident:
-5th at 7:00 p.m.,
-6th at 7:00 a.m.,
-7th at 7:00 a.m., and 7:00 p.m.,
-8th at 7:00 p.m., and
-9th at 7:00 p.m.

The DON was interviewed on 6/30/21 at 11:36 p.m. She reviewed and acknowledged the documentation on the resident’s MAR dated 3/1/21, which revealed the resident did not receive her physician ordered [MEDICATION(S)] six times and was administered the [MEDICATION(S)] six times.

However this was inaccurate according to the Pharmacy delivery form, the medication was not in the facility to administer to the resident. The DON said this medication was not kept in the facility’s computerized medication dispensing machine and it had to come from the pharmacy. She said if medication was not available, a nurse should call the resident’s physician and the pharmacy to see when the medication would be delivered to the facility. The DON said she first learned of this concern on 6/29/21 after the survey started, when she was asked to provide additional documentation on this issue.