DENVER, CO- SLOAN’S LAKE REHABILITATION CENTER

Based on record review and interviews, the facility failed to ensure the residents were kept free from significant medication errors for one (#1) out of three sample residents.

Specifically, the facility failed to ensure a licensed practical nurse (LPN #1) correctly transcribed the physician order for Resident #1. Resident #1 was administered 2.5 mg (milligrams) of apixaban
(anticoagulant/blood thinner) when the physician order was for 30 mg/0.3 ml (milligrams per milliliters) of lovenox (anticoagulant/blood thinner) solution for three days (6/23/22 thru 6/26/22) and then discontinue the lovenox and then begin the apixaban 2.5 mg twice daily starting on 6/27/22. The LPN administered the 2.5 mg of apixaban to Resident #1 on 6/23/22, and registered nurse (RN) #1 administered the 2.5 mg of apixaban as well as the 30 mg/ml lovenox on the morning of 6/24/22. On 6/25/22 the resident had altered mental status (according to the nursing progress notes) and was transported to a local hospital.

C. Facility investigation
On 6/24/22 the facility began an investigation of the incident immediately upon learning of the medication error. The investigation revealed the following:

Wrong medication was given; order was (to) continue lovenox until 6/26(22) and then start eliquis (apixaban). Pt (patient) was given the lovenox and eliquis this AM.

MD (medical doctor) made aware, monitor for bleeding, DON (director of nursing) made aware, and order has been updated.

The facility investigation determined LPN #1 had entered the hospital discharge orders incorrectly.

The LPN had both the lovenox and apixaban starting on the same date (6/23/22) when the apixaban should have been started on 6/26/22, after the lovenox had been discontinued.

The DON said she had provided education to LPN #1 regarding the medication error, and that the LPN had been terminated from the facility, although due to non-related issues.

Physician (MD) #1 was interviewed on 8/1/22 at 3:12 p.m. He said he had been made aware of the
medication error by the facility on the day it occurred. He said the order was written so that the apixaban and lovenox were not to be given together. The MD said those medications were not typically given together because apixaban is a fast-acting blood thinner and the lovenox was a long-acting blood thinner, so it would be like double treating and that could have the potential for increased bleeding. The MD said the resident was on the lowest dose of both medications, and since Resident #1 had only been given one dose, he felt monitoring for bleeding was an appropriate intervention.

The MD said he had reviewed the medication list that had been verified by the physician working when Resident #1 had been admitted to the facility, and after that review it was clear the order had been written for the apixaban to have a start date of 6/26/22.