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Warfarin administration in a rest home (07HDC11952)

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(07HDC11952, 17 October 2008)

Rest home ~ Registered nurse ~ Hospital discharge summary ~ Warfarin ~ Medication management ~ Documentation ~ Rights 4(1), 4(2)

An 89-year-old woman was transferred from a public hospital to an aged care facility following treatment for pneumonia, urinary retention and a rapid and irregular heart rate. She had developed a clot in her right arm while she was in hospital.  Her hospital discharge forms summarised her condition and treatment at the hospital and listed her current medications. The forms showed she had been prescribed warfarin, an anticoagulant, and augmentin, an antibiotic, and indicated the amount of warfarin to be given.

Over the next two days the woman did not receive the medication as it had been prescribed. Her daughter raised concerns about this a number of times. Three days later, the woman collapsed after suffering a further stroke. When she was urgently readmitted to hospital, she was also found to have pressure sores in her sacral area. She died two weeks later.

It is a fundamental requirement that a rest home will administer prescribed medications in a safe and consistent manner to an elderly patient who has been discharged from hospital. In this case there were a number of failings with respect to communication, and the prescription and administration of medications at different levels and by different staff. While various actions by individual nurses and the inexperience and actions of the new manager contributed to these events, it was held that the rest home failed to ensure that the woman received services provided with reasonable care, in breach of Right 4(1).

The decision by one of the registered nurses to withhold the woman's warfarin over the weekend also led to a breach finding. The nurse did not document the decision as she was required to, or seek medical advice and clarification when she was unable to understand the medication orders. She had a responsibility to her patients to use her professional judgement and consult when she needed to. It was held that the nurse did not provide services with reasonable care and skill and failed to meet the standard expected of a registered nurse. She also failed to comply with the rest home's own policy for documenting withheld medications, thereby breaching Rights 4(1) and 4(2).