Failure to Discontinue Medication Order
Penalty
Summary
The facility failed to ensure that an order to discontinue a medication was properly transcribed into the clinical record for a resident. The resident, who was admitted with a medical history of type two diabetes mellitus, had a follow-up appointment with an outside physician who noted that the resident's prescription for Pred Forte should be discontinued. Despite this, the medication order remained active in the resident's records, indicating a failure to update the clinical documentation as per the physician's instructions. Interviews with facility staff revealed that the physician's note regarding the discontinuation of the medication was not reviewed by nursing staff before being scanned into the resident's electronic medical record. The Licensed Vocational Nurse and the Medical Records Director confirmed that the note was not marked as reviewed, which is a necessary step before scanning. The Director of Nursing also stated that nursing staff should have checked for new orders and updated the resident's records accordingly upon their return from the appointment, which did not occur in this instance.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 03/05/25, Resident #84 had the order for Pred Forte (prednisolone acetate) immediately discontinued in the clinical record. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by the deficient practice, as the failure to document and discontinue medication orders can occur for any resident with outside medical appointments. On 03/19/25, medical records conducted a comprehensive review of all appointment/consult notes for each resident to ensure they are consistent with the most recent provider instructions. No further discrepancy noted. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On 03/21/25, the nursing and medical records staff were in-serviced on the facility's policies for reviewing, documenting, and transcribing medication orders, particularly those issued by outside providers. A new process has been implemented to ensure that all outside provider notes are promptly reviewed by nursing staff upon receipt. Nurses will be responsible for identifying and entering any new orders, including medication discontinuations, into the EMR. Medical records staff will ensure that all physician progress notes are not scanned into the EMR until they have been reviewed and acted upon by nursing staff. Before scanning and uploading to the resident's documents, Medical Records will make sure it is noted and verified by nursing staff. How the facility plans to monitor its performance to make sure that solutions are sustained: Regular audits will be conducted by Medical Records to review compliance with the new procedures. These audits will focus on ensuring that all provider orders, including medication discontinuations, are accurately documented in the clinical record and MAR. Outcomes related to restorative nursing services will be discussed in monthly Quality Assurance and Performance Improvement (QAPI) meetings to ensure ongoing accountability and improvement. Include dates when corrective actions will be completed: Completion date March 28th, 2025