Incorrect Transcription of Physician Order for Medication
Penalty
Summary
A deficiency occurred when a facility failed to maintain accurate medical records by not correctly transcribing a physician's order for a resident. The resident, who was admitted with diagnoses including high blood pressure, type 2 diabetes, congestive heart failure, and osteoporosis, had a hospital discharge order for Ergocalciferol (vitamin D2) to be administered once weekly on Mondays. However, during the admission process, the order was incorrectly transcribed as a daily administration instead of weekly. This transcription error was reflected in the resident's Medication Administration Record (MAR), which showed the medication being administered daily. On one occasion, the medication was not administered, and this was documented by an LPN. During a subsequent medication pass, the LPN identified the discrepancy in the order and sought clarification from the physician, after which the correct weekly order was entered. Interviews with the LPN and the Director of Nursing confirmed that the error originated during the admission process and resulted in the resident's medical record not being accurate or complete as required. The facility's policy on administering medications states that medications should be administered as prescribed, which was not followed in this instance.
Plan Of Correction
This Plan of Correction is being prepared and executed because it is required by the provisions of the State and Federal regulations and not because Kingston of Ashland agrees with the allegations and citations listed on the statement of deficiencies. Kingston of Ashland maintains that the alleged deficiencies do not individually or collectively jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Kingston of Ashland's written credible allegations of compliance. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Kingston of Ashland reserves all possible contentions and defenses in any civil or criminal actions or proceeding. Please accept the date of correction 4/17/2025 as the facility's credible allegation of compliance. Resident #348's orders for ergocalciferol and calcitriol were corrected at the time of discovery with no negative outcome noted. Resident #348 no longer resides in the center. Director of Nursing or designee will review medication orders for residents that have been admitted since the date of survey exit through the date of compliance to ensure that medication orders were transcribed appropriately upon admission. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. Director of Nursing or designee will educate licensed nurses on the electronic order entry process and transcription policy on or before 4/17/2025. Director of Nursing or designee will complete a medication order audit on 5 new admissions weekly for 4 weeks to ensure that medication orders are transcribed appropriately upon admission. The results will be presented to the QAA committee for review and consideration for further corrective actions.