Failure to Administer Steroid Taper as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to administer hydrocortisone (Cortef) as ordered for a resident who had recently undergone pituitary tumor removal and was readmitted from an acute care hospital. The resident, who had severe cognitive impairment and lacked capacity to make medical decisions, was discharged from the hospital with specific orders for a hydrocortisone taper. These orders included a series of scheduled doses to be administered over several days, starting with a 25 mg dose, followed by 20 mg and 10 mg doses, and then a maintenance dose of 5 mg every afternoon. Upon review, it was found that the hydrocortisone taper was not transcribed from the hospital discharge paperwork into the facility's electronic medical record. The process for admitting residents required the admission nurse to review and transcribe discharge orders, which were then to be double-checked by the night shift RN supervisor. However, the hydrocortisone order was missed during this process, and there was no documentation indicating that the required double-check or recapitulation of orders had been completed by the RN supervisor. Interviews with facility staff, including the RN, unit manager, pharmacy consultant, and DON, confirmed that the hydrocortisone order was present in the hospital discharge paperwork but was not entered into the facility's system or administered as prescribed. The pharmacy consultant explained the importance of a steroid taper and the potential effects of abrupt discontinuation, but the report did not document any specific adverse outcomes for the resident. The deficiency was substantiated by the lack of documentation and failure to follow the facility's policy and procedure for medication administration.
Plan Of Correction
How corrective action will be accomplished for those residents affected by the deficient practice: The Facility was made aware of the incident. MD was notified and transcribed the missing Hydrocortisone order. MD was notified of the incident, conducted an investigation, and completed an incident report. Initiated monitoring for resident 1. Resident remains in stable condition and no negative effects were noted on resident 1. How the facility will identify other residents having the potential to have been affected by the deficient practice and corrective action taken: The Medical Records Director/Designee conducted audits on all admissions on April 4, 7, 8, 9, 2025, and ensured that orders from the Hospital are carried out promptly. The DON conducted in-service to the Licensed Nurses on 4-4-25 regarding the admission process to ensure that discharge orders from the Hospital are being carried out correctly. The Admission nurse who failed to transcribe the Hydrocortisone was given 1:1 in-service and training on the admission process on 03-20-25 and guided on verification/comparing of hospital discharge orders and ensuring that each order is double-checked for accuracy and completeness. What measures will be put into place to ensure that the deficient practice does not recur: The Admission nurse will verify admission orders from the Hospital, review with the Attending Physician for accuracy, and transcribe to the resident's admission records. The RN Supervisor of the next shift will compare admission orders from the Hospital versus the ones on the resident's record. If noted with discrepancy, the MD will be notified for order clarification and will carry out the orders promptly. In addition, the RN Unit Manager/Designee will check again the next day if orders were carried out correctly by comparing orders and will sign the sheet to verify it was checked for accuracy. The DON/Designee will be notified of the findings for follow-up. How the facility plans to monitor its performance to make sure solutions are sustained: The facility will utilize QA tools every month for 3 months and quarterly thereafter. The results of the findings will be forwarded to the QA Committee monthly for follow-up and recommendations. The Designee will check again the next day if orders were carried out correctly by comparing orders and will sign the sheet to verify it was checked for accuracy. The DON/Designee will be notified of the findings for follow-up.