Failure to Accurately Transcribe Medication Orders on Admission
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including diabetes, anemia, heart failure, hypertension, seizure disorder, non-Alzheimer's dementia, and depression, did not have their medication orders correctly transcribed upon return from a hospital stay. The resident's psychiatric provider had increased the dose of Fluoxetine to 80 mg daily due to increased behavioral symptoms, and the hospital discharge instructions also specified this dosage. However, upon readmission, the facility transcribed the order as 40 mg daily instead of the intended 80 mg. As a result, the resident received only 40 mg of Fluoxetine daily from the time of readmission through several months, as documented in the electronic medication administration records. Interviews with nursing staff and the DON confirmed that the error occurred during the transcription process when the resident returned from the hospital, and the facility's policy required accurate transcription and clarification of medication orders.