Failure to Clarify Medication Order Delays Resident's Treatment
Penalty
Summary
The facility failed to clarify a medication order for a newly admitted resident, resulting in a delay in the resident receiving Pyridostigmine Bromide as directed. Upon admission, the resident had a documented history of anemia, hypertension, benign prostate hyperplasia, and arthritis, and required assistance with activities of daily living following a lumbar spine fusion. The resident was cognitively intact, with no memory impairments, and was able to communicate effectively. The resident's outpatient medication list indicated Pyridostigmine Bromide 60 mg to be taken up to four times daily, but the facility's medication record listed the order as every six hours as needed for muscle spasms, which was flagged as outside the recommended frequency. Progress notes revealed ongoing confusion and concern from the resident regarding the administration of his medication, with repeated requests for clarification and a copy of his medication list. The pharmacy also requested clarification before dispensing the medication. Despite these concerns, the order was not clarified until several days after admission, during which time the resident did not receive the medication as he was accustomed to at home. The delay persisted until the provider clarified the order to match the resident's home regimen. Interviews with facility staff, including the DON and the advanced registered nurse practitioner, confirmed that the medication order should have been clarified upon admission according to facility policy. The lack of timely clarification led to the resident not receiving the prescribed medication as intended, despite multiple opportunities to address the issue and clear communication from the resident regarding his needs.