Failure to Reconcile and Accurately Document Medications on Admission
Penalty
Summary
The facility failed to ensure proper reconciliation of medications upon admission for a resident who was admitted under hospice care and had multiple complex diagnoses, including dementia, Alzheimer's disease, COPD, and a malignant neoplasm. The hospice medication list specified Lorazepam 0.5 mg to be given every four hours for anxiety and/or restlessness, and Morphine Sulfate Oral Solution to be administered in varying doses based on pain level or shortness of breath. However, the physician order entered at admission incorrectly listed Lorazepam to be given four times a day instead of every four hours as per the hospice order. This discrepancy was confirmed by the Regional Clinical RN during an interview. Additionally, there were inconsistencies in the documentation and administration of Morphine Sulfate. The Medication Administration Record (MAR) and the narcotic count sheet did not match regarding the times and amounts of Morphine administered. For example, the MAR showed doses of 0.75 ml and 1.0 ml administered at specific times, while the narcotic count sheet recorded a 0.5 ml dose at different times, indicating inaccurate documentation. These failures in medication reconciliation and documentation were identified through medical record review and staff interviews.