Failure to Provide Complete Hospital Records at Admission Resulted in Medication Hold
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices. Specifically, upon admission from the hospital, the facility did not provide the admitting physician with the resident's complete hospital clinical discharge record. As a result, the physician held a recommended medication, colchicine, which had been prescribed for inflammation around the lungs and heart, not for gout as initially assumed by the physician due to incomplete information. The resident, who had a history of epilepsy, pleural effusion, pericardial effusion, atrial fibrillation, and hypotension, was admitted with only a hospital medication list available to the admitting nurse and physician. The physician, lacking the full clinical context, decided to hold colchicine and another medication, Toradol, until the complete hospital record could be reviewed. This led to the resident missing two doses of colchicine. The medication was reinstated the following day after the physician reviewed the full hospital record and understood the rationale for its use. Interviews with facility staff, including the admitting nurse, DON, business office manager, and administrator, confirmed that the full hospital record was not available at the time of admission, contrary to facility procedures and expectations. The facility's policies did not clearly address the requirement for a complete hospital record at admission, nor did they provide a checklist for reconciling hospital medications and clinical notes. The resident expressed frustration at not receiving the medication as expected, and staff acknowledged the lapse in continuity of care due to the missing documentation.