Failure to Transcribe and Administer Admission Medications
Penalty
Summary
A deficiency occurred when a resident was admitted to the facility and the admitting nurse failed to transcribe the hospital discharge medication orders to the Physician Order Sheet (POS) and Medication Administration Record (MAR) in a timely manner. The resident, who had multiple complex diagnoses including acute kidney injury, chronic kidney disease, hypertension, diabetes, and a history of cardiac issues, was admitted with specific medication orders from the hospital. These orders were not entered into the facility's records or sent to the pharmacy upon admission, resulting in the resident not receiving prescribed medications for several days. Record review showed that the hospital discharge orders, dated 4/2, were not transcribed to the POS and MAR until 4/5. The MAR for April documented no medication orders for the resident on 4/2, 4/3, and 4/4, and the orders only appeared on 4/5 and later dates. Interviews with facility staff, including the previous DON, interim DON, and LPNs, revealed that the admission process was handled by agency nurses, and the required triple check system for new admissions was not completed. The interim DON confirmed that medications should have been transcribed within the first few hours of admission, but this did not occur. The facility's policy requires that medication orders be documented and transcribed promptly upon admission, with orders entered into the electronic system and transmitted to the pharmacy. In this case, the process was not followed, and the resident did not receive their prescribed medications as ordered by the physician during the initial days of their stay. Staff interviews indicated a lack of clarity and follow-through in the admission process, particularly with agency nurses responsible for the resident's care.