Failure to Transcribe and Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure that medications for a newly admitted resident were transcribed to the Physician Order Sheet (POS) and Medication Administration Record (MAR), obtained from the pharmacy, and administered as ordered by the physician. The resident, who had multiple complex diagnoses including chronic kidney disease, heart conditions, diabetes, and a recent urinary tract infection, was admitted with specific hospital discharge medication orders. However, these orders were not transcribed or acted upon for several days following admission. Record reviews and staff interviews revealed that the admission process was not completed in a timely manner. The admitting nurse, who was from an agency, did not transcribe the medication orders upon admission as required. The facility's triple check system, designed to ensure accurate and complete admissions, was not performed. As a result, the resident did not receive critical medications, including antibiotics, cardiac medications, and diabetes medications, for several days. Staff interviews confirmed that the medications were not available or administered, and that the issue was only discovered days later when a nurse attempted to give the resident his medications and found none available. The failure to transcribe and administer the prescribed medications led to the resident experiencing significant adverse effects, including shortness of breath, heart palpitations, and an untreated urinary tract infection. The resident reported feeling as though he was going to die. Both the facility's pharmacist and medical director confirmed that the missed medications constituted significant medication errors, with the lack of antibiotic administration resulting in hospitalization for a urinary tract infection.