Failure to Transcribe and Administer Admission Medications
Penalty
Summary
The facility failed to complete the admission process and transcribe physician-ordered medications to the Physician Order Sheet and Medication Administration Record for a newly admitted resident. As a result, the resident did not receive multiple critical medications, including antibiotics for a urinary tract infection, antihypertensives, diabetes medications, and other essential treatments for several days following admission. Documentation shows that the hospital discharge orders were not transcribed until several days after admission, and medications were not obtained from the pharmacy or administered as ordered. The resident, who had a complex medical history including chronic kidney disease, diabetes, heart disease, and a recent fracture, repeatedly reported not receiving medications and experienced symptoms such as shortness of breath, heart palpitations, and elevated blood glucose levels. Progress notes and interviews confirm that staff, including agency nurses, were aware that medications were missing and not available, and that attempts to contact the pharmacy were made but not successful in a timely manner. The facility's own policies required prompt assessment and medication reconciliation upon admission, but these steps were not completed as required. Ultimately, the resident's condition deteriorated, leading to hospitalization where it was confirmed that he had not received his prescribed medications for several days, resulting in untreated infection and other complications. Interviews with staff and review of records indicate that the failure to transcribe orders, obtain medications, and administer them as ordered was due to lapses in the admission process, lack of oversight, and failure to follow established procedures for new admissions.