Failure to Transcribe and Administer Medications Results in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident was admitted with multiple complex diagnoses, including chronic kidney disease, heart failure, diabetes, and a recent urinary tract infection. Upon admission, the resident's hospital discharge orders, which included several critical medications such as antibiotics, antihypertensives, anticoagulants, and diabetes medications, were not transcribed to the Physician Order Sheet (POS) or Medication Administration Record (MAR) in a timely manner. The orders were not entered until several days after admission, resulting in the resident not receiving prescribed medications for multiple days. The facility's process required the admitting nurse to transcribe orders into the electronic health record system and send them to the pharmacy, with a triple check system in place to ensure accuracy. However, the admitting nurse was from an agency, and subsequent care was also provided by agency nurses. The facility's Assistant Director of Nursing (ADON) and other staff confirmed that the transcription and triple check processes were not completed as required. The delay in transcription and medication procurement led to the resident missing essential doses of medications, including antibiotics for a urinary tract infection and medications for chronic conditions. As a result of these failures, the resident experienced significant adverse effects, including shortness of breath, heart palpitations, and an untreated urinary tract infection, which ultimately led to hospitalization. Interviews with facility staff and the medical director confirmed that the lack of timely medication administration constituted a significant medication error with serious consequences for the resident.