Failure to Administer Discharge-Ordered Medication Resulting in Hospitalization
Penalty
Summary
The facility failed to follow physician orders for a resident who was admitted with multiple diagnoses, including hepatic encephalopathy risk factors. Upon admission, the resident's hospital discharge orders included a prescription for Lactulose to be administered three times daily. However, the facility did not include this medication in the resident's physician orders for February, nor was it documented as administered in the Medication Administration Record. Staff failed to review both the paper and electronic discharge records as required, resulting in the omission of Lactulose from the resident's care. As a result of not receiving Lactulose, the resident experienced a significant decline in mental status, including confusion, weakness, and inability to hold up their head. The family noticed these changes and requested hospital evaluation, where the resident was found to have elevated ammonia levels and was diagnosed with hepatic encephalopathy. Hospital records confirmed that the lack of Lactulose administration at the facility led to the resident's condition, which improved only after receiving the medication in the hospital.