Failure to Ensure Medication Reconciliation and Oversight After Hospital Readmission
Penalty
Summary
The facility failed to provide appropriate administrative oversight in clinical management, resulting in a resident not receiving tacrolimus, an immunosuppressant medication, after readmission from the hospital. The facility's Facility Assessment did not address the use of laboratory or pharmacy services, nor did it outline how discrepancies or concerns from these services would be communicated to administration. The assessment also lacked evidence of regular staff education or competency validation related to medication reconciliation, laboratory result reporting, or communication with consulting providers prior to the incident. A resident with a history of heart transplant, stroke, and heart failure was readmitted to the facility following a hospitalization for heart failure exacerbation. Upon return, the resident's medication regimen had changed, including the need for ongoing tacrolimus therapy. The medical record showed that the resident missed 40 doses of tacrolimus over a period of several weeks. The medication reconciliation assessment identified potential issues but did not specify the problems or their resolution. Additionally, an Admission Medication Regimen Review (AMRR) was not completed by the consultant pharmacist within the required timeframe after the resident's readmission, and abnormal laboratory results indicating a low tacrolimus level were not promptly communicated to the cardiology team. Interviews revealed that there was confusion and lack of communication among facility staff, pharmacy, and consulting providers. The acting DON and other staff were unaware of the missed AMRRs and medication errors until notified by external parties. The medication error was not fully investigated, as the facility's Performance Improvement Plan did not address the missed AMRR or the failure to notify the cardiology office of abnormal lab results. The incident was not reported to the governing body, and there was no evidence of prior staff education on medication reconciliation or provider notification of abnormal labs before the event.