Failure to Accurately Reconcile and Transcribe Physician Orders After Hospital Admission
Penalty
Summary
The facility failed to ensure accurate reconciliation and transcription of physician orders following a hospital admission for a resident with multiple complex medical conditions, including end-stage renal disease, diabetes, and heart failure. After returning from the hospital, the resident's discharge summary included a change to the midodrine order, specifying that it should be administered twice daily as needed for low mean arterial pressure and specifically before each scheduled hemodialysis session on Mondays, Wednesdays, and Fridays. However, the facility did not update the resident's physician orders to reflect this change, and the medication was only listed as an as-needed order without the specific instruction for pre-dialysis administration. Review of medication administration records and dialysis communication forms showed that midodrine was not consistently administered prior to dialysis sessions as directed in the hospital discharge summary. Facility staff, including the DON and Regional Clinical Manager, confirmed that the updated order from the hospital was overlooked and not transcribed into the facility's orders. The facility's policy required licensed nurses to accurately transcribe and initiate physician orders, but this process was not followed, resulting in the resident not receiving midodrine as intended after hospital discharge.