Missed Medication Hold and Appointment Due to Incomplete Review of Admission Orders
Penalty
Summary
A resident with diagnoses including acute kidney injury, bladder cancer, complicated UTI, and atrial fibrillation was admitted to the facility following a hospital stay. The resident's hospital Discharge Summary included an order to stop clopidogrel (Plavix) on a specific date pending a scheduled urinary stent removal. The After Visit Summary (AVS) also indicated a follow-up appointment for stent removal and other specialist visits. Despite these instructions, the facility continued to administer clopidogrel to the resident from admission through discharge, as documented in the Medication Administration Record (MAR), and did not stop the medication as ordered. The deficiency occurred because the facility failed to accurately review and implement the hospital discharge instructions and AVS. The stent removal appointment and the order to hold clopidogrel were missed during the admission process. Key staff, including the Admissions Director and Director of Nursing, did not see the relevant orders, as some paperwork was only scanned into the medical record without being reviewed in paper form. The oversight was only discovered after the resident's family brought the missed appointment to staff attention.