Failure to Accurately Transcribe Medication Orders and Notify Provider of Elevated Blood Glucose
Penalty
Summary
The facility failed to accurately transcribe and administer a prednisone taper as ordered for a resident who was readmitted following a hospital stay. The hospital discharge summary specified a tapering schedule for prednisone, but the orders entered into the electronic medical record (EMR) did not match the hospital's instructions. The medication administration record (MAR) showed inconsistencies in the dosage and administration dates, with some doses marked as refused and others not aligning with the prescribed taper. The resident reported receiving incorrect doses and missing doses on certain days. Additionally, the facility did not notify the provider of elevated blood glucose levels for the same resident, who had a diagnosis of diabetes mellitus. The resident's care plan included blood sugar monitoring as ordered by the physician, but the initial orders lacked specific parameters for when to notify the provider. Blood glucose readings over 400 mg/dL were recorded on two occasions, but there was no documentation that the provider was notified or that additional insulin or rechecks were performed. Staff interviews revealed uncertainty about notification protocols in the absence of explicit parameters, and the Director of Nursing confirmed that there was no evidence of provider notification for the elevated readings. The resident was cognitively intact and able to report her experiences, stating that staff did not respond to her high blood glucose readings and that she did not receive the correct prednisone taper. The facility's policies required medications to be administered as prescribed and for providers to be updated as needed, but these protocols were not followed in this case, resulting in the deficiencies identified.