Failure to Reconcile and Implement Admission Physician Orders
Penalty
Summary
The facility failed to accurately reconcile and implement physician's orders for a resident upon admission, specifically regarding the administration of Lithium for bipolar disorder. The hospital discharge summary provided clear instructions to continue both a 300 mg morning dose and a 600 mg evening dose of Lithium, but the facility only ordered and administered a 300 mg extended release dose at bedtime. There was no order for the required 300 mg morning dose, and the resident did not receive the evening dose on the day of admission due to the medication not being available. The hospital discharge instructions also did not specify the use of an extended release formulation, yet this was what was ordered and given by the facility. As a result of these discrepancies, the resident exhibited increased psychiatric symptoms during their stay, including agitation, throwing objects, combativeness, yelling, and difficulty cooperating with care. The resident's medical history included bipolar disorder and a recent psychiatric hospitalization where a new medication regimen was initiated. The facility's failure to follow the hospital's discharge orders led to the resident not receiving the prescribed medication regimen, which coincided with the onset of behavioral disturbances and other symptoms such as slurred speech and difficulty swallowing.