Failure to Accurately Implement Hospital Discharge Medication Orders
Summary
A deficiency occurred when a resident with bipolar disorder did not receive the correct dose of Lithium as specified in the hospital discharge instructions upon admission. The resident exhibited significant behavioral disturbances, including confusion, agitation, aggression, and disrupted sleep, which were documented by staff over several days. Despite these ongoing behaviors, there was no change to the resident's Lithium order, even after a pharmacy recommendation highlighted a discrepancy between the hospital discharge instructions and the medication being administered. The physician reviewed the resident and her medications but did not note the behavioral issues or adjust the Lithium dosage. Interviews with facility staff revealed that the process for entering and verifying admission orders involved both floor nurses and unit managers, with a second check for accuracy. However, the error in the Lithium order was not identified or corrected by nursing, the unit managers, or pharmacy. The DON acknowledged the mistake and stated that the orders should have been entered accurately, but no justification was provided for the failure to implement the correct Lithium order. The facility's policy on medication reconciliation requires careful review and resolution of discrepancies, but this process was not effectively followed in this case.
Penalty
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