Failure to Reconcile and Transcribe Physician Orders After Resident's Consultation
Penalty
Summary
The facility failed to review, reconcile, and transcribe physician orders for a resident who returned from consulting physician appointments. The resident, who had diagnoses including neurofibromatosis, elevated blood pressure, and pain, was alert and oriented at the time of the incident. After a hospital discharge, the resident's medication orders were correctly reconciled and transcribed onto the Medication Administration Record (MAR). However, subsequent consultation forms from the resident's oncologist, which included changes to the medication regimen, were not reviewed, reconciled, or transcribed onto the MAR for several weeks. This included changes to the dosing and frequency of Gabapentin and Dexamethasone, as well as the addition of a Lidoderm patch. Interviews with facility staff revealed that the process for handling new orders after outside appointments involved review and reconciliation by an Advanced Practice Registered Nurse, followed by transcription into the electronic health record by a supervisor, charge nurse, or unit manager. Despite this process, the orders from the consulting physician were not entered into the MAR, and staff did not follow up to obtain or verify the new orders. The Director of Nursing was unaware of the missed orders until notified by the hospital, and could not explain why the required follow-up did not occur. The facility's policy required orders from outside providers to be transcribed by licensed staff, but this was not followed in this instance.