Delay in Administration of Physician-Ordered Medications Upon Admission
Penalty
Summary
A newly admitted resident with multiple complex diagnoses, including pulmonary hypertension, muscle wasting, diabetes mellitus with peripheral angiopathy, atrial fibrillation, chronic kidney disease, osteoporosis, and hypothyroidism, did not receive physician-ordered medications for immediate care upon admission. The resident was assessed as having intact mental cognition and was admitted with weakness and a recent fall. The Advanced Registered Nurse Practitioner recommended continuation of current medications and fall risk precautions, and the pharmacist reviewed the medication regimen and made recommendations. However, there were no documented physician orders for several recommended medications, including gabapentin, carvedilol, calcitriol, allopurinol, and sodium bicarbonate, at the time of admission. Nursing progress notes indicated that medications were ordered by telephone on the day of admission, but these orders were not reflected in the resident's medical record or Medication Administration Record (MAR) until the tenth day of the resident's stay. During this period, there was a lack of documentation specifying which medications were unavailable or what new orders were implemented. The resident did not receive the recommended medications until the night before a resident-initiated discharge, despite facility staff stating that medications should be started as soon as possible after admission. Facility leadership was unable to provide an explanation for the delay in medication administration.