Failure to Clarify Medication Orders for Hospice Resident
Penalty
Summary
A resident with multiple complex medical conditions, including heart failure, diabetes, hypertension, repeated falls, hallucinations, and severe cognitive impairment, was admitted to the facility for a hospice respite stay following a fall at home. Upon admission, there were two separate medication lists for the resident: one from the local hospital emergency room and another from the hospice provider. The facility did not document any communication with the hospice provider to clarify which medication list should be followed during the resident's stay. As a result, the resident received several medications that were not included on the hospice provider's medication list, such as atorvastatin, carvedilol, cholestyramine aspartame, and potassium chloride. These medications were administered over multiple days during the resident's stay, despite the hospice provider's list specifying a different regimen. The facility's Director of Nursing and staff did not contact the physician or hospice provider to resolve the discrepancy between the hospital and hospice medication lists. Interviews with facility staff and the hospice nurse confirmed that the facility should have clarified the appropriate medication regimen, especially since the resident was under hospice care. The facility's own policy required coordination with hospice providers regarding medication information, but this protocol was not followed, leading to the administration of unnecessary medications.