Failure to Transcribe and Administer Discharge Medication Orders
Penalty
Summary
A deficiency occurred when the facility failed to correctly transcribe and administer discharge medication orders for one resident following admission and readmission from the hospital. The resident, who had diagnoses including osteomyelitis of the thoracic vertebra, chronic systolic heart failure, and chronic obstructive pulmonary disease, was admitted with a complex medication regimen that included antidepressants, anticoagulants, opioids, antibiotics, and other medications. Hospital discharge records specified which medications to continue, hold, or discontinue, but these orders were not fully or accurately entered into the facility's electronic medication administration record (eMAR). The error was discovered after the resident's family raised concerns about a missing medication, specifically Furosemide (Lasix), which was not being administered as ordered. Interviews with facility staff revealed that the standard process involved two nurses reviewing discharge orders and an auditing nurse conducting a follow-up review. However, during the resident's admission, the auditing nurse was on vacation, and the review process was not completed as intended. As a result, the resident did not receive all prescribed medications, and the omission was not identified until brought to staff attention by the resident's family. Staff interviews confirmed that the hospital discharge medications were not entered into the system, and the nurse practitioner only became aware of the missing medication after being notified by the resident's son. The facility's established check and balance system for medication order transcription failed due to the absence of the auditing nurse, and the responsibility for reviewing admissions was not reassigned, leading to the medication error.