Failure to Obtain Complete Physician Orders for Medications on Admission
Penalty
Summary
The facility failed to obtain complete and clarified physician orders for medications at the time of admission for a resident with multiple complex diagnoses, including paroxysmal atrial fibrillation, atrial flutter, cardiac murmur, hypertension, Alzheimer's disease, and various vitamin deficiencies. Upon admission from a local hospital following a cardioversion procedure for atrial flutter with rapid ventricular rate, the resident's discharge medication list included Metoprolol Succinate, Mirtazapine, and Fosinopril. However, the orders for these medications were incomplete, lacking essential details such as dosage, route, and time of administration, with instructions simply stating "See instructions" and no further clarification provided. The Director of Nursing confirmed that these medication orders were not clarified upon the resident's admission, acknowledging that this oversight should have been identified during the nurse's confirmation of orders. Facility policy requires that all physician medication orders be complete, including the date, medication name, dosage, route, time of administration, and, if appropriate, the duration of therapy. The policy also mandates that all new orders be promptly communicated to the pharmacy. The failure to clarify and obtain complete medication orders on admission resulted in a deficiency in meeting the immediate care needs of the resident.