Failure to Prevent Significant Medication Errors Due to Delayed Order Clarification and Pharmacy Delivery
Penalty
Summary
The facility failed to prevent significant medication errors for a resident admitted after a hospital stay for atrial flutter and electro-cardioversion. Upon admission, the resident's hospital discharge medication orders for Fosinopril, Metoprolol Succinate, and Mirtazapine were incomplete, lacking clear instructions for dosage, route, or administration times. The facility did not promptly clarify these orders with the prescribing providers, resulting in delays in obtaining and administering the medications. Communication between facility nurses and providers was delayed, with significant gaps in response times documented in the electronic messaging system. As a result of these delays, the resident missed multiple doses of critical medications, including six doses of Fosinopril, one dose of Metoprolol Succinate, and three doses of Mirtazapine. The Medication Administration Record (MAR) and pharmacy delivery records confirmed that these medications were not available or not administered as ordered during the initial days following admission. The errors were attributed to incomplete hospital discharge orders, delayed clarification by facility staff and providers, and delays in pharmacy delivery, including the lack of use of backup pharmacy services. Interviews with facility staff, including the DON, Nurse Practitioner, and Corporate Nurse Consultant, confirmed the sequence of events and acknowledged the significance of the medication errors. The family member of the resident also expressed concerns about the lack of timely medication administration. The facility's own Medication Error Report documented the delay in starting the medications and the contributing factors, with staff acknowledging that the errors were significant.