Failure to Timely and Accurately Administer Admission Medications and Treatments
Penalty
Summary
The facility failed to ensure that admission orders for medications and treatments were entered timely and accurately for two residents. For one resident with diagnoses including anxiety disorder and a right upper humerus fracture, the clinical record showed that several prescribed medications were not administered as ordered upon admission. Specifically, aspirin was initially given at the wrong frequency, clonazepam was not administered at all, and both paroxetine and lorazepam were not started until several days after admission. The resident reported difficulty obtaining medications over the weekend, resulting in missed doses of several prescribed drugs. Another resident, admitted with multiple complex medical needs including bowel perforations, intra-abdominal abscess, candidemia, and requiring total parenteral nutrition (TPN) and IV antibiotics, also experienced delays and omissions in medication administration. The hospital discharge instructions included a comprehensive list of medications and treatments, but upon admission, some orders such as IV antibiotics and TPN were not entered or transmitted to the pharmacy in a timely manner. The resident and her family reported that medications and treatments were not provided as expected, and the resident experienced pain and vomiting while waiting for her medications. Interviews with nursing staff revealed that there were issues with the admission process, including missing pages from the hospital medication list, confusion about which medications needed to be entered, and errors in how orders were entered into the system, resulting in some orders not being sent to the pharmacy. The facility's policy required nurses to execute physician orders or ensure a safe hand-off, but this was not consistently followed, leading to delays and omissions in medication and treatment administration for both residents.