Failure to Discontinue Medication per Hospital Discharge Orders
Penalty
Summary
A deficiency occurred when the facility failed to follow hospital discharge orders for a resident who had recently returned from the hospital with a diagnosis of acute blood loss anemia. The hospital discharge summary specifically instructed discontinuation of aspirin 81 mg daily, but the Medication Administration Record showed that the resident received aspirin after readmission. The resident, who was cognitively intact, reported being told that all blood thinners would be held for a while following her hospitalization for blood loss. The Director of Health Services confirmed that the resident's previous medication orders were not discontinued in the computer system when she was transferred to the hospital, resulting in all prior orders reappearing on her MAR upon readmission. Although facility policy required an admission checklist and review of new or discontinued orders by two nurses, this process was not followed, leading to the administration of a medication that should have been discontinued. The resident's care plans identified risks related to bleeding and anemia, with interventions to administer medications as ordered, but these were not adhered to in this instance.