Medication Error: Omission of Prescribed Amiodarone Following Hospital Discharge
Penalty
Summary
The facility failed to ensure that a resident was free from medication errors by not administering a prescribed medication as ordered upon the resident's return from hospitalization. Specifically, the resident, who had multiple diagnoses including Paroxysmal Atrial Fibrillation, heart failure, and psychiatric disorders, was discharged from the hospital with an updated medication list that included Amiodarone HCL 400mg to be taken every morning. Upon review of the resident's medical record, physician orders, and MAR for June 2025, it was found that Amiodarone was not initiated after the resident's re-entry to the facility. Interviews with the nurse practitioner and the Director of Nursing confirmed that the medication was overlooked and not administered as directed in the hospital discharge paperwork. The resident, who had moderately impaired cognition and required substantial assistance with activities of daily living, did not receive the medication as ordered, constituting a medication error. There were no reported adverse reactions related to this omission at the time of the survey.