Failure to Reconcile Medications on Readmission Leads to Significant Errors
Penalty
Summary
A deficiency occurred when a resident was readmitted to the facility and their medications were not accurately reconciled, resulting in multiple significant medication errors. The facility's policies required medication reconciliation upon admission and readmission, to be completed by two nurses and verified by nursing management. However, upon the resident's readmission, there was no documentation that a Medication Reconciliation Form was completed, nor evidence that nursing staff clarified or obtained new physician orders for the resident's medications. As a result, discrepancies arose between the hospital discharge summary and the facility's physician orders, particularly regarding the administration and discontinuation of Eliquis, Buspar, and Gabapentin. The resident, who had a history of subarachnoid hemorrhage, bilateral femoral DVTs, and an IVC filter, experienced missed doses and incorrect administration of critical medications. Eliquis was not administered for 48 days due to lack of order clarification, Buspar was given at an incorrect frequency before being increased, and Gabapentin was omitted entirely for 83 days. Interviews with nursing staff and management revealed a lack of awareness regarding the missed reconciliation, and the required documentation could not be located. The failure to follow established medication reconciliation procedures directly led to these significant medication errors.