Failure to Accurately Reconcile and Administer Medications Upon Admission
Penalty
Summary
Nursing staff failed to accurately reconcile and administer medications for a resident admitted for a five-day hospice respite stay with diagnoses including COPD, CHF, and dementia. Upon admission, the facility received two different medication lists from hospice, one of which was outdated and included a discontinued medication. The Unit Manager used the original, outdated list to reconcile medications with the physician, resulting in the transcription of incorrect medication orders. Specifically, risperidone was ordered and administered in the morning instead of the evening as per the current hospice medication list, and a scopolamine transdermal patch was administered despite its discontinuation prior to admission. Interviews with facility staff revealed a lack of clarity regarding which medication list was used for reconciliation and a failure to verify the most current orders. The Director of Nursing was unaware of the errors and the existence of two medication lists in the resident's record. The facility's policy required accurate reconciliation of all medications, including dose, route, and frequency, with the physician upon admission, but this was not followed, resulting in the administration of medications at incorrect times and the use of a discontinued medication.