Failure to Complete Timely Admission Orders and Assessments Resulting in Missed Medications
Penalty
Summary
The facility failed to ensure timely admission orders and nursing assessments for two residents upon admission, resulting in missed medication administration. For one resident with diagnoses including Type 2 Diabetes and Congestive Heart Failure, the hospital discharge orders listed multiple medications to be administered upon admission. However, only two medications were transcribed into the facility's physician order summary, and the resident did not receive any medications during their stay. Additionally, there was no nursing assessment completed at the time of admission for this resident. For another resident admitted in the evening with diagnoses of pneumonia, diabetes, heart disease, and high blood pressure, hospital discharge instructions required administration of night-time medications, including atorvastatin and Lantus insulin. Although these medications were ordered in the facility's system, the start dates were set for the day after admission, resulting in the resident not receiving their scheduled night-time medications on the day of admission. The DON confirmed that the expectation was for nursing staff to complete initial assessments and transcribe medication lists promptly upon admission, which did not occur in these cases.