Failure to Clarify Medication Orders After Hospital Discharge
Penalty
Summary
A deficiency occurred when nursing staff failed to clarify medication orders for a resident with a history of prostate cancer, atrial fibrillation, and diabetes, who was recently hospitalized for gross hematuria. Upon the resident's return from the emergency department, the After Visit Summary (AVS) instructed that the blood thinner rivaroxaban should be stopped, but the medication remained active in the facility's records. The nurse on duty relied on a nurse-to-nurse report stating there were no medication changes and did not seek clarification, resulting in the resident continuing to receive rivaroxaban for 11 days after the hospital had instructed it to be held. Documentation showed that the resident continued to experience blood in the urine during this period, and the facility's monitoring records reflected ongoing hematuria. Interviews with facility staff, including the RN, DON, and MD, confirmed that the order should have been clarified with the hospital, as the AVS instructions conflicted with the active medication list. The facility's policy required medications to be administered only upon written order from an authorized prescriber, but this was not followed in this instance.