Failure to Accurately Transcribe Hospital Discharge Medication Order
Penalty
Summary
Facility staff failed to accurately transcribe a medication order for Omeprazole for one resident following hospital discharge. The resident, who was assessed as cognitively intact and had diagnoses including heart failure, hypertension, and GERD, was discharged from the hospital with an order for Omeprazole 40 mg capsule to be taken once daily. However, upon review of the Physician's Order Sheet and Medication Administration Record, the order was incorrectly transcribed as 'give 40 capsules by mouth one time a day,' rather than the intended single capsule daily. Interviews with facility staff revealed that the Assistant Director of Nursing (ADON) and Director of Nursing (DON) were responsible for reviewing and entering hospital discharge medication orders, but there was no double-checking process between them. The ADON acknowledged responsibility for ensuring accurate transcription and recognized that errors in this process could lead to incorrect medication administration. The DON stated that staff are expected to follow physician orders and clarify any discrepancies, but in this instance, the error was not identified or corrected prior to being entered into the resident's records.