Failure to Update and Upload Hospital Discharge Orders in EMR
Penalty
Summary
The facility failed to ensure that a resident's medical record was updated with necessary and accurate hospital discharge orders. Upon admission, the resident had been receiving intravenous (IV) antibiotics for a severe infection, with hospital discharge orders specifying that the antibiotics should continue for four weeks post-discharge. However, the facility discontinued the antibiotics earlier than ordered and did not restart them until ten days later, after the nurse practitioner identified the error and re-ordered the medication. Interviews revealed that the admitting LPN received incomplete discharge orders and had to request updated orders, which were subsequently emailed to him. Although these updated orders were used for the resident's admission and reviewed with the nurse practitioner, they were not uploaded into the electronic medical record (EMR). The EMR only contained the original, outdated discharge orders, and the updated orders were not available for review by the state agency. The Director of Nursing confirmed that the updated orders should have been uploaded but were not.