Incorrect Transcription of Scheduled Respiratory Medication Order
Penalty
Summary
A deficiency occurred when a resident's physician-ordered medication for Ipratropium-Albuterol, intended to be administered by nebulization every 6 hours on a scheduled basis, was incorrectly transcribed into the facility's Electronic Medication Administration Record (EMAR) as an as-needed (PRN) medication rather than as a scheduled dose. This error was identified during a review of the resident's medical and hospital discharge records, which showed that all other medications were transcribed correctly except for this respiratory treatment. The resident had diagnoses including influenza, chronic pain, acute and chronic respiratory failure with hypoxia, and heart failure, making accurate respiratory medication administration critical. The Director of Nursing (DON) confirmed in an interview that the breathing treatment order was not entered into the EMAR as prescribed by the physician. The facility's new admission check-off list was completed two days after the resident's admission, at which point the transcription error was discovered. The resident also brought the issue to the DON's attention, and the error was subsequently corrected. However, the resident left the facility against medical advice shortly after. Facility policy requires that medications be administered as prescribed and in accordance with good nursing practices, which was not followed in this instance.