Failure to Reconcile Medication Orders and Monitor Lab Values After Hospital Readmission
Penalty
Summary
The facility failed to ensure that a resident's medical care was properly supervised by a physician, specifically regarding the reconciliation of medication orders for Aranesp, a drug used to treat anemia in chronic kidney disease. Upon the resident's readmission following a hospitalization, there was a discrepancy between the hospital discharge order for Aranesp (25 mcg every 7 days) and the existing facility order (40 mcg every 28 days). The facility's records did not show evidence that nursing staff or providers reconciled these differing orders upon the resident's return. Both the physician and nurse practitioner documented that medications were reviewed and reconciled, but neither addressed the specific change in the Aranesp order from the hospital discharge summary. A pharmacy consultation also identified the discrepancy and requested clarification, but the issue was not promptly resolved. Additionally, there was no physician order in place to obtain weekly hemoglobin values to determine whether Aranesp should be administered or held, as required by the medication parameters. Interviews with the nurse practitioner and physician revealed that they were unaware the hospital discharge order had not been transcribed and that no order for routine hemoglobin monitoring was in place. The Director of Nursing Services confirmed that it was her expectation that both the medication order and the monitoring order should have been reconciled and implemented upon the resident's readmission.