Incorrect Medication Order Entry and Incomplete Medical Record Documentation
Penalty
Summary
A deficiency was identified when a resident's medication order was incorrectly entered into the medical record. The resident, who had a complex medical history including type 1 diabetes mellitus, generalized anxiety disorder, chronic kidney disease stage 3, traumatic amputation of toes, bipolar disorder, and suicidal ideations, was admitted and readmitted to the facility. During a review of the resident's records, it was found that a physician's order for Hydroxyurea 25 mg by mouth every 12 hours as needed for anti-anxiety was documented, despite no diagnosis of sickle cell disease being present in the resident's record. Additionally, a nursing progress note indicated a verbal order to restart hydroxyzine 25 mg by mouth twice a day and as needed, but there was no active order for hydroxyzine in the medical record. Upon observation, hydroxyzine 25 mg was found in the medication cart for the resident, while hydroxyurea was not present. Interviews with an LPN revealed that medication orders were supposed to be double-checked and verified against the medication card, and the DON confirmed that nurses were expected to verify the correct medication was entered into the medical record. The incorrect entry of the medication order resulted in incomplete and inaccurate documentation in the resident's medical record.