Failure to Administer Ordered Medication Following Readmission
Penalty
Summary
A deficiency occurred when a resident did not receive furosemide (Lasix) as ordered by their physician for a period of 12 days following readmission from the hospital. The resident, an older adult with a history of cellulitis, hypertension, and post-surgical infection, was supposed to receive 40mg of furosemide daily. Hospital discharge paperwork included this medication, but it was not entered into the facility's medication administration system upon the resident's return. The lapse was identified when the resident attended a wound care appointment, and the clinic noted the absence of Lasix on the medication list. Review of the medication administration record confirmed that the resident did not receive the ordered furosemide between the dates in question. Interviews with staff revealed that the nurse responsible for entering the orders may have checked off the medication without actually inputting it, possibly due to distraction, and was unsure if a second nurse had verified the orders as required by facility protocol. Throughout the period when the medication was missed, progress notes and staff interviews indicated that the resident remained stable, with no significant changes in condition or complaints. Mild edema was noted, but this was consistent with the resident's baseline and did not worsen. The deficiency was attributed to a failure in the medication reconciliation and verification process during the resident's readmission.