Failure to Accurately Transcribe and Administer Medications After Hospital Readmission
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not correctly transcribing medication changes for a resident who was readmitted after a hospital stay. Upon the resident's return, the admitting nurse was responsible for entering the new medication orders into the electronic medical record (EMR) and ensuring they matched the hospital discharge instructions. However, the review of records showed discrepancies between the hospital discharge orders and the facility's active physician orders and medication administration records (MAR). Specifically, the dosages and administration frequencies for medications such as Bisacodyl, Buspirone, and Hydroxyzine were not accurately transcribed, resulting in the resident receiving incorrect medication regimens for an extended period. The resident involved had a history of chronic obstructive pulmonary disease with acute exacerbation, respiratory failure with hypoxia, constipation, pain, insomnia, and anxiety disorder. The resident was cognitively intact and able to communicate concerns about the medication regimen, reporting that the volume and timing of medications made him excessively sleepy and affected his ability to function. The MAR indicated that medications were administered as transcribed by the facility, not as ordered by the hospital, and there was no documentation of changes to the medication regimen following the resident's readmission. Interviews with staff revealed gaps in communication and process adherence. The admitting nurse who transcribed the orders was no longer employed at the facility, and the ADON described issues with providing an updated medication list to the hospital due to a malfunctioning fax machine. The hospital pharmacist reported recurring problems with obtaining accurate and current medication lists from the facility, leading to delays and potential complications in patient care. Facility policies required clarification and accurate transcription of new medication orders, but these procedures were not followed in this instance.