Failure to Reconcile and Administer Critical Medications on Admission
Penalty
Summary
A resident with a history of type 2 diabetes, hypertension, and cognitive impairment was admitted to the facility with a detailed hospital discharge medication list, including multiple critical medications such as insulin. Upon admission, the facility failed to accurately reconcile and transcribe the resident's medications. Several essential medications from the hospital discharge list, including insulin, were not entered into the facility's physician orders or administered. Instead, the resident received medications not listed on the hospital discharge summary, and some medications were given at incorrect dosages. The admitting nurse and another LPN were involved in entering the orders, but there was confusion and lack of clarity regarding the process, and the provider was not properly consulted to verify the medication reconciliation. Throughout the resident's stay, there was a lack of monitoring and response to abnormal clinical findings. The resident experienced multiple episodes of significantly elevated blood pressure and abnormal laboratory results, including extremely high blood glucose levels. Despite these findings, there was no documentation that the provider was notified of the abnormal results on several occasions, and the resident did not receive insulin or other diabetes medications as ordered by the hospital. Blood glucose checks were not performed until the resident's condition deteriorated significantly, at which point a critically high blood sugar was detected, and the resident was transferred to the hospital. Interviews with staff revealed that the medication reconciliation process was not properly followed, and there was no documentation that the provider reviewed or clarified the orders before they were entered. The facility's admission checklist lacked a mechanism for verification or sign-off, and staff could not produce completed checklists for the resident. The resident's representative and staff confirmed that the resident was unable to advocate for herself due to confusion, and her condition worsened during her stay, culminating in a hospital transfer for severe hyperglycemia and other complications.