Failure to Ensure Accurate Medication Reconciliation and Administration on Admission
Penalty
Summary
A resident with a history of type 2 diabetes mellitus, hypertension, and other significant medical conditions was admitted to the facility with clear hospital discharge instructions that included multiple medications, notably sliding scale insulin and long-acting insulin glargine. Upon admission, the resident was confused and unable to communicate her medication needs. Despite the hospital records and the resident representative informing staff about the insulin requirement, the facility failed to enter the correct medication orders into the resident's medical record. Instead, several medications not listed on the hospital discharge summary were ordered and administered, while critical medications, including insulin, were omitted. The medication reconciliation process was not properly completed or documented. The admitting LPN and another assisting LPN did not ensure that the hospital discharge medication list was accurately transcribed or reconciled with a provider before entering orders into the system. There was no evidence that the provider reviewed or clarified the orders, and the required chart checks by night shift staff were not documented. As a result, the resident did not receive insulin or have blood glucose monitoring performed for several days, despite having abnormal lab results and elevated blood glucose levels documented in the record. Providers were not consistently notified of these abnormal findings, and the resident's condition deteriorated, leading to hospitalization for severe hyperglycemia. Interviews with facility staff, including nurses, the DON, ADON, and the medical director, confirmed that the medication lists did not match and that the expected process for medication reconciliation and provider review was not followed. The consultant pharmacist also confirmed that the facility is responsible for entering medication orders correctly and that she was not aware of the full extent of the medication errors. The resident's health declined during her stay, with documented confusion, lethargy, and ultimately a critical episode of hyperglycemia requiring emergency intervention.