Significant Medication Errors Due to Improper Discontinuation and Lack of Documentation
Penalty
Summary
A resident was discharged from the hospital with orders for Metoprolol Succinate, Midodrine, and Novolog insulin, which were to be administered according to specific schedules. The resident's Medication Administration Record showed that these medications were discontinued after the morning dose on 7/23/25 and were not given again prior to the resident's subsequent hospitalization on the evening of 7/24/25. There was no documentation in the medical record explaining why the medications were stopped or indicating that the physician was notified about the missed doses. The Assistant Director of Nursing stated that they mistakenly believed the resident was still hospitalized and used a batch order to discontinue the medications, later attempting to resume them, but not all orders were restored due to the timing of the batch process. This resulted in missed doses of significant medications, which were acknowledged as medication errors.