Failure to Transcribe and Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure that physician orders for medications were correctly transcribed and administered to two residents upon admission, resulting in significant medication errors. One resident, with diagnoses including HIV, COPD, osteoporosis, and multiple fractures, did not receive the prescribed HIV medication, Biktarvy, for 13 days during their stay. Documentation in the Medication Administration Record (MAR) and nurses' notes repeatedly indicated that the medication was 'waiting on delivery' or 'on order,' but the medication was never provided. The pharmacy had attempted to obtain payment approval from the facility due to the high cost of the medication, but did not receive a response from the facility's administrative nursing staff, despite multiple emails and assurances that a response would be given. Social services staff had been informed by the discharging hospital that a grant would cover the medication, and this information was shared with the facility's administrative nurses, but no further action was taken to secure the medication for the resident. A second resident, admitted with diagnoses including protein-calorie malnutrition, diabetes mellitus, atrial fibrillation, and cerebral infarction, did not receive the prescribed diabetes medication, Mounjaro, for four weeks. The hospital discharge orders included Mounjaro, but the medication was not transcribed into the facility's Medication Administration Record (MAR) or electronic medical record (EMR), and there was no documentation that the order had been discontinued. The pharmacy consultant confirmed that the medication list sent by the facility did not include Mounjaro, and nursing staff verified that the physician's order for Mounjaro had not been discontinued and should have been continued at the facility. The facility's own medication administration policy required that medications be administered in accordance with written physician orders and that all administration, refusals, or holds be documented in the MAR. In both cases, the failure to correctly transcribe and follow through on physician orders led to residents not receiving essential medications as prescribed, with documentation and interviews confirming the lapses in communication and follow-through among facility staff and between the facility and the pharmacy.