Failure to Ensure Nursing Staff Competency in Medication Reconciliation
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to provide proper nursing care for one of three sampled residents. Specifically, a nurse did not review the resident's hospital discharge orders when writing admission orders and did not clarify with the physician whether the resident should continue his home medications. The resident was admitted with multiple diagnoses, including surgical aftercare, diabetes with neuropathy, and other chronic conditions. The hospital discharge orders included instructions to continue home medications, such as Pioglitazone 45 mg daily, but did not list Riluzole 50 mg twice daily. However, the admission orders written by the Assistant Director of Nursing (ADON) specified Pioglitazone 30 mg daily and omitted Riluzole entirely. Record review and interviews revealed that the resident and his family brought all home medications to the facility and specifically informed the admitting nurse about the need to continue Riluzole 50 mg twice daily for one month. The nurse took possession of the medications but did not ensure that Riluzole was included in the admission orders or administered during the resident's stay. The resident only discovered the omission upon discharge, when he noticed the Riluzole bottle was still full. The Director of Nursing (DON) and ADON later stated that the medication was not given because it was not on the hospital discharge orders, and the ADON had based admission orders on faxed information rather than the hand-written discharge orders that accompanied the resident. Further interviews confirmed that the admitting nurse did not recall being told about the need to continue Riluzole and did not review the discharge orders that came with the resident. The DON acknowledged that the ADON should have reviewed all discharge documentation and clarified medication orders with the physician, especially regarding the discrepancy in Pioglitazone dosage and the omission of Riluzole. The failure to review all available discharge information and to clarify medication orders resulted in the resident not receiving prescribed medications as intended.