Failure to Administer Prescribed Anti-Rejection Medications After Admission
Penalty
Summary
A deficiency occurred when a resident with a history of organ transplant did not receive prescribed anti-rejection medications, specifically Sirolimus and Tacrolimus, following admission from a hospital. The resident's hospital discharge summary included these medications, but a review of the facility's physician orders and Medication Administration Record (MAR) for the relevant period showed no orders or administration of these drugs. The omission was discovered after the resident's cardiologist, during a routine appointment, noted low therapeutic drug levels and requested a review of the resident's active medication list, revealing the absence of the necessary anti-rejection medications. Interviews and record reviews indicated that the failure to administer these medications resulted from multiple system failures during the admission process. The admitting nurse did not enter orders for the anti-rejection medications as listed on the discharge summary, and the pharmacy's medication regimen review also failed to identify the omission. Additionally, when the cardiologist requested lab troughs for the medications, staff did not question the absence of active orders for these drugs. These oversights led to the resident not receiving essential immunosuppressive therapy for an extended period.