Failure to Reconcile and Administer Discharge Medications for Transplant Patient
Penalty
Summary
The facility failed to ensure that all medications listed on a hospital discharge summary were ordered and administered for a resident with a history of organ transplant. Upon review of facility-reported incidents and the resident's medical records, it was found that two essential anti-rejection medications, Sirolimus and Tacrolimus, were not ordered or given as prescribed following the resident's admission from the hospital. The omission was discovered after a discussion with the resident's cardiologist, who identified low therapeutic drug levels, indicating the resident had not received the necessary anti-rejection medications. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for medication reconciliation. The Certified Registered Nurse Practitioner (CRNP) stated that she reviews hospital discharge summaries but does not change or stop medications, and believed that the admitting nurse was responsible for reconciling medications. The Director of Nursing confirmed that while the admitting nurse enters medication orders, the provider is expected to reconcile the medication list. This lack of clear accountability led to the failure to order and administer critical medications as required.