Failure to Accurately Review and Reconcile Hospital Discharge Medications
Penalty
Summary
The facility failed to ensure an accurate pharmacy medication regimen review for a resident who was re-admitted following a hospital stay. Upon review of the resident's medical records, it was found that the hospital discharge summary included two essential anti-rejection medications, Sirolimus and Tacrolimus, which were not identified during the pharmacy's new admission medication review. The omission was discovered during a review of the resident's records and confirmed by the Director of Nursing, who stated that the pharmacy is responsible for reconciling the hospital discharge medication list upon admission. The deficiency was specifically related to the pharmacy's failure to recognize and include the two anti-rejection medications listed on the hospital discharge summary in the resident's medication regimen review. This oversight was evident in the documentation and was acknowledged by facility leadership during interviews. The resident's medical history included the need for immunosuppressant therapy following an organ transplant, making the accurate review and reconciliation of these medications critical at the time of re-admission.