Incomplete and Inaccurate Medical Record Due to Medication Order Error
Penalty
Summary
The facility failed to ensure the completeness and accuracy of a resident's medical record in two significant ways. First, a physician electronically signed a medication order for Methotrexate to be administered twice daily, rather than the correct frequency of once weekly as indicated in the hospital discharge summary. The physician stated that he reviewed the discharge summary and intended to continue all listed medications, but due to the high volume of electronic orders received, he did not identify the transcription error made by nursing staff when entering the order. As a result, the incorrect order was signed and became part of the resident's medical record. Additionally, a nurse practitioner documented in progress notes that all of the resident's medications were reviewed at each visit, including the erroneous Methotrexate order. However, the nurse practitioner later stated that only medications pertinent to the visit were actually reviewed, and that he was not familiar enough with Methotrexate's recommended administration frequency to question the order as written. The medical director and director of nursing both confirmed their expectations that providers should identify such errors and that all medical record entries must be complete and accurate. The resident involved had diagnoses of Antiphospholipid Syndrome and CREST syndrome at the time of the incident.