Failure to Timely Implement Hospital Discharge Medication Orders on Admission
Penalty
Summary
Nursing staff failed to ensure that a newly admitted resident received care in accordance with professional standards by not implementing hospital discharge medication orders in a timely manner. The resident, who had diagnoses including gastroparesis, returned from the hospital with a comprehensive list of prescribed medications for various conditions such as nausea, vomiting, pain, and heartburn. Upon admission, the responsible LPN entered the medication orders into the computer system but did not complete the process required to transmit these orders to the pharmacy, as a second nurse was expected to confirm and activate the orders. As a result, the pharmacy did not receive the medication orders on the day of admission. The delay in confirming and activating the medication orders led to the resident missing multiple scheduled doses of essential medications, including those for nausea, pain, and other chronic conditions. The resident reported not receiving her prescribed medications for nausea and vomiting, which resulted in her being readmitted to the hospital two days after her initial return to the facility. Documentation confirmed that several doses of medications were missed during this period, as the pharmacy only received the orders the following morning after another nurse discovered the oversight and activated the orders. Interviews with nursing staff and pharmacy personnel revealed that the facility's process required a double-check and activation of new medication orders before they could be sent to the pharmacy. However, this step was not completed by the night shift nurse, leading to a significant delay in medication administration. The resident's care was compromised due to the failure to follow established procedures for timely medication order processing and administration upon admission.