Failure to Administer Critical Antirejection Medications Post-Transplant
Penalty
Summary
A significant medication error occurred when a resident, recently admitted following a kidney transplant, did not receive critical antirejection and immunosuppressive medications as ordered. The resident was discharged from the hospital with a supply of essential medications, including Tacrolimus, Myfortic, Prednisone, Valganciclovir, and Bactrim, and had a therapeutic level of antirejection medication at the time of discharge. Upon admission, the facility failed to document the presence of these medications, and the care plan did not address the need for post-transplant antirejection therapy. Facility staff did not administer the ordered medications on multiple occasions, citing that they were waiting for the pharmacy to deliver them. Medication Administration Records (MAR) and medication card observations confirmed that several doses were missed, and staff documented the absence of medication as the reason. Interviews with staff, including the DON, CMT, and LPNs, revealed a lack of knowledge regarding the process for reconciling and ordering medications upon admission, as well as uncertainty about who was responsible for ensuring timely medication availability. Staff also reported that the DON was informed about the missing medications, but no action was taken to resolve the issue or notify the attending physician. The resident was subsequently readmitted to the hospital with sepsis and a near-undetectable level of antirejection medication, as confirmed by laboratory results and the transplant team. Hospital and transplant staff confirmed that the resident had received all necessary medications prior to discharge and that missing even a single dose could result in serious harm. The facility's failure to ensure the resident received prescribed antirejection medications led to a significant medication error and placed the resident at risk for organ rejection and severe illness.