Failure to Accurately Transcribe and Administer Medications After Hospital Discharge
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident following discharge from the hospital. Upon the resident's return, staff did not properly transcribe or clarify new medication orders, resulting in discrepancies between the hospital discharge instructions and the medications entered into the facility's electronic health record (EHR). Several medications ordered at discharge, including fluphenazine, Seroquel, ketoconazole, clotrimazole, and Miralax, were not added to the physician's order sheet, and there were inconsistencies in the dosages and administration instructions for other medications such as gabapentin and oxybutynin. Additionally, staff failed to document administration or reasons for omission of multiple medications on the Medication Administration Record (MAR) for the day of the resident's return. The resident involved had a complex psychiatric and medical history, including schizoaffective disorder, bipolar type, PTSD, depression, and a history of suicidal ideation. The care plan required close monitoring, administration of psychotropic medications as ordered, and assessment for side effects. Despite these needs, the facility did not ensure that the resident's medication regimen was accurately reconciled or administered as prescribed after the hospital stay. Interviews with staff revealed confusion about the process for entering and verifying new medication orders, with several staff members unsure of their responsibilities or the accuracy of the orders entered into the EHR. Further, the nurse practitioner and other staff reported that the medication list in the EHR did not match the hospital discharge orders, and it took several days to identify and attempt to correct the discrepancies. During this period, the resident was not receiving all prescribed medications, and staff did not consistently document or clarify missing or incorrect orders. The lack of timely and accurate medication reconciliation and administration directly contravened facility policy and resulted in the resident not receiving necessary pharmaceutical care as ordered.