Failure to Enter and Implement Admission Medication Orders on Re-Admission
Penalty
Summary
A deficiency occurred when a resident was re-admitted to the facility and their admission medication orders were not entered into the electronic medical record or implemented until two days after their return. The facility's policy requires that admission or readmission orders from a licensed provider be entered into the electronic system upon a resident's arrival, but this process was not followed. As a result, the resident did not receive any prescribed medications during this period. The resident in question had a medical history including schizophrenia, anxiety disorder, and hypertension, and was discharged from the hospital with a comprehensive list of medications. Upon re-admission, the resident reported not receiving any medications after arrival at the facility, despite having received their morning medications at the hospital. Nursing staff confirmed that no medication orders were present in the electronic system, and the resident's name did not appear in the electronic medication administration record (EMAR), preventing medication administration. Interviews with facility staff revealed a breakdown in communication and process. The unit manager assumed that batch orders in the system were complete, but these did not include the resident's hospital discharge medications. The on-call provider was not notified to review or sign admission orders, and the Director of Nursing confirmed that the responsibility for entering orders was not fulfilled. As a result, the resident did not receive any medications until the orders were finally entered and signed two days after re-admission.