Failure to Administer Scheduled Admission Medications Due to EMR Entry Error
Penalty
Summary
A deficiency occurred when a newly admitted resident with diagnoses including type 2 diabetes mellitus with chronic foot ulcer and atrial fibrillation did not receive scheduled evening doses of Lantus insulin and Apixaban on the day of admission. The nurse responsible for transcribing the admission orders entered the medications into the electronic medical record (EMR) but did not adjust the automatically generated start date and time, resulting in the medications being scheduled to begin the following morning. The nurse did not check the Pyxis system to verify if the medications were available for administration that evening, nor did she review whether any medications were due that night. As a result, the resident did not receive the prescribed 8:00 PM and 9:00 PM doses on the day of admission, despite the medications being available in the Pyxis system. The direct care nurse for the evening shift was unaware that the resident had scheduled medications due that night, as the EMR reflected a start date of the following day. The Director of Nursing confirmed that the transcribing nurse should have verified the start date and time for the medications and ensured administration per physician orders. The physician interviewed stated that medications should be administered on the date of admission if scheduled, and although there was potential for negative outcomes, none were documented as a result of the missed doses.