Failure to Accurately Implement Discharge Medication Orders
Penalty
Summary
The facility failed to accurately implement discharge medication orders for a resident who was admitted with diagnoses including hypertension, diabetes mellitus, and adult failure to thrive, and who was assessed to have impaired cognition. Hospital discharge instructions specified that the resident should continue taking one half of a 25 mg metoprolol tablet (12.5 mg) twice daily. However, upon admission, the physician's order was transcribed incorrectly, resulting in the resident receiving one whole 25 mg tablet twice daily. Review of records confirmed this discrepancy, and staff interview with the DON verified that the hospital's instructions were not followed as written. There was no documentation of adverse effects from the medication error.