Failure to Transcribe and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that hospital discharge medication orders were fully transcribed and administered as ordered for one resident, and failed to administer medications as ordered for another resident. In the first case, a resident admitted with diagnoses including volvulus, heart failure, and chronic kidney disease had a hospital discharge summary listing several medications, including Lasix and Colace. Upon review, it was found that while most medications were ordered by the facility, Lasix and Colace were not ordered at admission as required. The Director of Nursing (DON) confirmed that these medications should have been ordered and that the facility's process involves initialing orders and having them checked by the DON or assistant DON. In the second case, a resident with diabetes, hypertension, and mobility issues had a physician's order for Lortab to be given every six hours for pain. The medication administration record (MAR) showed that several doses were held, some without documented reasons, even when the resident reported significant pain. Staff interviews revealed that medications were sometimes held due to unavailability or other undocumented reasons, and there was no evidence of communication with the pharmacy or physician regarding the missed doses. The DON stated that staff should notify the physician if medications are held for reasons not specified in the orders.