Failure to Administer Hospital-Ordered Medications Upon Readmission
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident who was re-admitted from the hospital after treatment for bacterial pneumonia. Upon re-admission, the resident's hospital discharge medication list included several new and changed medications, such as bronchodilators, diuretics, antipsychotics, cardiac medications, anticonvulsants, supplements, and other treatments. These medications were not added to the resident's physician orders in the facility, and none of them were administered as ordered during the resident's stay following re-admission. Documentation shows that the resident was re-admitted to the facility with specific medication orders from the hospital, but these were not implemented. The Director of Nursing confirmed that the medications listed on the hospital discharge papers were not given to the resident from the time of re-admission until the resident was transferred back to the hospital due to respiratory concerns. The failure to follow physician orders for medication administration was identified through record review and staff interview.