Failure to Accurately Transcribe Physician Orders on Admission
Penalty
Summary
The facility failed to ensure that physician orders were transcribed accurately upon admission for two residents. For one resident with diagnoses including encephalopathy, COPD, and dementia, the medication Hydroxyurea was ordered at 1000 mg by mouth daily, but was incorrectly transcribed and administered as 1000 mg by mouth twice daily throughout the resident's stay and included in discharge instructions. This error was identified after the resident was hospitalized, and the facility administrator confirmed the transcription failure. For another resident admitted with a history of elbow fracture, benign prostatic hyperplasia, and heart disease, the medication Omeprazole was ordered at 20 mg by mouth twice daily per hospital discharge summary, but was initially transcribed and administered as 20 mg by mouth once daily. The discrepancy was noted in physician progress notes, and the order was later adjusted to match the hospital discharge instructions. Both the Nursing Home Administrator and Director of Nursing confirmed the failure to accurately transcribe physician orders on admission for these two residents.