Failure to Reconcile Medication Orders on Readmission Leads to Medication Error
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician completed a medication reconciliation upon a resident's readmission. The resident, who had diagnoses including heart failure, pulmonary hypertension, and chronic kidney disease, was readmitted after a hospital stay for congestive heart failure exacerbation and respiratory distress. Upon readmission, the hospital discharge documentation ordered Metolazone 5 mg to be administered three times a week. However, a registered nurse incorrectly transcribed this order into the facility's record as three times daily. The resident's physician saw the resident after readmission and reviewed the medical record but did not identify the transcription error regarding the Metolazone order. During interviews, the physician stated that he does not reconcile medication orders between the facility's system and the hospital's continuity of care form, considering it the nursing staff's responsibility. The Director of Nursing Services, however, indicated that it is expected for the provider to reconcile these records to ensure accuracy. This failure resulted in the resident receiving Metolazone in error.