Failure to Reconcile and Implement Admission Orders Results in Immediate Jeopardy
Penalty
Summary
The facility failed to accurately reconcile and implement physician orders upon the admission of a resident, resulting in the omission of multiple critical medications and treatments. Upon admission, the resident had a complex medical history including schizophrenia, narcolepsy with cataplexy, osteoporosis, frequent falls, recurrent UTIs, and hypertension, and was admitted for short-term rehabilitation following multiple fractures. The hospital discharge orders included Keflex for UTI, a transition to nitrofurantoin, guaifenesin, sliding scale insulin with blood sugar checks four times daily, lidocaine patches for pain, and quetiapine (Seroquel) for psychiatric management. None of these orders were implemented at the time of admission due to incomplete review of the discharge summary, as only every other page was available and reviewed by staff. As a result of the missing orders, the resident did not receive Seroquel, leading to withdrawal symptoms and a significant decline in psychiatric stability, including hallucinations, agitation, medication and care refusals, and increased wandering. The resident also did not receive appropriate blood sugar monitoring or sliding scale insulin, resulting in multiple episodes of hyperglycemia and unmonitored blood glucose levels. Additionally, the prescribed antibiotics and lidocaine patches for pain management were not administered, leaving the resident at increased risk for infection and unmanaged pain. The resident experienced a series of adverse events following these omissions, including worsening psychiatric symptoms, refusal of care, and multiple falls. One fall resulted in a subdural hematoma, which was later identified as the cause of death. The facility did not identify the missing orders until questioned by the resident's family and further review by surveyors. Interviews with facility staff and leadership confirmed that the discharge summary was not fully reviewed, and the expectation for thorough reconciliation of admission orders was not met.