Failure to Reconcile and Administer Critical Medications on Admission
Penalty
Summary
A significant medication error occurred when a resident was admitted for short-term rehabilitation following a fall and was not provided with several critical medications as ordered upon hospital discharge. The resident, who had a complex medical history including schizophrenia, narcolepsy with cataplexy, osteoporosis, frequent falls, and recurrent UTIs, was supposed to continue Seroquel 600 mg for schizophrenia, a sliding scale insulin regimen, antibiotics for a UTI, and lidocaine patches for pain. However, the facility failed to order and administer Seroquel, the sliding scale insulin, antibiotics, and lidocaine patches as per the hospital's discharge instructions. The omission of Seroquel, in particular, led to abrupt withdrawal, which is known to cause severe psychiatric and physical symptoms, especially at high doses. Following the missed medications, the resident exhibited a marked decline in mental and physical health. Documented symptoms included hallucinations, increased behavioral disturbances such as combativeness and medication refusals, unmonitored and untreated blood sugars, and increased risk for infections. The resident experienced repeated falls, one of which resulted in a major head injury. The facility's documentation showed that blood glucose monitoring was not performed as frequently as ordered, and hyperglycemia episodes were not properly managed due to the lack of sliding scale insulin coverage. Additionally, the prescribed antibiotics and pain management patches were not provided, leading to an untreated UTI that progressed to a hemolytic Strep Group B infection. The facility's failure to reconcile and implement all hospital discharge orders was attributed to missing pages in the discharge paperwork, which was not identified or corrected until the surveyor's review. The facility did not follow its own policy for reporting and documenting medication errors, as no incident report was completed for the missed Seroquel or other medications. The resident's condition deteriorated, culminating in a fatal fall resulting in a subdural hemorrhage. Interviews confirmed that the errors were not recognized or communicated in a timely manner, and the primary physician was not fully informed of all missed medications.