Delayed Initiation of Antifungal Medication Due to Failure to Transcribe Admission Order
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors by not transcribing a physician's order for an antifungal medication upon admission. The resident, who had been diagnosed with a candida urinary tract infection during a recent hospitalization, was discharged with an order to begin fluconazole 200 mg daily for thirteen days. Upon review, it was found that the order for fluconazole was not entered into the facility's system at the time of admission, resulting in a three-day delay before the medication was started. The medication was eventually initiated, but only after the delay was identified during a chart check by the unit manager. Interviews with nursing staff confirmed that there was no reason for such a delay, as medications are typically available in the facility's automated dispensing system or can be delivered by the pharmacy multiple times a day. The facility's policy requires that all admission physician orders, including medications, be recorded by a licensed nurse upon admission, but this process was not followed in this instance. The Director of Nursing confirmed that the medication should have been started as ordered and acknowledged the lapse in following the established procedure.