Failure to Follow Physician Discharge Orders on Admission
Penalty
Summary
Facility staff failed to follow physician discharge orders for one resident upon admission. Instead of adhering strictly to the hospital discharge summary, staff used the resident's at-home medication list to enter admission orders, resulting in the administration of two medications (amitriptyline and trazodone) that were not included in the discharge orders. Interviews with LPNs, the DON, and the Regional Director of Clinical Services confirmed that the at-home medication list was used in addition to the hospital discharge summary, despite facility policy requiring medications to be administered only as per written prescriber orders. The nurse practitioner was unaware of the incorrect medication entries and had intended to discontinue medications at the request of the resident's son, but this was not completed. Facility documentation review showed that the policy required patient information and orders from the discharging physician to be reviewed and approved by the attending physician at admission. However, the staff's unfamiliarity with the hospital's discharge summary format contributed to the error, and the pharmacy was involved in reviewing new medications, but the process did not prevent the addition of non-discharge medications. The deficiency was identified through clinical record review, staff interviews, and policy review, confirming that the admission process was not completed according to physician discharge orders.