Failure to Accurately Reconcile and Administer Discharge Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not accurately reviewing and implementing the hospital discharge medication regimen. Upon admission, the resident, who had a history of hypertension and COPD and required continuous oxygen, was supposed to receive a specific set of medications as outlined in the hospital discharge summary, including new prescriptions for budesonide, prednisone, and levalbuterol, as well as continuation of several home medications. However, the facility administered a different set of medications, which were not those prescribed at discharge, over a period of several days. This error occurred because the hospital discharge paperwork provided to the facility included medication lists for a different individual, and staff failed to verify the correct resident's name and date of birth on the documents. As a result, the resident did not receive the prescribed breathing treatments and other necessary medications, and instead received multiple doses of medications not intended for her. The error was not identified until the resident's family questioned the medication regimen, prompting a review that revealed the discrepancy. During the period the resident was given the incorrect medications, she experienced shortness of breath and anxiety, leading to a decrease in oxygen saturation and subsequent transfer back to the hospital, where she was admitted for an exacerbation of COPD and anxiety. Interviews with staff indicated that the admitting nurse was responsible for reconciling medications with the physician, but the process failed due to lack of verification of the resident's identity on the discharge paperwork and incomplete transcription of orders.