Failure to Accurately Transcribe Hospice Medication Orders and Notification Instructions
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident who was admitted for hospice respite care. The resident, an elderly female with diagnoses including dementia, depression, and anxiety, had a hospice order upon admission specifying that her responsible party must be notified prior to the administration of Alprazolam .5mg as needed for anxiety. This instruction was documented in the hospice orders and discussed between the hospice RN and the admitting LVN, but it was not transcribed into the resident's physician orders or Medication Administration Record (MAR). As a result, the MAR only reflected an order for Alprazolam .5mg every 4 hours as needed for anxiety, without the requirement to notify the responsible party before administration. The medication was subsequently administered to the resident without prior notification to the responsible party, as confirmed by interviews with nursing staff and the responsible party. The responsible party became aware of the administration after observing the resident's drowsiness and inquiring with staff, at which point it was confirmed that the medication had been given without her knowledge or consent. Interviews with facility staff, including the LVN who completed the admission and the DON, revealed that the omission occurred because the responsible party notification instruction was not entered into the electronic medical record system or the MAR. The staff acknowledged the importance of accurately transcribing all hospice orders, including special instructions, to ensure that all care directives are followed as intended.