Failure to Discontinue Medications per Hospital Discharge Orders
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, as required. Upon admission from an acute care hospital, a female resident with diagnoses including metabolic encephalopathy, acute pancreatitis, acute kidney failure, and depression was supposed to have four medications (mirtazapine, escitalopram, tizanidine, and tramadol) discontinued per the hospital's discharge instructions. However, these medications continued to be administered for up to 24 days after admission, as evidenced by medication administration records and interviews with facility staff. The error occurred during the transcription of hospital discharge orders into the facility's electronic health record (EHR). The process involved charge nurses, MDS nurses, and at times, assistant directors of nursing (ADONs), but there was confusion and lack of clarity regarding who was responsible for entering and verifying the orders. The MDS RN indicated that the ADON entered the orders for this resident, but the ADON did not recall doing so. The facility's policies required review and documentation of psychotropic medications on admission, but there was no clear policy for transcribing all hospital orders into the EHR. Additionally, the facility was unable to provide an unnecessary medication policy when requested. Multiple staff interviews confirmed awareness that administering discontinued medications could negatively impact residents, depending on the medication. The nurse practitioner (NP) who identified the error stated she noticed the medications had not been discontinued upon her return from vacation and subsequently notified staff, but there was a delay in this notification due to her being behind on charting. The resident received the discontinued medications until the error was discovered and corrected, with documentation showing daily administration of mirtazapine and escitalopram, and multiple doses of tramadol, while tizanidine was not administered.