Failure to Administer Medication as Ordered Following Hospital Discharge
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not following the physician's discharge orders after the resident returned from the hospital. The resident, who had a history of dementia with mood disturbances and behavioral issues, was discharged from the hospital with an order for Divalproex Sodium (Depakote) 250 mg to be administered twice daily (BID). However, upon readmission, the facility continued to administer the medication only once daily, as per a previous order, and did not implement the new BID order from the hospital. As a result, the resident missed six doses of the prescribed medication. Review of the resident's medical records and interviews with facility staff revealed that the hospital discharge order for Depakote 250 mg BID was not transcribed into the resident's clinical records or the Medication Administration Record (MAR). The nurse practitioner (NP) and other nursing staff confirmed that there was no documentation of a new order to discontinue the BID dosing or to revert to once-daily dosing. The facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) both acknowledged that the process for verifying and transcribing new orders upon readmission was not properly followed in this case. The ADON, who was responsible for auditing new admission and readmission medications, did not identify the error until it was brought to her attention during the survey. The resident's care plan and progress notes indicated ongoing behavioral disturbances and a need for mood stabilization, which were to be managed with antiepileptic medication as ordered. Despite the hospital's clear instructions to increase the Depakote dosage to BID, the facility failed to update the medication orders accordingly. There was no evidence in the clinical records of any order to discontinue or modify the hospital's discharge instructions, nor was there documentation explaining the deviation from the prescribed regimen.