Failure to Transcribe and Administer Physician-Ordered Medications
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to transcribe physician-ordered medications into the electronic medical record (EMR) for a resident who had recently been admitted with multiple fractures and a recent fall. The resident, who was cognitively intact and able to make their own decisions, attended a urology appointment where the physician prescribed two creams: Clotrimazole cream for skin irritation and Esterace cream for vaginal symptoms. The facility's process involved sending residents to appointments with a blank physician's order form, which the physician completed and the nurse was responsible for reviewing and transcribing into the EMR. Despite the physician's orders being noted and acknowledged by the RN, the two medications were not entered into the EMR, and as a result, the resident did not receive the prescribed treatments during their stay. This failure was confirmed through interviews and record reviews with facility leadership, who verified that the orders were not transcribed and the medications were not provided as directed by the physician.