Failure to Reconcile and Transcribe Admission Orders for Wound Care and Insulin
Penalty
Summary
The facility failed to properly reconcile and transcribe medication and wound care treatment orders for a resident admitted from the hospital. Upon admission, the wound care treatment order for the resident's right lower extremity, as specified in the hospital discharge instructions, was not transcribed into the facility's Treatment Administration Record (TAR) until several days after admission. As a result, wound care treatments scheduled for specific days were missed, with no documented evidence that treatments were provided on three separate occasions. The lapse was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the wound care order should have been transcribed on the day of admission and that the treatments should have been administered as ordered. Additionally, the facility did not transcribe two insulin aspart orders from the hospital discharge instructions onto the facility's medication list, resulting in a delay in initiating blood sugar monitoring and insulin administration according to the prescribed sliding scale. The LVN responsible for medication reconciliation used the hospital inpatient medication list instead of the discharge to SNF medication list, leading to the omission of these critical orders. Consequently, blood sugar checks and insulin administration were not performed for an extended period after admission, despite the resident's diagnoses of type 2 diabetes mellitus and chronic skin ulcers.