Medication Reconciliation and Bowel Regimen Protocol Failures
Penalty
Summary
The facility failed to ensure accurate medication reconciliation and adherence to physician orders for two residents. For one resident admitted with multiple fractures, delirium, glaucoma, GERD, depression, and dementia, the hospital discharge summary listed specific medications to be continued. However, during the admission process, two medications—gabapentin and senna-s—were incorrectly transcribed into the electronic physician's orders, despite not being included in the hospital discharge instructions. The resident subsequently received two doses of gabapentin and one dose of senna-s before the error was identified. The medication reconciliation process required a second nurse to verify the accuracy of transcribed orders, but this verification failed, allowing the error to proceed undetected until after administration. For another resident admitted with a cervical spine fusion, cognitive communication deficit, and weakness, the facility did not follow the prescribed bowel regimen as per physician order and facility policy. The resident, who was receiving scheduled oxycodone, had not had a bowel movement for several days. Although a bowel regimen was ordered after the resident experienced a syncopal episode and was found to have a firm, distended abdomen, the medications were not administered according to the protocol. There were significant delays between the ordering and administration of each step in the bowel regimen, with the first medication given 17 hours after the order and subsequent steps delayed further, contrary to the facility's bowel evacuation protocol. Interviews with nursing staff revealed lapses in the medication reconciliation and bowel regimen processes. The admitting nurse acknowledged accidentally transcribing incorrect medications, and the verifying nurse failed to catch the error. In the case of the bowel regimen, staff could not recall whether medications were administered as ordered, and documentation did not support timely administration. The facility's policies for medication reconciliation and bowel management were not followed, resulting in medication errors and delayed care.