Failure to Transcribe and Implement Hospital Discharge Orders for Diabetes Medication
Penalty
Summary
A deficiency occurred when the facility failed to accurately transcribe and implement a hospital discharge order for diabetes management for a resident with Type-2 diabetes mellitus and severe cognitive impairment. The hospital discharge summary specified an order for Janumet XR (metformin-sitagliptin extended release), but the facility entered and administered only metformin immediate release, omitting both the sitagliptin component and the extended-release formulation. The medication administration record showed the resident received only metformin 1000 mg once daily for several days following admission, rather than the prescribed combination medication. Interviews with facility staff and the consulting pharmacist confirmed that the order for Janumet XR was not entered or administered, and that metformin and Janumet XR are not equivalent medications. The pharmacist described this as a significant medication error, as the resident did not receive the intended glycemic control. The DON and Administrator both acknowledged that the facility's two-step order entry and verification process was not followed, as the same nurse entered and confirmed the orders without a second nurse's review, leading to the error.