Failure to Transcribe and Administer Admission Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident received the correct medications upon admission, as required by physician orders and facility policy. Upon review, it was found that the resident, who had diagnoses including respiratory failure, abdominal aortic aneurysm without rupture, and high blood pressure, was admitted with hospital discharge orders for Xanax 0.25mg four times a day for five days and Diovan 80mg every evening. However, the nursing staff did not transcribe the Xanax order into the facility's physician orders or Medication Administration Record (MAR), resulting in the medication not being administered as prescribed. Additionally, the Diovan was not administered on the evening of admission because it was not available from the pharmacy, and the nursing staff did not follow facility procedures for handling a missing medication. Specifically, the staff failed to notify the physician regarding the missed dose of Diovan. The Director of Nursing confirmed these omissions, acknowledging that the required procedures for medication transcription and notification were not followed.