Failure to Complete Accurate Medication Reconciliation Resulting in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not completing an accurate medication reconciliation upon admission. Despite having an updated medication list from the referring facility dated November 3, 2025, staff used an outdated list from May 22, 2024, during the reconciliation process. This resulted in the resident being prescribed and administered multiple medications that had previously been discontinued, including methimazole, simvastatin, and lisinopril. The resident had a medical history that included hypertension, hypothyroidism, and other chronic conditions. Upon admission, the resident was placed on methimazole for hyperthyroidism and lisinopril for hypertension, despite the current medication list indicating treatment with levothyroxine for hypothyroidism and losartan for blood pressure control. The referring facility's documentation confirmed that methimazole, simvastatin, and lisinopril had been discontinued due to an episode of hyperkalemia. Following the administration of these discontinued medications, the resident experienced another episode of hyperkalemia, as evidenced by elevated potassium levels in laboratory results. The facility's failure to follow its own medication reconciliation policy, which required resolving discrepancies and using the most current medication information, directly led to the resident receiving inappropriate medications and experiencing a significant medication error.