Failure to Obtain Timely Medication Admission Orders
Penalty
Summary
The facility failed to obtain medication admission orders for a newly admitted resident with multiple complex medical conditions, including metabolic encephalopathy, acute and chronic respiratory failure, type 2 diabetes mellitus with hyperglycemia, and seizures. Upon admission, the resident did not have discharge medication orders from the transferring hospital. The registered nurse (RN) notified the attending physician via text message on the day of admission to request medication orders, but the physician did not respond. The RN did not escalate the issue to the Medical Director as required by facility policy. As a result, the resident's medications were not ordered until the following day, delaying the administration of necessary treatments such as amiodarone, insulin lispro, ipratropium-albuterol, Keppra, olanzapine, and pantoprazole sodium. Interviews with facility staff confirmed that the lack of timely physician response and failure to follow up with the Medical Director led to the delay in obtaining and administering the resident's medications. Facility policy requires the attending physician to provide medication orders upon admission, which was not followed in this instance.