Failure to Ensure Accurate Medication Reconciliation and Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident. Upon admission, a nurse entered medication orders into the resident's medical record without verifying them against an accurate and current medication list. The records received from the previous facility included another resident's medication administration record (MAR) mixed in with the correct resident's paperwork. As a result, the nurse entered a long list of medications, some of which were not prescribed for the resident, and the facility physician subsequently signed these orders without further verification. The resident, who had multiple diagnoses including Parkinson's disease, vascular dementia, hypothyroidism, bradycardia, hyperlipidemia, anemia, and a cognitive communication deficit, was administered several incorrect medications, including Metformin, Insulin Glargine, Farxiga, Lasix, and Insulin Lispro. These medications were not prescribed for the resident and, in some cases, posed significant clinical risks due to potential drug interactions and the resident's underlying conditions. The care plan did not specify the diagnosis associated with insulin use, and there was evidence of documentation errors, such as another resident's medication action plan being mixed into the records. The error was discovered after the resident was found unresponsive and transferred to the hospital, where he was diagnosed with acute renal failure, aspiration pneumonia, and sepsis. The facility's internal investigation confirmed that the incorrect medications were administered due to the mix-up in records and lack of proper verification during the admission process. Interviews with staff and the physician revealed that the medication reconciliation process was not properly followed, and there was a reliance on nursing staff to accurately enter and verify medication orders without adequate checks.
Removal Plan
- Transfer the resident to the hospital and ensure they no longer reside in the facility.
- The Director of Nursing (DON) or designee conducts a facility-wide review of all residents admitted or readmitted to ensure medication orders are accurately reconciled with hospital discharge instructions and physician orders, including any transfers from other facilities.
- Nursing supervisors verify MAR accuracy, medication availability, and physician clarification as needed. Correct any discrepancies identified immediately.
- The Administrator reviews audit findings and confirms that no additional residents are at risk.
- Terminate the staff member who input the orders.
- All staff are in-serviced by the DON/designee on abuse, neglect, and misappropriation. Staff members not present are in-serviced prior to working their next shift and before providing resident care. Completion is verified and documented.
- Revise the admission and readmission medication reconciliation process to require dual verification confirming that admit orders/discharge summary matches the orders entered in the EMR by the admitting nurse and another licensed nurse.
- The DON/designee establishes a requirement for immediate physician notification, clarification, and documentation when discrepancies are identified.
- Update the admission checklist to include MD verification, dual nurse verification, and DON/designee verification to be completed for every admission and readmission.
- The DON/Designee verifies that the admission checklist is completed for all admissions.
- Require DON or designee review of all new admissions and readmissions by next business day.
- The Director of Nursing (DON) or designee provides re-education to all licensed nursing staff on proper medication reconciliation, verification of physician orders prior to medication administration, escalation procedures, and documentation requirements. Education is provided by the DON/designee through in-service training, with staff competency validated through verbal review. Staff members not present are in-serviced prior to working their next shift and before providing resident care. Completion is verified and documented.
- Nursing management notifies the Regional Nurse of any significant medication error requiring physician intervention or hospitalization.
- The Regional nurse notifies the administrator to in-service nurse management regarding notification of the regional nurse of any significant medication error requiring physician intervention or hospitalization.
- The Director of Nursing (DON) or designee conducts weekly audits of all new admissions and readmissions for four weeks, then monthly thereafter, to ensure continued compliance with medication reconciliation requirements. Audit results are reviewed by the Administrator and incorporated into the facility's QAPI program. Any identified noncompliance results in immediate corrective action and re-education.