Failure to Discontinue Medications as Ordered by Specialist
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not discontinuing several medications as ordered by the resident’s nephrologist. The resident, who was cognitively intact and had diagnoses including type 2 diabetes, asthma, and a history of falls, attended a nephrology appointment where the specialist ordered the discontinuation of metformin, potassium citrate, prenatal vitamins, and valsartan-hydrochlorothiazide. Despite these clear instructions, the resident continued to receive these medications for nearly three weeks after the appointment, as documented in the medication administration records. The after-visit summary with the discontinuation orders was reportedly handed to facility staff by the resident upon return from the appointment. However, there was no documentation in the progress notes regarding the medication changes until two weeks later, when concerns were raised by a family member. Interviews revealed confusion and lack of follow-up among staff regarding the receipt and processing of the specialist’s orders. The nurse responsible did not promptly verify or act on the nephrologist’s instructions, and the facility’s process for handling post-appointment paperwork and communication with physicians was not effectively followed. Facility leadership, including the DON and administrator, confirmed that the expectation was for transportation staff to deliver all paperwork to the nurse, and for the nurse to follow up with the specialist or the facility physician if documentation was missing. The failure to follow these procedures resulted in the resident receiving medications that had been ordered discontinued, with no timely communication or documentation of the specialist’s orders in the resident’s medical record.