F0760

D

Failure to Reconcile Hospital Discharge Orders Leads to Administration of Discontinued Rifampin

Lowell, Massachusetts Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when admission medications were not accurately reconciled and transcribed. Facility policy required that all physician and authorized practitioner orders be accurately transcribed, verified by a second licensed nurse, and reconciled with the physician upon admission and after hospitalization, with discrepancies clarified immediately. Another policy required use of the official, final hospital discharge document for medication reconciliation, with the admitting nurse resolving discrepancies prior to order entry and a second nurse confirming accuracy before activating orders in the EMR.

Resident #1 was admitted with diagnoses including latent tuberculosis, anemia, muscle wasting, diabetes mellitus, and acute kidney failure. The preliminary hospital discharge summary indicated a discharge diagnosis of hepatotoxicity secondary to Rifampin and stated that Rifampin was stopped due to toxicity and to remain off it indefinitely. The finalized hospital discharge summary explicitly directed that Rifampin 150 mg capsules and Ibuprofen 600 mg tablets were not to be administered. A physician’s progress note in the resident’s record also stated that the resident was to remain off Rifampin indefinitely due to hepatotoxicity. Despite these documented instructions, the resident’s MAR contained an active order for Rifampin 150 mg, three capsules once daily, and the medication was documented as administered on two days.

Interviews and record review showed that the Nursing Supervisor used the preliminary discharge summary sent to the admission coordinator, saw Rifampin listed as a current medication, called the on‑call provider, verbally reviewed and reconciled the medication list, and then entered the orders into the EMR without using the finalized discharge paperwork that accompanied the resident on the actual admission date. The second nurse responsible for double‑checking admission orders did not verify the medication orders against the final discharge summary. There was no documentation that nursing staff reviewed the finalized discharge summary or clarified discrepancies related to Rifampin with the provider. The Unit Manager reported being unaware that the medications were not reconciled or transcribed accurately upon admission, even though she stated that medication reconciliation should always be completed by two nurses using the final hospital discharge summary. As a result of these failures, the resident received two doses of Rifampin after it had been discontinued at the hospital, and the resident was subsequently transferred back to the hospital with recurrent symptoms related to liver injury.