Failure to Transcribe Acetaminophen Order to MAR Resulting in Multiple Missed Doses
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when a standing order for acetaminophen 1000 mg by mouth every six hours for pain/discomfort, with a start date of 8/21/25, was not correctly entered into the electronic system and therefore did not appear on the resident’s MARs. The facility’s medication orders policy requires that each medication order be documented on the physician order sheet and the MAR, and that newly prescribed medications be transcribed or ensured to appear in the electronic MAR. Despite this, the acetaminophen order, which was present under the physician orders tab, was not listed on the resident’s MARs for multiple consecutive months, resulting in the resident missing 48 doses in August, 120 in September, 124 in October, 120 in November, 124 in December, and 53 in January, for a total of 589 missed doses. The resident had been admitted with a left periprosthetic distal femur fracture treated surgically and had ongoing pain management needs, with documentation from an APNP and an orthopedic clinic after-visit summary confirming continued orders for acetaminophen 1000 mg every six hours. Surveyor review of the MARs for August through January confirmed the absence of the acetaminophen order despite its presence in the physician orders. During medication pass observation, the LPN administered only eye drops and insulin to the resident and confirmed there were no other medications to be given at that time. When questioned, the nurse manager/LPN explained the facility’s process for entering new admission medications, including using the hospital after-visit summary and a three-check review system, and confirmed that the physician orders tab reflected current orders. Upon reviewing the resident’s electronic orders, the nurse manager identified that the acetaminophen order type had been incorrectly entered as “pharmacy” instead of “standard medication MAR,” which prevented it from appearing on the MAR and from being visible to nurses during medication administration. The DON reported that the facility also relies on remote pharmacy checks and recommendations but stated that no pharmacy recommendation had been received regarding this resident’s acetaminophen order.
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