Failure to Transcribe and Implement Verbal Tamiflu Order for Influenza-Positive Resident
Penalty
Summary
The facility failed to ensure that a nurse practitioner’s verbal order for Tamiflu was properly processed and implemented for a resident who tested positive for influenza. The resident, who had diagnoses including heart failure, stage four chronic kidney disease, and COPD, was cognitively intact and self-responsible, with documented capacity to make medical decisions. On 2/2/2026 around noon, the resident’s influenza antigen test was positive for Influenza A, and an SBAR documented fever of 103°F, vomiting, and coughing. The infection preventionist reported that the nurse practitioner was notified of the positive test and verbally ordered Tamiflu 75 mg twice daily for five days to treat the influenza. However, the infection preventionist stated she forgot to carry out the order and did not notify the pharmacy. Review of the resident’s physician orders and MAR for February 2026 showed no entry for Tamiflu, and nursing staff confirmed that there was no Tamiflu order documented. The nurse practitioner later confirmed that Tamiflu 75 mg had been ordered to treat Influenza A and that he was not notified that the resident did not receive the medication. The facility’s policy titled “Physician Orders” required that when receiving a telephone or verbal order, the licensed nurse must repeat the order to clarify, transcribe all components onto a telephone order form with time, date, and signature, transcribe the order onto the MAR, and notify the pharmacy of the new order. These required steps were not completed, resulting in the resident missing two doses of Tamiflu on the evening of 2/2/2026 and the morning of 2/3/2026.
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