Failure to Transcribe and Administer Furosemide for CHF Resident Leading to Harm
Penalty
Summary
The deficiency involves the facility’s failure to transcribe and administer a prescribed diuretic, Furosemide, for a resident with a diagnosis of chronic congestive heart failure and chronic respiratory failure with hypoxia. The resident was discharged from the hospital with an order for Furosemide 20 mg tablets, with instructions to begin on a specified date and take two tablets (40 mg) by mouth once daily in the morning for acute chronic diastolic congestive heart failure. This order was not entered into the facility’s electronic health record (EHR) when the resident was admitted, and the congestive heart failure (CHF) order set was not initiated as required by the facility’s admission checklist and procedures. As a result, the resident’s physician orders in the EHR did not include Furosemide, and the CHF monitoring order set, including daily weights and respiratory assessments, was not started as expected. The resident’s care plan indicated that medications were to be administered as ordered and that staff were to monitor fluid restriction and record weights according to facility policy. However, the resident was not placed on daily weights upon admission, and daily weights were only initiated later, after a delay. Weight records showed a progressive and significant weight gain over a period of days, including an increase of more than 7 pounds in three days and a total gain of over 17 pounds in less than three weeks. Despite these documented weight increases, there was no evidence in the record of a comprehensive assessment or analysis to determine the cause of the weight gain. The January medication administration record confirmed that the resident did not receive any doses of Furosemide 40 mg for 13 consecutive days following the date the medication was to be started per the hospital discharge order. The medication incident was eventually identified when an outside vascular clinic contacted the facility for the resident’s medication administration and weight information and discovered that Furosemide had not been given as ordered. Facility staff then reviewed the hospital discharge summary and confirmed that the Furosemide order and CHF order set had not been transcribed into the facility’s physician orders. Interviews with the LPN who transcribed the admission orders and the RN who verified them revealed that distractions during order transcription and failure to recognize the CHF diagnosis contributed to missing the Furosemide order and not initiating the CHF order set. Subsequent progress notes and hospital records documented that the resident experienced rapid weight gain, worsening respiratory status, hypoxia, and was transferred and admitted to the hospital with acute on chronic congestive heart failure and hypoxic respiratory failure. Multiple clinical staff, including nursing, a physician assistant, a pharmacist, the regional clinical director, and the medical director, acknowledged that the resident did not receive the prescribed Furosemide doses and described the relationship between missed Furosemide and the resident’s fluid overload, weight gain, and respiratory distress.
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