F0684

J

Failure to Transcribe Admission Lithium Order and Address Pharmacy Alert Leading to Psychiatric Decompensation

Warren, Pennsylvania Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow nursing standards of practice and accurately transcribe and implement admission medication orders for a newly admitted resident, resulting in the omission of a prescribed psychotropic medication. Pennsylvania Code Title 49 requires RNs to carry out nursing care actions that promote, maintain, and restore well-being and to be fully responsible and accountable for the quality of care delivered. Facility policies required clarification and transcription of newly prescribed medications onto the MAR or into the electronic MAR, implementation of written transfer orders unless unclear or incomplete, and acting upon and documenting pharmacist recommendations. The RN job description required delivery of care using the nursing process while maintaining professional standards.

The resident, admitted with schizoaffective disorder bipolar type, Parkinson’s disease, and major depressive disorder, had transfer orders that included lithium carbonate 300 mg extended-release orally with no stop date. On admission, the facility’s physician orders dated the same day did not include the lithium carbonate 300 mg order, and the resident’s MARs for the subsequent period showed no evidence that this medication was ordered or administered. A pharmacy admission medication review identified a potential clinically significant irregularity, noting that the lithium carbonate 150 mg dose fell below the recommended daily dose and was potentially subtherapeutic, but there was no evidence that this review was addressed by facility staff or the physician. Documentation from the resident’s last behavioral health visit prior to admission showed active orders for both lithium carbonate 150 mg daily and 300 mg daily, indicating that the higher dose should have been part of the resident’s regimen.

Following admission, the resident’s clinical record documented escalating behavioral and psychiatric symptoms over multiple days, including pacing, wandering, screaming, yelling, loud and unusual religious statements, hitting staff, increased anxiety, arguments with other residents, and repeated administration of anti-anxiety medications. Progress notes described manic behavior, flight of ideas, talking to self and to people not present, delusional thoughts, agitation, disruptive behavior in common areas, lack of sleep, and the need for one-on-one care due to mania. The resident experienced falls and was noted to be confused, disoriented, and in a manic state. Laboratory results showed a lithium level of 0.14 mmol/L, below the referenced normal range of 0.60–1.20 mmol/L, and a neurology progress note stated that the resident’s lithium doses were not correctly dosed and that the resident was showing signs of active psychosis. In interviews, the DON confirmed that the lithium carbonate 300 mg order from the transfer orders was not transcribed into the facility medication record and that the pharmacy admission medication review identifying a potential clinically significant irregularity was not addressed by facility staff or the physician.

The resident’s care plans included a plan for risk of adverse effects related to antipsychotic medication, with a goal of no side effects, and a plan for risk of behavioral symptoms related to schizoaffective disorder with an intervention to administer medications per physician order. Despite these care plans, the lithium carbonate 300 mg order was not implemented because it was never transcribed into the electronic medical record or MAR, and the pharmacy’s alert about a potentially subtherapeutic lithium dose was not acted upon. The facility’s failure to accurately transcribe the admission medication orders and to respond to the pharmacist’s identified irregularity created a situation that surveyors determined placed the resident in Immediate Jeopardy of the likelihood of serious bodily injury, harm, or death.

Removal Plan

• All Registered Nurses will receive education regarding the proper process for entering physician orders for new admissions, including thorough review of hospital discharge orders, accurate entry of orders into the electronic health record, and the required process for transcription and clarification to ensure accuracy within the medical record.
• Nursing staff will utilize a standard Medication Transcription/Clarification Tool during the admission process to ensure all medication orders are completely and accurately transcribed.
• Any discrepancies identified will be clarified with the physician prior to implementation, and physicians will be notified promptly of any transcription error or clarification needs.
• Implement a revised admission process requiring use of the Medication Transcription/Clarification Tool to validate that medication orders are accurately entered into the electronic health record and appropriately populate in the electronic medication administration record.
• Director of Nursing or designee will audit admissions to verify accuracy of order transcription and clarification.
• Admission audits will be conducted until sustained compliance is achieved.
• Audit results will be reviewed at the Quality Assurance Performance Improvement meetings and additional corrective action or re-education will be implemented as indicated by audit findings.