Medication Reconciliation Errors After Hospital Readmission
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for one resident when reconciling medications after a hospital stay. The facility’s person-centered care plan policy required that care and services be provided according to accepted standards of clinical practice. The resident had diagnoses including cirrhosis of the liver, chronic kidney disease, and dementia, and experienced multiple hospital transfers, including a discharge from the hospital and readmission to the facility. After the resident’s return, the consultant pharmacist’s progress note dated November 4, 2025, identified transcription errors between the hospital discharge medication orders and the current facility orders. These discrepancies included lactulose ordered at 30 ml three times daily on the hospital discharge summary but ordered once daily at the facility, tamsulosin ordered at 0.4 mg once daily on discharge but ordered as 0.8 mg (two capsules) at the facility, and bumetanide ordered at 1 mg twice daily on discharge but ordered as 0.5 mg twice daily at the facility. Further review of the monthly consultant pharmacy recommendations dated November 20, 2025, showed that the hospital discharge summary ordered levothyroxine 37.5 mcg by mouth once daily, but on November 3, 2025, it had been ordered twice daily at the facility, despite this medication typically being dosed once daily. In an interview, the DON stated that the RN responsible for readmission medication reconciliation did not have the hospital discharge record and instead used the resident’s pre-hospitalization medication list when reviewing medications with the physician at readmission. The DON indicated that the RN should have used the hospital discharge medication orders to review with the physician and to update the resident’s clinical record, rather than relying on the medication list from before the hospitalization. These actions and omissions resulted in the resident not receiving treatment and care according to the hospital discharge orders and accepted professional standards of practice.
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