Failure to Verify and Transcribe Admission Medication Orders
Penalty
Summary
The facility failed to ensure a resident’s hospital discharge medication orders were verified with the admitting physician upon admission, resulting in inaccurate transcription and missed medications. The resident was admitted with multiple diagnoses including hemiplegia and essential hypertension. The hospital’s short-term Medicare referral and discharge documents included an active medication list and discharge orders. The DON later acknowledged being confused by multiple medication lists from the hospital and confirmed that several discharge medications were not transcribed onto the admission orders or MAR and therefore were not administered for three days. The medications omitted included Amlodipine for blood pressure, Buprenorphine for pain, Clopidogrel as a blood thinner, and Hydralazine for heart and blood pressure management. The resident’s responsible party met with the DON and expressed concerns about missing medications on the MAR. The admitting LVN stated the resident did not arrive with paper discharge orders and that he located the discharge orders via fax in the electronic record and used them to create admission orders, but he did not contact the admitting physician to verify or clarify those orders. The LVN also did not document any contact with the physician regarding admission orders. The resident’s primary physician, who was the admitting physician, reported he was not contacted by nursing staff at the time of admission and stated he expected licensed nurses to verify and clarify admission orders upon admission. Facility policy on admission documentation required the admitting nurse to document the time physician orders were received and verified, but there was no documentation that this occurred for this resident, and the resident did not receive the ordered medications for three days, culminating in a transfer to the hospital for syncope.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.