Failure to Accurately Transcribe Cancer Medication Order Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and maintain a continuous physician order for an anti-neoplastic medication, resulting in a resident not receiving the drug for three days. The facility’s medication administration policy requires that all medication orders and any changes be accurately documented in the medical record, and that errors or omissions be recorded and reported. The resident was admitted with multiple diagnoses including malignant neoplasm of the prostate, malignant pleural effusion, and secondary malignant neoplasm of bone. Hospital discharge orders dated 2/9/26 directed Abiraterone 250 mg, four tablets orally once daily on an empty stomach, with no stop date. However, the facility’s MAR for the month showed the Abiraterone order entered with a stop date of 2/24/26, and the MAR documented that the resident did not receive the medication on 2/25, 2/26, and 2/27. The resident and family reported that the resident had missed several doses of his cancer medication because nurses told him there was no order for it or that it was not available. The resident stated he had brought a four-day supply from home and had it renewed after admission, and that he was told he could not miss taking it because his prostate cancer had spread to his bones. The LPN who transcribed the admission orders confirmed she entered the Abiraterone order and acknowledged that the hospital discharge orders did not contain a stop date, and she did not know where the 2/24/26 stop date came from. Another LPN stated she only changed the administration time based on the resident’s usual home schedule and that the stop date was already present on the order. The former DON reported that the resident had voiced concerns that a nurse would not administer his cancer medication because there was no order for it, and that the order had been incorrectly stopped, leading to the documented missed doses.
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