Failure to Accurately Transcribe and Follow Medication Orders Resulting in Significant Med Errors
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and follow physician and hospital discharge medication orders, resulting in multiple significant medication errors for two residents. For one resident with a recent hospitalization for acute kidney injury, the hospital discharge instructions directed that Bumex, Spironolactone, and Eliquis 5 mg be stopped and Eliquis 2.5 mg twice daily be started. These changes were not entered into the resident’s EHR upon readmission, and the MAR showed that the resident continued to receive Spironolactone 25 mg daily, Bumex 1 mg twice daily, and Eliquis 5 mg twice daily beginning the day after readmission, with later dose reductions not aligned with the original discharge orders. Laboratory results over the following days showed abnormal BUN, creatinine, eGFR, and potassium levels, and a nurse practitioner documented hyperkalemia likely due to chronic kidney disease and dehydration, with IV fluids administered. The nurse practitioner later confirmed that the hospital discharge orders and the MAR did not match and identified this as a nursing medication error, noting that the medications involved can affect blood pressure and kidney function. For another resident, the hospital discharge orders for Keflex 500 mg by mouth four times daily for four days were incorrectly transcribed and administered as twice daily for two days. A subsequent hospital discharge also ordered continuation of Losartan 12.5 mg daily, but this medication was never entered as an active order in the EHR after the resident’s return. Additionally, the MAR documented Midodrine 5 mg three times daily with instructions to hold the dose if systolic blood pressure was greater than 120, yet the resident received multiple doses in February and March when the documented systolic blood pressure exceeded that threshold. The nurse practitioner confirmed there were no ordered changes to the Keflex and Losartan orders and identified these as medication errors. The DON stated that nurses are responsible for reviewing, verifying, and transcribing admission orders, and confirmed that a check mark on the MAR indicates a medication was administered.
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