F0760

D

Failure to Verify Hospital Discharge Orders Resulting in Medication Errors

Silver Spring, Maryland Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that a newly admitted resident was free from significant medication errors by not verifying the accuracy of hospital discharge paperwork before entering admission medication orders. The resident was admitted from the hospital with discharge paperwork dated 02/20/2026 that listed Eliquis 5 mg by mouth twice daily, amiodarone 200 mg by mouth once daily, and Buspirone 5 mg by mouth twice daily. Facility records showed that orders were instead entered for Eliquis 5 mg by mouth once daily and amiodarone 200 mg by mouth twice daily, both starting on 02/21/2026 and discontinued on 02/25/2026, and these medications were administered as ordered. Additionally, Losartan Potassium 50 mg by mouth once daily was ordered and administered from 02/21/2026 through 02/27/2026, even though this medication was not listed on the hospital discharge medication list. Buspirone was not started until 02/27/2026, despite being included on the hospital discharge medication list.

During interviews, the Medical Director confirmed that a medication error had occurred involving these medications for the resident and stated that the errors were present when he evaluated the resident. The DON reported that the facility had received a hospital discharge summary from a prior hospitalization dated 07/18/2025 and that nursing staff misread the date and did not identify that it was from an earlier admission. As a result, the resident received incorrect medications for the first four days of their stay until the error was identified by a family member. The surveyor reviewed the 07/18/2025 hospital discharge paperwork and confirmed that the wrong discharge summary had been used, leading to the inaccurate medication orders and administration.