Failure to Implement Hospital Discharge Medication Orders After Readmission
Penalty
Summary
Facility staff failed to transcribe and implement hospital discharge orders for one resident following readmission from the hospital. The resident, who had diagnoses including necrotizing fasciitis, acute and chronic respiratory failure, type 2 diabetes, and obstructive and reflux uropathy, was discharged from the hospital with an after visit summary (AVS) dated 02/27/26. The AVS contained new orders for Ciprofloxacin 500 mg every 12 hours for 13 doses and vancomycin 125 mg four times a day for nine days. Review of the Medication Administration Records (MARs) for February and March 2026 showed that neither Ciprofloxacin nor vancomycin was administered during those periods. An RN confirmed that the resident was not taking the prescribed antibiotics. The AVS also included orders dated 02/27/26 to discontinue enoxaparin 40 mg/0.4 ml and to hold Metformin 500 mg until 03/02/26. However, review of the March 2026 MAR revealed that enoxaparin was administered once on 03/01/26, 03/02/26, and 03/03/26, and Metformin was administered twice on 03/01/26, contrary to the hospital discharge instructions. In an interview, the DON verified that the resident’s orders were not transcribed upon readmission and acknowledged that the discharge orders should have been implemented when the resident returned. This deficiency was identified during an investigation of a complaint and affected one of three residents reviewed, with a facility census of 69.
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