Failure to Administer Ordered Medications After Resident’s Hospital Transfer
Penalty
Summary
Facility staff failed to follow physician orders for a resident’s medications, resulting in missed doses. The resident was admitted with diagnoses including chronic pain and sepsis, and the Medication Administration Record (MAR) for late December listed orders for Linezolid for sepsis, Oxcarbazepine for convulsions, and Gabapentin for pain, with directions to see Administration Notes. The Administration Notes for the same date documented that these medications were on order from the pharmacy. A complaint later alleged that the resident missed physician-ordered medications. During interview, a CMA reported that after the resident was sent to the hospital and then returned, someone had destroyed all of the resident’s medications, and the resident was not gone long, resulting in the resident not receiving the ordered medications. The DNS stated she would expect staff to communicate with the pharmacy and have no lapse in resident medication. These findings show that despite active physician orders and documentation that medications were on order from the pharmacy, the resident did not receive the prescribed Linezolid, Oxcarbazepine, and Gabapentin after a hospital transfer and return, due to the destruction of the medications and lack of continuity in medication administration.
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