F0760

D

Medication Reconciliation and Administration Errors Leading to Significant Medication Variances

Philadelphia, Pennsylvania Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when medications were not administered in accordance with physician orders. The resident was admitted for rehabilitation following a right total knee arthroplasty with additional diagnoses including hypertension, hyperlipidemia, coronary artery disease, obesity, and osteoarthritis. Hospital discharge medications included Aspirin EC 81 mg, Cefadroxil 500 mg every 12 hours, and Enoxaparin (Lovenox) 30 mg subcutaneously every 12 hours. The facility’s own policies required accurate medication reconciliation on admission, verification of correct medication, dose, time, and route, and administration in accordance with physician orders.

Record review showed that Aspirin 81 mg was administered earlier than ordered. The original order entered at the facility directed Aspirin 81 mg chewable twice daily starting on a specific date, but this was later corrected to start two days later due to concurrent Lovenox therapy. Despite the corrected order specifying that Aspirin was to be held until the later start date, the MAR showed that Aspirin 81 mg was administered before that start date. Physician and nursing notes documented that Aspirin 81 mg, which was ordered to be held until a specified date because of concurrent Lovenox therapy, was given early.

The review also revealed that the wrong antibiotic within the same drug class was transcribed and administered. Hospital records showed an order for Cefadroxil 500 mg every 12 hours for postoperative prophylaxis, but the MAR documented administration of Cefaclor 500 mg every 12 hours instead. The corrected order clarified that Cefadroxil 500 mg was the intended medication, to be given every 12 hours for 7 doses starting on a later date. Additionally, Lovenox 30 mg subcutaneously every 12 hours was ordered to start on a specific date and continue until another specified date, but the MAR indicated that Lovenox was administered earlier than the ordered start date and discontinued before the ordered end date. The DON reported that these errors resulted from a transcription error during admission medication reconciliation, where the nurse did not accurately enter the physician’s discharge orders into the electronic medical record.

The resident was informed of the administration of the wrong medications and expressed upset and dissatisfaction. Physician and nursing progress notes documented that the resident experienced mild nausea but remained stable with no other adverse effects noted at that time. The facility’s incident report identified that the licensed nurse responsible for reconciling the admission orders entered the wrong medication and incorrect start dates, leading to the administration of Aspirin before the ordered start date, substitution of Cefaclor for Cefadroxil, and incorrect timing of Lovenox administration, all of which were not in accordance with physician orders.