Community Extended Care Hospital Of Montclair

continuation of care, including medication orders and any other necessary care.

During an interview on December 30, 2025, at 3:30 PM, with Registered Nurse 1 (RN 1), the RN 1 stated she is aware of her responsibility as the admission nurse to review hospital records and verify medication indications upon admission. RN 1 further stated, I am not sure how the mistake happened; I ended up putting the medication order to the wrong resident.During a follow up interview on December 30, 2025, at 3:30 PM, with RN 1, the RN 1 stated, It was my mistake that caused Resident [1] did not receive his Valproic Acid to manage his clinical condition that make Resident [2] received Valproic Acid that was unnecessary for her, unfortunately.

RN 1 further stated she should have double checked the medication order against hospital discharged records and confirmed with the physician prior to entering the order, but she did not.

During an interview on December 31, 2025, at 1:00 PM, the Administrator acknowledged the medication reconciliation practice error, stating Resident 1 did not receive his prescribed medication to manage his medical condition, and it was instead entered under Resident 2, who received six doses unnecessarily.

The Administrator stated the facility expects the admission nurse to review hospital records and verify medication indications at admission and DON will review the admission chart the next business day after admission for accuracy and completeness.

The Administrator also acknowledged that the facility does not have a written P&P governing the admission process, including medication orders upon admission. A review of Resident 1's MAR for the period of December 16, 2025, through December 31, 2025, indicated that Valproic Acid 250 mg, 1 capsule by mouth three times daily, was not initiated for Resident 1 until December 21, 2025, because the medication order had been entered under another resident (Resident 2).

The MAR confirmed Resident 1 did not receive a total of twelve doses of his Valproic Acid required to manage his clinical condition.During an interview on January 2, 2026, at 2:00PM, with the Pharmacist, the Pharmacist stated that after a resident is admitted to the facility, the pharmacy typically reviews new admission medication orders within 4 to 8 hours or on the same day.

The pharmacist stated that this review includes verification of medication strength, frequency, potential drug interactions, and clinical indication.

The pharmacist further stated that it is not the pharmacy's usual process to review the hospital medication list, and that review of hospital discharge records is typically the responsibility of the facility.

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