Overland Park Post Acute

orders with his palliative care team on 05/07/26 to make sure the orders matched what they had.

the admissions and they should have caught the discrepancy in R1's orders that next day.

She stated

four days of Lyrica, and he did not receive scheduled oxycodone, but he did have PRN oxycodone available if he asked. On 05/26/26 at 04:00 PM, Administrative Nurse D stated the lack of reconciliation of R1's scheduled oxycodone HCl 20 mg every eight hours and pregabalin 300 mg twice daily orders prescribed by the hospital were medication errors.

She stated she talked to the Administrative Nurse F and Administrative Nurse E, and Administrative Nurse F stated she reviewed R1's hospital orders on 05/08/26 and discovered his oxycodone and pregabalin were not reconciled.

Administrative Nurse D stated she educated Administrative Nurse F that it was a medication error and stated Administrative Nurse F should have notified Administrative Nurse D on 05/08/26.

She stated the process at the time of R1's readmission to the facility was the nurse put the medications in and Administrative Nurse E completed the reconciliation but now the facility had an admissions nurse, Administrative Nurse F, who went over the medications with Administrative Nurse E.

Administrative Nurse D stated she expected R1's medications to match the hospital orders and if there were any changes then the nurse should document as to why.

The facility's Reconciliation of Medications on Admission policy, last revised July 2017, directed staff reviewed the medication list carefully to determine if there were any discrepancies or conflicts. If there were discrepancies or conflicts, the facility determined the most appropriate action to resolve the discrepancy such as contacting the referring facility, contacting the physician from the referring facility, contacting the resident's primary care physician in the community, contacting the admitting or attending physician, or discussing it with the resident or their family.

The facility's Adverse Consequences and Medication Errors policy, last revised June 2025, directed a medication error included omission where a drug was ordered but not administered.

When a resident received a new medication order, the facility reviewed the following: the dose, route of administration, duration, and monitoring consistent with current clinical practice; the written diagnosis supported the use of the medication; and documentation of the clinical rationale for using the medication if prescribed outside the accepted standard of practice.