Failure to Document and Reconcile Discharge Medications
Penalty
Summary
The facility failed to ensure that the Post Discharge Plan of Care for a resident discharged to a board and care facility was completed according to its own policy and professional standards. The discharge documentation did not include the names, dosages, or amounts of post-discharge medications, specifically omitting details about a controlled substance, Norco, which was dispensed in significant quantity. The medication section of the discharge plan was left blank, and there was no indication of the interdisciplinary team member responsible for completing the document, nor was there a signature from the party accepting the plan. The resident in question had a history of Alzheimer’s disease, cardiomegaly, difficulty walking, and a history of falls, and required supervision or assistance with daily activities. The resident was discharged with a large quantity of Norco, a narcotic pain medication, but the physician order did not specify which medications or amounts were to be provided upon discharge. The discharge summary and transfer/discharge report also failed to document the specific medications and quantities given to the resident or their family. Interviews with facility staff revealed that the normal process for discharging a resident with narcotics was not followed, and the documentation was incomplete due to the nurse being in a hurry. Further, the attending physician was not informed about the medications being sent with the resident and stated that he would not have approved the discharge of Norco due to its risks. The facility’s policy required a reconciliation of all pre-discharge and post-discharge medications, but this was not completed. The lack of proper documentation and communication regarding the controlled medication placed the resident at risk, as noted in the report.