Failure to Review Discharge Instructions and Medication Disposition
Penalty
Summary
The facility failed to ensure proper discharge procedures for a resident, resulting in the resident being sent home with another resident's medications. Specifically, the discharge paperwork for the resident did not include evidence that discharge instructions or medications were reviewed with the resident or their representative. The medication administration records showed that the medications sent home (sulfamethoxazole and lisinopril) were not prescribed for the discharged resident, but for another resident. The discharge form lacked a nurse's signature as a witness, and the medication sticker for the other resident's medication was included in the discharged resident's record. Interviews with facility staff revealed a lack of awareness regarding the medication error, and the process for reviewing discharge paperwork and medications was not followed. The family of the discharged resident confirmed that no review of discharge paperwork or medications occurred at the time of discharge, and the medications were simply handed over in a bag. Facility policy required review and documentation of discharge planning and medication disposition, but these steps were not completed, leading to the error.