Failure to Provide Prescribed Medication at Discharge
Penalty
Summary
A 93-year-old resident admitted for short-term rehabilitation was discharged to his daughter's home. Upon review of the electronic medical record and interviews, it was found that the resident was prescribed multiple medications, including Metoprolol Succinate ER 12.5 mg twice daily. After discharge, the resident's daughter discovered that the Metoprolol was missing from the medications sent home, and also found a medication belonging to another resident mixed in with the discharge medications. Interviews with facility staff revealed that the discharge process includes reviewing and itemizing medications with the resident or their representative to ensure accuracy. The facility's policy requires complete client and family education about treatments and medications, as well as arranging for medication needs at home. Despite these procedures, the resident did not receive all prescribed medications at discharge, and an incorrect medication was included among those provided.