Failure to Provide Discharged Resident with Prescribed Medications
Penalty
Summary
A resident with an intact mental status and multiple medical conditions, including a history of stroke, congestive heart failure, and chronic pain, was discharged to another facility without her prescribed medications, including controlled substances for pain and anxiety. The resident was private pay and had recently received refills for her medications, which included Lyrica, Hydrocodone/Tylenol, and Lorazepam. Upon arrival at the receiving facility, it was discovered that none of her medications had been sent with her, leaving her without necessary pain management for over 10 hours. Staff interviews revealed that the facility's standard discharge process was to return unused medications to the pharmacy and destroy controlled substances, regardless of the resident's payment status or ownership of the medications. The Director of Nursing confirmed this process was followed in this case and was unaware of the facility's policy that allowed for the release of controlled substances upon discharge if permitted by state law and authorized by the physician. The failure to provide the resident with her medications upon discharge resulted in a gap in her pain management and did not honor her right to retain and use personal possessions.