Failure to Provide Discharge Medications to Resident
Penalty
Summary
The facility failed to ensure that a resident was discharged with all prescribed medications, specifically an as-needed opioid pain medication, as required by facility policy and physician orders. The resident, who had recently undergone hip replacement surgery and had diagnoses including end stage renal disease and acute postprocedural pain, was discharged home with home health care. Despite having a current physician order for Hydrocodone-Acetaminophen 5-325 mg to be taken as needed for pain, the medication was not sent home with the resident at discharge. Interviews with facility staff, including an LPN, the MDS nurse, the DON, and the Administrator, confirmed that the standard procedure was to send all current medications with the resident unless otherwise directed by the physician. The LPN responsible for the discharge did not send the pain medication, citing unclear instructions and without consulting the prescribing physician or the resident's primary healthcare provider. The MDS nurse and DON both confirmed that there were no orders to discontinue the medication and that the resident was expected to continue all current medications at home. Documentation reviewed included the resident's admission record, MDS, history and physical, physician orders, and discharge instructions, all of which indicated the ongoing need for pain management and continuation of prescribed medications. The controlled drug record showed that the remaining Hydrocodone-Acetaminophen tablets were destroyed after the resident's discharge, rather than being provided to the resident as required. The resident later contacted the facility to report that the pain medication had not been sent home.