Resident Discharged with Another Resident's Medications Due to Discharge Process Error
Penalty
Summary
A deficiency occurred when a resident was discharged from the facility and was inadvertently provided with medications belonging to another resident. The error was discovered after the responsible party (RP) administered the incorrect medications for four days before noticing that the medication packaging had another resident's name. The RP reported that the resident became confused and exhibited jerking motions in her arms, prompting a visit to the emergency department (ED) for evaluation. The ED assessment found the resident to be clinically stable, with normal laboratory and electrocardiogram results, and no evidence of a major medication reaction. The incident was precipitated by a rushed discharge process during a shift change. The RP took the resident to the car without notifying the nursing staff, and when prompted, returned to the facility to receive discharge instructions and medications. Two nurses were involved in reviewing and handing over the medications, but neither identified that medications belonging to another resident were included in the discharge bag. Both nurses confirmed that the resident's narcotic pain medication was properly counted and signed out, but could not explain how the other resident's medications were included. Interviews with the resident, RP, nursing staff, and the medical director confirmed the sequence of events. The resident did not recall the ED visit, and the RP admitted to not reviewing the medication instructions provided by the facility, instead relying on the medication cards. The medical director and DON acknowledged that the error occurred during the discharge process and was only identified after the hospital notified the facility. The facility's records and interviews confirmed that the resident was cognitively intact at admission and that the error was not detected until after discharge.