Resident Discharged Without Adequate Medication Supply
Penalty
Summary
The facility failed to ensure that a resident was discharged with an adequate supply of prescribed medications. Record review showed that the resident, who had diagnoses including intractable epilepsy, severe intellectual disabilities, PTSD, bipolar disorder, and conversion disorder with seizures, was discharged to home with family. The care plan included interventions for safe discharge, such as involving home care agencies and providing written instructions. Physician orders indicated the resident required zonisamide for seizures and midodrine for hypotension. However, at discharge, only nine capsules of zonisamide and two tablets of midodrine were sent home with the resident, despite pharmacy delivery records showing that larger quantities had been delivered to the facility prior to discharge. Further review revealed that 120 capsules each of zonisamide and midodrine were returned to the pharmacy after the resident's discharge, indicating that the full supply was not provided to the resident. The LPN Unit Manager responsible for the discharge stated that she removed all medications from the resident's slot in the medication cart but may have overlooked additional medications stored in the overflow area. She also confirmed that she did not call in any medications to the resident's pharmacy. Facility policy required a discharge summary with medication reconciliation, but this was not adequately followed, resulting in the resident being discharged without sufficient medication.