Failure to Provide Adequate Medication Supply at Discharge
Penalty
Summary
The facility failed to ensure that a resident received an adequate supply of medications upon discharge to home. The resident, who was cognitively intact and admitted for a short-term rehabilitation stay with diagnoses including epilepsy, was discharged following a planned process that included care conferences and discharge planning interventions. Despite these preparations, there was no documentation that prescriptions were sent to the pharmacy upon discharge, and the resident was only sent home with the remaining medications available at the facility, rather than a two-week supply as ordered. Staff interviews revealed that the registered nurse responsible for the discharge was not aware of the discharge until the resident's spouse arrived and demanded it. The nurse obtained a telephone order from the physician to discharge the resident and to send the remaining medications, but was unsure of the exact quantity provided. The facility's typical process of sending electronic prescriptions to the pharmacy was not followed, and there was no evidence that prescriptions were sent for the resident to obtain additional medication after discharge. The Director of Nursing confirmed that the facility did not have documentation of electronic prescriptions being sent and that the resident was only discharged with the remaining medications on hand. The facility's discharge planning policy did not specify the amount of medication to be sent with residents upon discharge. There was no indication in the record that the resident or their representative reported issues obtaining medications after discharge, but the lack of proper documentation and follow-through on medication supply constituted the deficiency.