Failure to Provide Medications and Follow Sign-Out Policy for Resident Leaving Facility
Penalty
Summary
A deficiency occurred when the facility failed to establish and follow a written policy regarding the return of residents after hospitalization and the provision of medications for residents leaving the facility. Specifically, a male resident with diagnoses including metabolic encephalopathy, psychosis, schizophrenia, and schizoaffective disorder, who was cognitively intact with a BIMS score of 14, was not provided with his required medications when he left the facility on pass. The resident had a history of behavioral and mental health issues that necessitated consistent medication administration. Record review showed that the resident's care plan identified him as a smoker at risk of injury, but there was no smoking assessment uploaded to his medical record. Interviews with the resident's primary care provider (PCP), a registered nurse (RN), and the director of nursing (DON) revealed that the facility's policy required residents to sign out when leaving and to receive their medications if they were cognitively able. The PCP and RN both expressed concerns that the resident was not safe without his medications, and the RN noted that the resident required education to take his medications properly. The DON confirmed that the nurse was responsible for ensuring the resident signed out and received medications, but was unsure who monitored compliance with this policy. On the day of the incident, the resident expressed a desire to leave, refused assistance from the social worker (SW), and exited the facility despite staff attempts to persuade him to stay. The facility's policy stated that medications needed during the resident's absence should be provided, along with instructions, but this was not done. The failure to provide the resident with his medications and to ensure proper sign-out procedures were followed constituted the deficiency.