Failure to Reconcile and Transfer Discharge Medications
Penalty
Summary
The facility failed to ensure proper reconciliation and transfer of discharge medications for one resident who was discharged to an assisted living (AL) facility. The resident, who had complex medical needs including Alzheimer's/dementia, Parkinson's disease, anxiety, depression, congestive heart failure, and pulmonary hypertension, was discharged following a hospital stay and had an activated Power of Attorney for Healthcare. At the time of discharge, the resident did not receive their prescribed medications, and the facility did not maintain documentation of which medications, if any, were delivered to the AL facility. Interviews with the AL facility director revealed that the AL facility was unable to obtain the resident's medications from the pharmacy because they had already been filled by the nursing facility less than 30 days prior. The AL facility communicated with the nursing facility multiple times, requesting that medications be sent with the resident, but the resident arrived at the AL facility without them. The AL facility director reported that the resident missed three doses of carbidopa levodopa and one dose of amantadine, both critical for managing Parkinson's disease symptoms. Family members attempted to retrieve medications from the resident's home, and the nursing facility eventually delivered some medications the day after discharge, but there was no record of which medications were provided. Facility staff, including the social worker, nurse manager, and director of nursing, were unable to provide documentation or recall specific details regarding the transfer of medications. Pharmacy records indicated that certain medications were filled by the facility and could have been sent with the resident, but there was no confirmation or documentation of this. The nursing home administrator stated that reimbursement was offered for medication costs, but there was no documentation of this offer being communicated or received by the AL facility. The lack of documentation and communication resulted in the resident missing essential medication doses after discharge.