F0658

D

Resident Discharged Home With IV Access Device and Another Resident’s Medications

New Rochelle, New York Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that services provided met professional standards of quality when a resident was discharged home with an intravenous (IV) access device still in place and with medications that belonged to another resident. The resident had diagnoses including seizure disorder, hypothyroidism, and malignant neoplasm of the brain, and an admission MDS documented moderately impaired cognition. A physician’s order dated 03/14/2025 authorized a midline IV and 0.45% sodium chloride IV solution at 50 cc/hour every shift for nine doses for hydration, and this order was discontinued on 03/17/2025. On the same day, nursing notes documented that the resident was discharged home with medications taken and with discharge medications provided. The facility’s Day of Discharge Protocol and Procedure required licensed nurses to verify discharge medications with two nurses for accuracy and to remove all medical appliances, such as IV lines, per physician’s order prior to discharge.

Despite these requirements, the resident’s interdisciplinary discharge summary did not include any discharge plan or care instructions related to the IV access device. An occurrence report investigation documented that the facility was notified by a hospice nurse that the resident had been discharged home with an IV access device still in place and a blister pack of medication that did not belong to the resident. The Director of Nursing’s review of the incident found that the nurse responsible for the discharge disconnected the IV line but did not remove the IV access device, and that the resident was given discharge medications that included another resident’s blister pack. These actions and omissions occurred during the discharge process conducted by the nursing staff on the unit.