Incorrect Medication Sent Home at Discharge Due to Failed Medication Reconciliation
Penalty
Summary
Surveyors identified a deficiency in the facility’s discharge process related to medication reconciliation and accuracy of prescriptions provided at discharge. The facility’s own Discharge Planning policy, dated 10/01/2021, required that when discharge is anticipated, the facility prepare a discharge summary that includes reconciliation of all pre-discharge medications with the resident’s post-discharge medications. For one resident with a diagnosis including rhabdomyolysis and moderate cognitive impairment, the admission MDS dated 11/28/2025 documented this cognitive status. The resident reported that after discharge they were taking four medications daily, and later discovered with their case worker that one of the medications provided by the facility had another person’s name on the container. Record review of the resident’s December 2025 MAR showed only three prescribed medications ordered to be sent home at discharge, indicating a discrepancy between the reconciled medication list and what was actually provided. During an interview, the DON acknowledged the facility had been made aware that an incorrect medication, belonging to another resident, was sent home with this resident at discharge. The DON also stated that the nurse who provided the wrong medication had been identified. This sequence of events demonstrated that the prescriptions and medications supplied at discharge did not accurately reflect the reconciled medication list in the discharge summary for this resident.
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