F0628

D

Failure to Ensure Safe Discharge and Correct Medications at Discharge

Palos Hills, Illinois Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe discharge and transfer, including providing the correct medications and required documentation or notification related to the resident’s needs, appeal rights, or bed-hold policies. A resident with end stage renal disease and dependence on renal dialysis was discharged home with the wrong medications. Interview with the resident’s family member indicated that the facility called their cell phone after discharge and asked them to bring the medications back, and the family confirmed that the medications they initially received were not theirs. The family reported that they returned the medications and that they were not used.

An LPN reported that on the day of discharge she educated the resident’s family on the medications, and the family expressed understanding before leaving with the medications. About an hour later, the LPN noticed that the resident’s medications were still at the facility and realized the family had been discharged with the wrong medications, prompting a call to the family to return and exchange them. The DON stated that nurses are expected to use a two-nurse system to verify correct medication and dosage at discharge, and acknowledged that the resident had been discharged with the wrong medications. Record review showed a discharge home order, an order summary with the resident’s medications, a care plan to administer medications as ordered, a discharge summary progress note documenting medication education and discharge teaching, and an incident report for discharge of wrong medications. The facility’s discharge policy requires completion and review of discharge instructions and a medication list with the resident or representative, and that all appropriate medications be given per physician orders at the time of discharge.