F0760

D

Failure to Renew Time-Limited Discharge Medications Resulting in Missed Doses

Iowa City, Iowa Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident remained free from significant medication errors when routine medications were not reordered prior to the exhaustion of the supply, resulting in three full days without multiple prescribed medications. The resident had a moderate cognitive impairment with a BIMS score of 11/15 and diagnoses including Alzheimer’s disease, diabetes mellitus, thyroid disease, and atrial fibrillation. The resident had been admitted in early December with a series of hospital discharge medication orders written for 20 days. Review of the December Medication Administration Record (MAR) showed that numerous medications, including aspirin, atorvastatin, bupropion, vitamin D3, divalproex, donepezil, duloxetine, empagliflozin, levothyroxine, pantoprazole, polyethylene glycol, amiodarone, budesonide, Eliquis, formoterol, metoprolol, senna, and carbidopa-levodopa, were administered through December 28 but then had no further doses scheduled for December 29–31, as indicated by "x" marks for all scheduled times on those dates.

Review of the January MAR revealed that many of these same medications were not scheduled at all, indicating that they had not been renewed after the initial 20‑day period. An ED note from early January documented that the resident’s daughter called EMS because the resident was missing appointments and medications had been stopped without explanation, and the daughter reported the resident appeared more confused and was not eating; the ED note further stated that, upon speaking with the pharmacy, it appeared the resident’s discharge medications from previous visits had not been renewed while she was going between rehab hospitals. Staff interviews confirmed that the medications were not administered on December 29, 30, and 31, and that there was no documentation that nurses had brought the 20‑day duration of the discharge medications to the provider’s attention.

Nursing staff and leadership interviews revealed confusion and inconsistent understanding of responsibility for renewing time‑limited hospital discharge orders. One RN stated that when a resident has medications ordered for a certain time frame after admission, the nurse is responsible for notifying the physician to renew the orders, but also suggested that perhaps the pharmacy did not send the medications and reported believing it was the pharmacy’s responsibility to notify the doctor for renewal. Another RN verified that the resident’s medications were not administered for three days and described that an "X" on the MAR would indicate a scheduled medication, and that if a medication was not given there should be another code to indicate the reason; she also stated that if a medication was discontinued it would not appear on the MAR during pass and that the facility NP was responsible for reviewing medications after a hospital return. The NP could not recall the specific issue or explain why some medications had been discontinued. The DON stated she would have expected the nurse to question why medications were written to be discontinued after 20 days and to speak with the provider, and the ADON stated the nurse should always give discharge paperwork to the provider; the DON verified there was no documentation that nurses had alerted the provider about the 20‑day duration. Facility policies on Medication Reconciliation and Medication Reordering required systematic verification, transcription, ordering, and reordering of medications, including reordering when six or fewer doses remained, but these processes were not effectively carried out for this resident’s time‑limited discharge medications.