Failure to Accurately Reconcile and Send Insulin at Discharge
Penalty
Summary
The facility failed to ensure that a discharged resident’s summary included an accurate reconciliation of all pre-discharge and post-discharge medications. The resident, an adult male with hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, bipolar disorder, type 2 diabetes mellitus, and a cognitive communication deficit, was discharged home to his sister, who was his POA. A physician’s order dated the day prior to discharge directed that the resident may discharge home with his sister with scheduled medications, no narcotics, and all other belongings. Progress notes confirmed the discharge home, and the discharge summary referenced the MAR for drug therapy. Record review showed that at the time of discharge, the resident had active orders for two types of insulin: Humalog (insulin lispro) 5 units subcutaneously twice daily, and insulin glargine 30 units subcutaneously twice daily, both ordered for diabetes management. The resident’s care plan identified diabetes mellitus as a focus and listed insulin glargine as a medication the resident was receiving, with interventions to monitor and document side effects and effectiveness of diabetic medications. However, the document titled “Medications Released on Leave of Absence,” which was saved in the electronic record as the discharge medication list and signed by the DON and the responsible party, did not list insulin as a medication sent home with the resident. Interviews revealed that the DON, who worked the shift of the discharge, gathered the resident’s scheduled medications (excluding narcotics) and had the responsible party sign the discharge medication list, stating she did not think the resident had insulin prescribed and that if he had, she would have sent it home. LVN A, the nurse assigned to the resident on the day of discharge, stated that the DON said she would handle the discharge medications and that insulin should be sent home with a resident being discharged, along with other scheduled medications except narcotics. In a subsequent interview, the DON acknowledged that the resident did have active insulin orders at discharge, that the insulin should have gone home, and that she overlooked it because the insulin was stored separately in the nurse’s medication cart while the medications handed to her came from the medication aide’s cart. The Regional Senior Administrator stated that, to her understanding, narcotics are the only medications not sent home at discharge, insulin usually goes home with residents, and there was no written policy specifying nurses’ actions for discharging a resident, though discharge processes were covered during nurse orientation. The facility guide for planned discharge documentation instructed staff to send medications, except discontinued medications and/or narcotics, with the resident or responsible party and to obtain verification signatures for medications received upon discharge.
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