Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that prescribed medications were sent with a resident upon discharge. Record review showed that a resident with multiple complex diagnoses, including acute kidney failure, acute respiratory distress syndrome, bacteremia, sacral pressure ulcer, congestive heart failure, and atrial fibrillation, was discharged after a respite stay. The resident was dependent for all activities of daily living and had an intact cognition. The discharge documentation included a handwritten list of medications, but the sections indicating which medications were sent with the resident and which prescriptions were called in for pick-up were left blank. Additionally, the discharge form was not signed or dated. Interview with the DON confirmed that nursing staff did not complete a full discharge assessment and did not ensure that medications were provided to the resident at discharge. Review of the facility's discharge policy indicated that a discharge summary should include a reconciliation of all medications and a post-discharge plan of care, but these requirements were not met in this case.