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Based on review of hospital documents and staff interviews, it has been determined that the hospital failed to electronically submit a patient's medication to the correct pharmacy upon discharge, resulting in a delay in the patient receiving their medications for 1 of 1 patient reviewed who was receiving Subutex (medication that minimizes opiate withdrawal symptoms), Patient ID #1.

Findings are as follows:

A community reported complaint was submitted to the Rhode Island Department of Health on 9/1/2025, identifying that Patient ID #1, who was discharged from a hospital to a skilled nursing facility had to be sent out to an acute care hospital for opiate withdrawal symptoms after the skilled nursing facility was unable to obtain their prescriptions because the hospital sent the discharge prescriptions to the incorrect pharmacy.

Review of the patient's medical record revealed the patient was discharged from the hospital to a skilled nursing facility on 8/30/2025 at approximately 4:00 PM. The patients discharge medications were electronically sent to Omnicare of Rhode Island Pharmacy in error. One of the medications to be filled was Subutex, 8 milligrams, sublingual (under the tongue) to be taken twice daily.

During a surveyor interview on 9/4/2025 at 9:00 AM with the hospitals Discharge Planning Nurse, Staff B she confirmed that it is her role to complete the patient's discharge paperwork, which includes identifying the appropriate pharmacy for the physician to electronically send the patients prescriptions upon their discharge. She stated that the hospital keeps a list to refer to of skilled nursing facilities and their contracted pharmacies. Staff B stated she usually confirms the pharmacy with the skilled nursing facility but did not.

On 8/31/2025 Staff B stated she received a call from a nurse at the skilled nursing facility stating that Patient ID #1's medications were never delivered as expected from the pharmacy. After Staff B reviewed the hospitals discharge information, she noticed that she had entered the wrong pharmacy information for that facility which resulted in the physician sending the prescriptions to the wrong pharmacy.

This error resulted in Patient ID #1 not receiving the prescribed medications to prevent opiate withdrawal, resulting in the need to be sent out to an acute care hospital.



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