HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 4 clinical records (Pt #1) reviewed for medications prescribed following discharge, the Hospital failed to ensure that the discharge medication list was accurate.

Findings include:

1. The Hospital's policy titled "Patient/Family Discharge and Aftercare Plan" (dated 8/2023) was reviewed and required, "The Physician completes the discharge order: Provides prescriptions for current psychotropic medications...RN (Registered Nurse) checks chart for prescriptions and gives to patient/family...RN completes discharge note, including date, time, type of discharge, manner in which patient left, destination, patient's status and who accompanied patient. Note if prescriptions were given to patient/family and that family/patient was instructed about how to administer medication at home. Document education provided for appropriate medical care/follow-up as needed."

2. Pt #1's clinical record dated 11/20/2023 thru 11/27/2023 was reviewed and indicated:
-Pt #1 was admitted to inpatient behavioral health unit on 11/20/2023 with the diagnosis of paranoid schizophrenia.
-Pt #1's discharge medication summary report, completed on 11/24/2023, noted, "these discharge prescriptions ePrescribed to local pharmacy" included "Remeron [antidepressant] 45 mg at bedtime, Cogentin [anti-tremor] 2 mg twice a day and Zyprexa [antipsychotic]10 mg at bedtime." The discharge medication summary was signed by Registered Nurse (no longer employed at the Hospital) and Pt #1 on 11/27/2023.
-Pt #1's discharge medication summary dated 11/27/2023, and signed by MD #1, for Pt #1 noted the following medications:
-Cogentin 2 mg twice a day for eps (extrapyramidal side effects - drug induced movements disorders), Remeron 45 mg at bedtime for sleeplessness, Zyprexa 10 mg at bedtime for major depressive disorder, and Risperdal [antipsychotic] 2 mg twice a day for mood/psychosis.

3. On 2/13/2024 at 2:30 PM, an interview was conducted with MD #1. MD #1 stated that Pt #1's Zyprexa was discontinued on 11/24/2023, and Pt #1 was started on Risperdal 2 mg twice a day (beginning 11/24/2023). MD #1 stated that Pt #1 was supposed to be discharged with a prescription medication order for Risperdal not Zyprexa. MD #1 stated that it may have been his error that Pt #1 signed a discharge medication summary (discharge prescriptions sent to pharmacy) for Zyprexa instead of Risperdal. MD #1 stated that MD #1 cancelled the Zyprexa with the pharmacy prior to Pt #1's discharge, and the pharmacy did not dispense Zyprexa. MD #1 stated that the pharmacy dispensed Risperdal, not Zyprexa. [This was confirmed through review of report which had been obtained from pharmacy where ePrescription had been sent.] However, MD #1 did not ensure that the discharge paperwork had been updated before Pt #1 signed and was discharged.