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CLEAR VISTA HEALTH & WELLNESS
DISCHARGE PLANNING- TRANSMISSION INFORMATION
Tag No.: A0813
Based on record review, interview and policy review, the facility failed to ensure a patient received prescribed medications at discharge. This affected one (Patient #5) of ten patients reviewed.
Findings include:
Record review revealed Patient #5 was admitted from an emergency department on 08/30/23 with a diagnosis of bipolar disorder, in the manic phase.
Review of progress notes dated 09/11/23 at 10:30 AM stated Patient #5's responsible party was called regarding discharge planned for tomorrow [09/12/23].
Review of the discharge summary by Nurse Practitioner (NP) #100 documented Patient #5's mood had stabilized with utilization of psychotropic medication and non-therapeutic intervention with this patient receptive to all interventions and engaged. The discharge summary stated medications were sent to the pharmacy via the electronic system.
Discharge instructions were given on 09/12/23 with the list of medications (Clonazepam, Hydrochlorathiazide, Lisinopril, Gabapentin, Trileptal, Geodon and Prilosec) sent to their pharmacy electronically by the nurse practitioner.
The electronic record for medications was reviewed with Staff E on 12/14/23 at 2:30 PM. Staff E stated Health Care Strategies (HCS) is a electronic medication record system that communicates with pharmacies and hospitals. The medical record for Patient #5 was reviewed with Staff E. The electronic prescription was attempted to be sent to Walgreens on 09/12/23 but a response note stated "Error cannot send, the order is configured not to send".
During interview on 12/14/23 at 3:56 PM., NP #100 stated she didn't know of this ever happening before, they don't get any error information reports.
During interview on 12/14/23 at 4:15 PM, Staff E verified the discharge medications for Patient #5 were never sent to the pharmacy.
Review of the policy titled "Discharge Process", dated July 2017, instructs the physician at discharge to write any applicable prescription, or they may call the prescription into the pharmacy and note this on the discharge form.