HospitalInspections.org

Based on interview and record review, the facility failed to provide clear and accurate medication discharge instructions for post hospital care for 2 of 4 discharged patient records reviewed (#1 & 2).

Findings:

1. Review of patient # 1's record revealed an admission date of 1/15/21 and a discharge date of 1/19/21. Diagnosis included Bipolar disorder, current episode mixed, and borderline personality disorder. Review of the physician's discharge summary on page 2 under "Discharge Medications" read, "Trazadone 50 mg. (milligrams) nightly,
Zyprexa 5 mg. PO (by mouth) nightly, Prozac 20 mg. PO daily." Under the "Home Medication List" read, "Paxil 20 mg. PO every morning for depression/anxiety."

The Medication administration record showed the patient was given Paxil 20 milligrams in the hospital until 1/16/21, when it was discontinued. The record contained a "Discharge Current Medication List" that read, "Prozac 20 mg. oral route, indications-depression - Continue at discharge? No." A line was marked through an area that read "Script given"; Zyprexa 5 mg. oral route - nightly- indications-Psych. Continue at discharge? Yes. Script given showed a check mark and also a line though it. Trazadone 50 mg. oral route indication - depression. Script given" showed a check mark with a line through it. At the bottom of the form read, "DO NOT TAKE ANY OTHER MEDICATIONS THAT ARE NOT LISTED ABOVE-DESTROY ANY OTHER MEDICATION LISTS."

Patient #1's record showed copies of prescriptions were given to the patient. The prescriptions listed Trazadone 50 mg. PO every hour/sleep #15-one refill, Zyprexa 5 mg. PO every hour/sleep #15 one refill, Prozac 20 mg. PO every day #15, one refill.

In an interview with the Director of Quality Assurance/Process Improvement on 1/29/21 at 1:20 PM, the discharge summary home medication list and the patient discharge list was discussed. She related the physician did not document that the Paxil 20 mg. was to be discontinued and it was unclear why it was not designated to be discharged and not continued in the discharge form.

2. Review of patient #2's record revealed admission to the facility on 1/07/21 and discharged on 1/13/21. Diagnosis included Paranoid schizophrenia. Review of the physician's Discharge Summary revealed on page 2 an area that documented "Discharge Medications: Depakote 250 mg. PO twice daily."

Patient #2's "DISCHARGE CURRENT MEDICATIONS LIST" included documentation of "Depakote 750 mg. oral route frequency-AM/PM, indication- mood, continue at discharge- Yes, script given. The record contained a copy of the prescriptions that were given to the patient. The prescriptions included Depakote 250 mg. take 3 PO twice daily #90 with 1 refill.

In an interview with the Director of Quality Assurance/Process improvement on 1/29/21 at 2:00 PM, she related the discharge medication list was confusing and unclear and did not reflect the same dosages as stated in the discharge summary and was confusing regarding the daily Depakote milligram dosages.