The Department found that the discharged resident (“Resident #1”), who lacked medical decision-making capacity and was non-English speaking, was discharged without a representative present, and their medications were not reviewed or verified at the time of discharge: “Resident #1 was discharged with a supply of medications that were ordered for Resident #2. Resident #1 ingested those medications for 7 days after discharge resulting in medical complications [REDACTED]. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy … there was no documented evidence the facility communicated discharge medication orders (other than insulin) or discharge instructions to Resident #1’s PHL surrogate.”
The Department determined: “The resident was initially admitted for post-acute care secondary to [MEDICAL CONDITION] after complications with stents,[MEDICAL CONDITION] (infection that spread to the blood) and [MEDICAL CONDITION]. The resident required temporary [MEDICAL TREATMENT]. – The resident was medically stable to be discharged to their relative’s home in another state. – The discharge medications were well documented in the permanent medical record and a 30-day supply of medications given to the resident … The resident arrived to PHL surrogate’s home with 2 pharmacy bags, one with their name on it and one with Resident #2’s name, although they did not notice Resident #2’s name at the time. Since the pill packets were stapled together, they did not realize the pills were for Resident #2. Both Residents #1 and #2’s medications were given to Resident #1 from [DATE] to [DATE]. – One bag also contained discharge paperwork for Resident #2 and a lab report for another unidentified resident … On [DATE], the resident’s primary care physician (PCP #8) in the community reported the following to the New York State Department of health (NYS DOH) via email: – Resident #1 was discharged from the nursing facility and moved out of state where PCP #8 took over their care. – Resident #1 came to PCP #8’s office on [DATE] for an appointment and brought the discharge paperwork and medications received from the nursing facility. The discharge paperwork included some of another resident’s discharge paperwork (Resident #2) and several sheets of Resident #1’s discharge paperwork were missing. – PCP #8 reviewed the pill packs Resident #1 received from the facility and noticed there were pills labeled for Resident #2. – Resident #1 received medications that were not ordered for them including [MEDICATION NAME] (anticonvulstant), [MEDICATION NAME] ([MEDICAL CONDITION] medication), and [MEDICATION NAME] (medication for muscle spasms). PCP #8 noted Resident #1 had [MEDICAL CONDITION] and was elderly and some of the medications provided could worsen kidney function and are generally unsafe in the elderly. PCP #8 noted [MEDICATION NAME] in someone with normal [MEDICAL CONDITION] function can cause [MEDICAL CONDITION] (over-active [MEDICAL CONDITION] function) which can be deadly. – PCP #8 checked the resident’s blood work and noted the resident was in renal (kidney) failure possibly related to these medications and had [MEDICAL CONDITION] (high potassium).”
“The resident was referred urgently to the emergency room (ER) … In the ER, the resident was put on a cardiac monitor and their heart rate was noted to be in the 20’s (normal range = ,[DATE]). – During the examination, the resident seized and became unresponsive, went into [MEDICAL CONDITION], was given one round of CPR (cardiopulmonary resuscitation), intubated (breathing tube inserted), and renal (kidney doctor) was consulted. – Hospital laboratory results documented the resident’s potassium level was 7.4 mmol/L(normal=3XXX,[DATE] mmol/L) on [DATE] at 2:48 AM. – The resident presented with [MEDICAL CONDITION] and was now in the MICU (medical intensive care unit) after suffering bradycardic (low heart rate) arrest likely from [MEDICAL CONDITION].”
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