Prescribing in the Nursing Facility: What Non-Nursing-Facility Doctors Need to Know

Sending a patient's medication orders to the nursing facility may seem straightforward. It may even give you a sense of reassurance that the challenges of polypharmacy,¹ medication timing, administration, and picking up medications from the pharmacy will no longer be the patient's responsibility, but instead will be handled by health care professionals. Unfortunately, just prescribing the medications to the facility doesn't guarantee the patient will receive them as ordered, on time, and as you intended.

When it comes to procuring and administering medications, nursing facilities (meaning both skilled and long-term care environments for the purposes of this article) have protocols and rules that may not be familiar to physicians who haven't worked in such settings. Here's what family physicians need to know.

To avoid delays in care, nursing facility clinicians need to approve admission medication orders from the hospital on the same day the patient leaves the hospital, prior to the patient's arrival at the facility. Best practice is for the hospital clinician to send their hospital discharge summary to the nursing facility at the same time the admission medication orders are sent. Unfortunately, the physician discharge summary is not always ready when a patient leaves the hospital (federal law only requires that hospitals make the discharge summary available within 48 hours). This opens the door for medical error. When the physician discharge summary is received after the day the patient is discharged from the hospital, there are often changes to the medication list or further clarifications to the recommended treatments. Such discrepancies can't always be avoided, so reviewing the discharge summary and updating facility orders to reflect any changes is an important step in admitting a patient to the nursing facility. If the hospital physician discharge summary is not available at the time the nursing facility clinician performs the initial visit and review of hospital documentation (within 24–72 hours), the review of the discharge summary and final verification of hospital orders may not be possible until the next visit. Depending on the acuity of the patient and availability of the clinician, the next visit could be in one day or 28 days. Thus, having the hospital clinician complete the discharge summary as soon as possible assures continuity of care and prevents medication errors during the transition from one medical setting to another.