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Based on policy and procedure review, medical record review, and interview, for 1 of 10 patients reviewed, nursing staff did not perform medication reconciliation accurately at the time of admission, resulting in the patient unintendedly receiving a medication throughout hospitalization that her primary care physician did not have ordered for her prior to admission.

Findings include:

Review of facility policy #CL.97 "Medication History: Process of Home Medication History thru Discharge Reconciliation Medication List", effective 6/27/11, revealed: "Reconciliation is the act of comparing a patient's home medications with the medications that will be ordered and prescribed during and at the conclusion of a hospital encounter. . . When the patient is received from another institution, the admission nurse or other provider is to obtain a list of the patient's home medications and document it in Powerchart. This list can be obtained from the patient, family and/or transfer paperwork." The policy stated that reconciliation of Initial Orders with Current Home Medications is then performed by the physician, pharmacist or nurse (who contacts the physician if there are concerns).

Medical record review for Patient A showed the transfer documentation dated 3/13/15 at 7:30 AM from the skilled nursing facility where Patient A resided contained documentation that Patient A had received Effexor 75 mg by mouth one time a day from March 1, 2015 through March 3, 2015 at the skilled nursing facility, and then the medication was discontinued.

Review of the medication reconciliation document for the day of hospital admission on 3/13/15 showed that prior to admission, Patient A had a history in the hospital's electronic medical record (EMR) system of taking Effexor 225 mg, 3 XR caps, po daily ordered by psychiatrist for mood. The Reconciliation Action as documented by nursing staff was "Convert to Inpatient". The first dose of Effexor was ordered to start 3/14/15 at 8:00 AM

Review of the medication list in the EMR revealed Patient A received Effexor daily from 3/14/15 through day of discharge 3/18/15.

Review of the physician's Discharge Summary addendum dated 3/18/15 at 10:47 AM revealed: "I spoke to patient's PMD (primary medical doctor) . . . and updated her about patient's hospital course. Patient was not on . . . Effexor . . . as outpatient and so . . . (it) will be discontinued at this time."

These findings were verified with Staff #8 on 7/15/15 at 1:45 PM.