HospitalInspections.org

Surveyor: 15168
A. Based on Hospital Policy, clinical record review and staff interview, it was determined that in 1 of 5 (Pt. #1) clinical record of discharged patients, the Hospital failed to ensure the nurse give the correct medication list to the correct patient prior to discharge.
Findings include:

1. Hospital Policy entitled, " Verification of Patient Identity, " reviewed on 10/11/11 at approximately 9:25 AM required, " It is the policy of ... ... ... ...Hospital to ensure the patient identification is confirmed using two-specific identifiers, patient name and birth date... "

2. The clinical record of Pt. #1 was reviewed on 10/11/11 at approximately 10:00 AM. Pt#1 was a 72 year-old female admitted to the Hospital on 4/3/11 with diagnoses of Right Leg Cellulitis and Bilateral Knee Pain. On 4/6/11, Pt. #1 was transferred to a Skilled Nursing Facility (SNF) and given Pt.#2's medication list. Pt.#2 was a 60 year-old female with the same first and last names as Pt#1.

3. On 10/12/11 at approximately 10:00 AM, the nurse (E#2) caring for Pt. #1 on the day of discharge was interviewed. E#2 stated that she was the day shift nurse caring for Pt#1 and that when she prepared the discharge medication list and printed it from the computer, she did not notice that the list was for Pt#2 and not Pt#1 because they both had the same first and last names. E#2 stated that she did not notice that Pt#1's inpatient medications were not included on the medication reconciliation list.

4. On 10/12/11 at approximately 1:00 P.M., Pt#1's primary physician (E#4) was interviewed via telephone. E#4 stated that he had been Pt#1's physician for approximately 30 years and that when Pt#1 was discharged on 4/6/11 to the SNF to await knee replacement, he did not notice that the medication on the Medication Reconciliation Form had the name of the wrong patient (Pt #2). E #4 stated that when he "now" discharges a patient, he carefully reviews the reconciliation form for correct names, date of birth and list of medications before signing the medication forms.

5. On 10/12/11 at approximately 1:30 PM, the nurse (E#3) who discharged Pt#1 on 4/6/11 was interviewed. E#3 stated that on 4/6/11, Pt#1 was discharged around 4:00 PM to a SNF and that she was told by E#2 that all discharge paper work was completed and that Pt#1 was ready to be discharged. E#2 stated that she give Pt.#1 the discharge medication list given to her by E#3 and did not review the forms for completeness or accuracy at that time.

6. The above findings were verified by the Nursing Quality Safety Coordinator (E#1)during an interview on 10/13/11 at approximately 1:45 PM.

Surveyor: 16853

A. Based on Hospital policy, clinical record review and staff interview, it was determined that in 1 of 5 (Pt#3) discharged patients, the Hospital failed to ensure that patients were not discharged with duplicate medications.

Findings include:

1. Hospital policy # 28.12 titled, "Medication Reconciliation," was reviewed on 10/12/11 at approximately 3:30 P.M. The policy required, "Inpatients, observation patients, and outpatients who will be receiving medications during their hospital visit, will have all home medication(s) reconciled within 24 hours of admission. Medications will also be reconciled prior to discharge and with patient transfers involving a change in level of care."

2. The closed clinical records of Pt #3 was reviewed on 10/11/11 at approximately 11:30 AM. Pt #3 was an 87 year-old male from a Skilled Nursing Facility (SNF) admitted on 7/31/11 with diagnoses of Urinary Tract Infection and Possible Pneumonia. Pt.#3's list of medications from the SNF included, Potassium Chloride liquid 10%, 15 ml (milliliter) with 4 to 6 oz (ounces) of liquid, oral once daily. The admission Medication Reconciliation/ Physician Order form on 7/31/11 indicated to continue the order of Potassium 10%, 15 ml.

3. On 10/11/11, the Medication Administration Record (MAR) dated 7/31/11 was reviewed. The MAR listed Potassium Chloride 20 mEq(milliequivalent)/15 ml q AM (every morning) dilute with 4 - 6 oz liquid. On 8/3/11, the physician order an increase in the above potassium from daily to twice daily.

4. On 10/11/11, Pt.#3 clinical record reviewed indicated that Pt. #3 was discharged on 8/5/11 and the Reconciled Discharge Medication List of 8/4/11 included 2 orders of potassium: Potassium Chloride liquid 10%, 15 ml with 4 to 6 oz of liquid, oral once daily and Potassium Chloride 20 mEq (milliequivalent)/15 ml q AM twice daily, dilute with 4- 6 oz. liquid.

5. On 10/11/11, Pt.#3's clinical record reviewed also indicated that Pt.#3 was readmitted again on the following dates:

- 8/6/11: Admitted to the Emergency Department (ED) with Exacerbation of Chronic Obstructive Pulmonary Disease (COPD). The medication list from the Skilled Nursing Facility (SNF) included the same 2 orders of potassium (Potassium Chloride Capsule, Extended Release, 10 meq, amt 20 meq, oral twice daily and Potassium Chloride liquid 10% amt 15 ml oral once a day). Pt. #3 was discharge on 8/6/11 in stable condition with the same two orders or Potassium. There was no admission and discharge medication reconciliation record found for PT.#3.

- 8/14/11: Admitted to the ED with Shortness of Breath (SOB), Renal Insufficiency and Hyperkalemia. The medication list from the SNF included the same 2 orders of Potassium (Potassium Chloride Capsule, Extended Release, 10 meq, amount 20 meq, oral twice daily and Potassium Chloride liquid 10 %, 15 ml, oral once a day). The lab report of 8/14/11 indicate a Potassium level of 6.6 mmol/L (millimole/Liter)-Reference range (3.5 - 5.1 mmol/L). During hospitalization, Pt.#3's potassium level was monitored and stabilized and the physician ordered a one time dose of Potassium 20 meq on 8/20/11 because the potassium had reduced to 3.3 mmol/L. The Discharge Medication Reconciliation order dated 8/19/11 included Potassium 15 ml oral every day. However, the Discharge Medication List was not found in the clinical record. Pt.#3 was transferred to an Assisted Living Facility per family request in a stable condition on 8/20/11.

- 8/23/11: At 1:40 PM, Pt.#3 arrived via ambulance from the Assisted Living Facility to the ED unresponsive. On arrival in the ED , the cardiac rhythm was asystole and vital signs on arrival were: B/P - 0/0; Pulse - 0; Respiration - 0. Pt.#3 was pronounced dead at 1:46 PM. Documented information from the Assisted Living Facility indicated that Pt.#3 administered his own medication.

6. On 10/13/11 at approximately 9:30AM, the Clinical Manager of Pharmacy Department (E#6), was interviewed. E#6 explained that the Medication Reconciliation/ Physician Order Form was used to generate the patient's inpatient medications in the (MAR) and for the reconciliation of admission and discharge medications. E#6 stated that Potassium Chloride liquid 10%, 15 ml is not stocked in the pharmacy and Potassium Chloride 20 mEq/15 ml was substituted. E#6 stated these are equivalent dosage. On 10/19/11, E#6 provided the AHFS (American Hospital Formulary Service) Drug Information 2011 on Potassium Supplements to support the above substitution.

7. On 10/20/11 at approximately 11:00 AM, a telephone interview with Pt #3's Physician (E #8) for the admission 7/31/11 -8/5/11 was conducted. E #8 stated that on 8/5/11/ discharge, he intended the order to be only for Potassium Chloride 20 mEq/ 15 ml, oral, twice daily since Potassium 10% was the same medication and did not intend to include 2 orders of potassium for Pt.#3.

8. On 10/13/11 at approximately 11 :00 AM, Pt #3's Physician (E#5) for admission 8/14/11 was interviewed. E#5 stated that Pt#3 was his patient at the SNF and may have seen Pt#3 in the hospital while covering for another physician. E#5 stated that the patient should only have received one prescription of potassium order on 8/5/11 and has no recollection of the discrepancy in the order.

9. On 10/13/11 at approximately 11:10 AM, the above findings were confirmed with the Pt.#3's Physician (E#5) and the Director of Risk Management (E#10).