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Based on interview and record review, the hospital failed to ensure the nursing staff implemented the medication reconciliation P&P for one of three sampled patients (Patient 1). This failure had the potential to cause poor patient outcomes due to lack of communication and delayed treatment.

Findings:

Review of the hospital's P&P titled Medication Reconciliation last revised 03/2025, showed:

* Purpose: To define the medication reconciliation at the hospital.

* Definitions:

- Medication Reconciliation: A process for identifying the most accurate list of all medications the patient is taking, including name, dosage, frequency and route by comparing to home medication list in the electronic health record to the medication list obtained from the patient, or other provide(s), or other organization(s) or sources such as prescription claim database and resolving any discrepancies found.

- Medication: Medications include prescription drugs/products, non-prescription drugs/products, herbal, and/or dietary supplements, homeopathic products, and home remedies.

- Staff: Medical Assistant, Licensed Vocational Nurse, Registered Nurse, Pharmacy Technician, or Pharmacist, etc.

- Provider: Physician or physician extender

* Policy: The home medication list will contain the following elements: medication name, dose, route, frequency, and for "as needed" medications, the indication.

* Procedures:

A. When patient is admitted to inpatient or seen in a non-24-hour setting, staff will obtain a list of current medications the patient is taking prior to admission or prior to the visit, as described by the patient or his/her designee and verify whether the patient is taking the medications as prescribed or instructed.

B. The staff will compare the home medication list with what was recorded in the electronic health record as the patient's home medication list and update the list.

C. For Inpatient:

1. A provider from the admitting service will review the home medication list and order the medications are to be continued as inpatient, determines which ones are to be held and which ones are to be discontinued based on the patient's clinical condition.

On 12/11/25 Patient 1's closed medical record was reviewed with the Associate Administrator and the Risk Manager.

Patient 1's medical record showed the patient was admitted to the hospital on 10/5/25.

Review of the ED Note-Physician dated 10/5/25 at 2256 hours, showed Patient 1's home medications. The general assessment section showed no "edema." Patient 1's list of home medications contained torsemide (diuretic medication) 20 mg oral tablet, 2 tablets daily.

Review of the Admission H&P dated 10/6/25 at 1255 hours, showed "No edema". The list of medications ordered did not include a diuretic as per Patient 1's home medications list.

Further review of Patient 1's medical record showed that on 10/6/25, the patient was evaluated by the infectious disease (ID) physician. The ID provider notes showed the following:

* On 10/6/25 at 1430 hours, the ID provider documentation showed "BLE edema."

* On 10/7/25 at 1850 hours, the ID provider note showed "edema both legs."

* On 10/8/25 at 2020 hours, the ID provider documented "edema both legs."

* On 10/9/25 at 1330 hours, the ID provider follow up visit note showed "edema both legs."

Review of the nursing documentation dated 10/5, 10/6, 10/7, 10/8, and 10/9/25, failed to show an ongoing accurate assessment and evaluation of Patient 1's lower extremity edema or evidence that the physician was notified of the patient's condition.

Review of Patient 1's Medication Administration Record showed a one-time order for "40 mg Lasix (a diuretic medication), IVP." dated 10/9/25 at 1100 hours. The medication was administered on 10/9/25 at 1116 hours, prior to the patient's transfer to a higher level of care.

The above finding was verified by the Associate Administrator.