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Based on record review and interview, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by failing to clarify discontinued medications from the ED with the physician during admission for 1 (#2) of 7 records reviewed for admit to the hospital.

Findings:

Review of the policy titled Nursing Services, Initial Nursing Assessment and Admission Data, Number 7003, dated 06/12/07 revealed in part: Admissions data: 3. Current medication- Licensed staff gather information regarding patient/resident's current/previous medication use. The RN assesses the patient/resident's use of current medication to determine his/her need to continue a certain medication due to untoward effects of abruptly discontinuing medications. The RN conveys information to the physician.

Review of Paitent #2's medical record revealed that she was admitted to the behavioral hospital on a PEC for homicidal and violent behaviors, a danger to self, danger to others, and gravely disabled from an acute care hospital on 02/03/17. Patient #2's diagnoses were documented as Schizphrenia, MR, HTN, OA, and DJD.

Review of Psychosocial note dated 02/03/17 revealed patient #2 had multiple past hospitalizations for aggressive/violent behaviors. Patient #2 resides in a group home in Alexandria with 24 hour caregivers.

Review of patient #2's admission record revealed information sent to the behavioral hospital from the ED that listed home medications as follows:
Meloxicam (Mobic) 7.5 mg daily.
Gemfibrozil (Lopid) 600 mg PO BID.
Calcium Citrate/Ergocalciferol PO daily.
Cetrizine (Zrytec) 10 mg PO daily.
Potassium Chloride (KCL 20%) 40 MEQ PO daily.
Latanoprost (xalatan 0.005%) 1 drop each eye daily.

Further review of the information from the ED record listed medications discontinued as follows:
Desmopressin (DDAVP) 0.2 mg PO daily.
Ferrous Sulfate 325 mg PO daily.
Calcium Citrate (Citrical) 950 mg PO daily.
Potassium Chloride (K-DUR) 20 MEQ PO daily.
Propranolol (Inderal) 10 mg PO BID.
Docusate Sodium (Colace) 100 mg PO BID>
Polyethylene Glycol 3350 (Mirilax) 17 grams PO daily.
Furosemide (Lasix) 20 mg PO daily.
Fluticasone Propionate (Flonase 50 mcg/act) 2 sprays daily.
Meloxicam (Mobic) 7.5 mg PO daily.
Gemfibrozil (Lopid) 600 mg PO BID.
Calcium Citrate/Ergocalciferol PO daily.
Cetrizine (Zrytec) 10 mg PO daily.
Potassium Chloride (KCL 20%) 40 MEQ PO daily.
Latanoprost (xalatan 0.005%) 1 drop each eye daily.
Lisinopril (Zestril) 5 mg PO daily.
Valproic Acid (Depakene) 5oo mg PO daily.
Valproic Acid (Depakene) 100 mg PO Bedtime.
Norethindrone/Ethinyl Estradol (Necon 7/7/7) 1 tab PO daily.
Loperamide 2 mg daily PRN diarrhea.
Calcium Carbonate (Tums) 2 tab PO PRN indigestion.
Acetaminphen (Tylenol) 650 mg PO q4 hours PRN Pain/Fever.
Paliperidone (Invega) 6 mg PO daily.

Review of Initial Nursing Assessment dated 02/03/17 for medication reconciliation stated "See MAR", further review revealed Home Medications Identified as follows:
Mobic 7.5 mg 2 PO daily.
Lopid 600 mg PO BID.
Citrus Calcium D 950 mg PO daily.
Zyrtec 10 mg PO daily.
Potassium 40 MEQ PO daily.
Latanoprost 1 drop each eye daily.
Amoxicillin 875 mg PO BID X 8 days.
Further review of patient #2's record revealed no documentation of clarifying any of the discontinued medications listed from the ED documentation.

Review of the History and Physical dated 02/04/17 revealed S3FNP documented home medications reviewed.

Interview on 03/08/17 at 11:05 a.m. with S3FNP confirmed after reviewing patient #2's medical record stated that you usually don't see the ED discontinuing home medications. S3FNP was not sure why the medications were discontinued in the ED. S3FNP stated that she doesn't remember looking at the list of medications sent to the ED from the group home. S3FNP further stated that if there are any discrepancies with the medications the nursing staff will contact either the group home in this case or the primary physician for a current list of medications. S3FNP further stated that sometimes patient's will come with a list of medicines, but after checking the medicines, find out some of the medicines haven't been filled by the pharmacy for months. S3FNP stated that she does not usually call about the medicines but the nursing staff here in the behavioral unit will during admission. S3FNP stated that she does collaborate with the psychiatrist on certain things but mainly focuses on the medical issues with patients, not behavioral issues. S3FNP further stated that she must have reviewed where the medicines were discontinued by the ED but just does not remember any specifics.

Interview on 03/08/17 at 11:55 a.m. with S4MHNP stated after reviewing patient #2's record confirmed that normally she focuses on the behaviors exhibited by the patient at the time of admission and those medications associated with those behaviors. S4MHNP stated she does review the patient's medications and collaborates with medical but usually leaves it up to medical to resolve those issues related to medical diagnosis unless she feels it is associated or contributing to the patient's behaviors. After reviewing the record S4MHNP stated she did recall looking at the discontinued list of medications and noted that the Depakote had been discontinued and ordered a Valproic Acid level which was 13 below therapeutic level, and restarted the Depakote due to the patient's behaviors at the time. S4MHNP further stated, the other medicines she would leave for medical to address and would collaborate with them, but in this case did not remember discussing the discontinued medications with medical on this patient.

Interview on 03/07/17 at 2:50 p.m. with the S1DON confirmed the S7RN working at the time of patient #2's admission and performed the Admission Nursing Assessment was on leave during time of survey. S1DON stated that S7RN was on leave and was out of the state on vacation and was not due back to work until 03/11/17.

Interview on 03/06/17 at 2:30 p.m. with S1DON confirmed that she had received a call from S6Pharmacy concerning patient #2's medication discrepancies. The pharmacy was claiming that she only had some of her meds and some were missing and needed the scripts for all of patient #2 medications. S1DON stated that she was confused and would look into the problem. S1DON stated that she had reviewed the patient's record and saw where the medications that were being questioned by the pharmacy were listed as discontinued on the ED documents. The ED documents also had a blank MAR of the patient's medicines from the patient's group home. The MAR listed all of the patient's current meds, but the ER physician had listed them as discontinued. S1DON stated that patient #2 was admitted from 02/03/17 to 02/08/17 and had reviewed the documents and saw where the Valproic Acid had been restarted, but none of the other discontinued medications. S1DON further stated that she did not know why the medications were not followed up on by the staff. S1DON stated that she had responded back to the pharmacy with a letter dated 02/21/17. S1DON further stated that on 02/21/17 was the first time that anyone had called and/or inquired about issues with patient #2's medications. S1DON stated that after looking into the discharge record it was determined that the medications in question by the pharmacy were listed as discontinued by the ED staff physician and were not continued during the patient's admission. S1DON called S6Pharmacy back and also sent a letter stating that since the patient #2 was no longer a patient they would not be able to get the scripts for the medications that the pharmacy were requesting. S1DON stated that she had spoken with the S4MHNP and S3FNP. S1DON explained that since the patient #2 was no longer in their care that they could not order the medications the pharmacy was requesting. S1DON stated that she knows the group home was faxed a copy of the discharge medications when the patient was discharged. S1DON doesn't remember the group home calling and having any questions at the time of discharge, she further stated that patient #2 had been in the behavioral unit several times so this was not the first time dealing with this group home. Surveyor asked if she had documented or did a complaint or grievance on this issue. S1DON stated that the only documentation she had was the letter she faxed to the pharmacy, but that she did not initiate this issue as a grievance because she had resolved the issue with the pharmacy and never heard back from them. S1DON further stated that she did not understand if there was a problem with the discharge medications that no one had called about them until 2 weeks later, and then the pharmacy contacted her, no one from the group home.

Interview on 03/06/17 at 2:50 p.m. with S1DON surveyor asked to interview S7RN working at the time of admission and performed the Admission Nursing Assessment. S1DON stated that S7RN was on leave and was out of the state on vacation and was not due back to work until 03/11/17.

Interview on 03/08/17 at 11:35 a.m. with S1DON confirmed that when patient #2 was admitted, the admission nurse should have documented and questioned the discontinued list of medications. There should have been documentation that the nursing staff followed up with medical about the discontinued medications.