HospitalInspections.org

Based on policy review, medical record review, and interview, the facility failed to ensure a patient's representative participated in the development and implementation of the plan of care for 1 of 3 (Patient #3) sampled patients.

The findings included:

1. Review of the facility policy, "Medication Reconciliation," revealed, "...Medication Reconciliation is a process of comparing medications that a patient has been previously taking with medications that are to be given. The purpose of medication reconciliation is to avoid errors of transcription, omission, duplication of therapy, drug-drug and drug-disease interactions...Inpatient Good Faith Effort: An attempt to obtain from the patient, family, or primary care provider a list of the patient's current medications, including the dose, route frequency, and last dose received...Upon admission, the RN [registered nurse] will interview the patient to compile a complete and accurate list of the patient's home medications...The Home Medication List is then printed and placed on the chart for the physician/LIP/LIP [licensed independent practitioner] [sic] to review and reconcile...The physician/LIP reviews the home medication list and the hospital medication list choosing either to continue, discontinue, or change the medications...Medication Reconciliation should occur within the first 24 hours of admission..."

2. Medical record review for Patient #1 revealed an admission date of 3/21/2022 with diagnoses which included Hypertension, Rheumatoid Arthritis, Gastroesophageal Reflux Disease (GERD), and Dementia.

The Durable Power of Attorney (DPOA) for Health Care dated 9/30/1997 listed DPOA #1 as one of two individuals designated as the Durable Power of Attorney. The Consent for Voluntary Admission dated 3/21/2022 was signed by DPOA #1.

The Medications Prior to Admission list (home medication list) revealed the following medications and dosages: hydroxychloroquine sulfate (Plaquenil) (for arthritis) 200 milligrams (mg) by mouth daily with an additional 200 mg on Monday, Wednesday, and Friday, nebivolol (Bystolic) (for hypertension) 5 mg by mouth daily, buproprion hydrochloride (Wellbutrin) (for depression) extended-release 150 mg by mouth daily, celecoxib (Celebrex) (for pain) 200 mg by mouth daily, oxycodone/acetaminophen (Percocet) (for pain) 10/325 mg by mouth every 6 hours as needed, magnesium oxide (for magnesium deficiency) 250 mg by mouth daily, omeprazole (Prilosec) (for GERD) 40 mg by mouth daily, ondansetron hydrochloride (Zofran) (for nausea and back pain) 4 mg by mouth four times daily as needed, and polyethylene glycol (Miralax) (for constipation) 17 grams by mouth daily.

A social worker progress note dated 4/1/2022 documented by Social Worker #1 revealed, "...LATE ENTRY FOR 3/31...[DPOA #1] ASKED WHAT OTHER MEDICATIONS pt [Patient #1] IN [sic] ON. SW [Social Worker] STATED SW WILL READ THEM TO HER...SHE ASKED ABOUT A COUPLE OF MEDICATIONS NOT LISTED AND WAS INFORMED THEY WERE NOT ON THE LIST...[DPOA #1] BECAME EVEN MORE UPSET AS SHE STATED THE MISSING MEDICATIONS ARE FOR pt's RA [rheumatoid arthritis]. [DPOA #1] STATED SHE GAVE A PRINTED LIST OF pt's HOME MEDICATION TO PROPER STAFF IN THE ER [Emergency Room/Department] AND ALSO VERBALLY WENT OVER THOSE WITH THEM..."

An internal medicine progress note dated 3/31/2022 documented by Nurse Practitioner #1 revealed, "...[Patient #1] has RA and chronic back pain and at home takes Plaquenil 200 mg on Sunday, Tuesday, Thursday, and Saturday and 400 mg on Monday, Wednesday, and Friday as well as Celebrex 200 mg daily, Oramorph SR [morphine sustained-release] 15 mg bid [twice daily], Percocet 10/325 mg qid [four times daily] scheduled, and Zofran 4 mg off-label prn [as needed] breakthrough pain. During this hospitalization she has been taking Oramorph SR 15 mg bid, Percocet 10/325 q [every] 6 h [hours] prn, APAP prn, and ibuprofen prn. [DPOA #1] expressed concern to me regarding the discrepancy between her home regimen and her inpatient regimen...When I spoke to [Patient #1] today she was very cooperative and pleasant and denied pain. She reports that when she does have pain it is mostly in her lower back. However, per chart review, she was unusually aggitated [sic] earlier today...[DPOA #1] reports that [Patient #1] has not tolerated other BB [beta blockers] in the past due to bradycardia, but she typically does not have a problem with Bystolic when it is given at bedtime...HTN [hypertension]: Mostly uncontrolled. Continue losartan 50 mg daily, and restart Bystolic 5 mg at bedtime...Bradycardia: Mild, intermittent even with cessation of Bystolic [discontinued on 3/29/2022 at 10:01 AM]. Discussed with [DPOA #1] who reports that at home she takes this medication at bedtime to avoid awake bradycardia. Will cautiously restart Bystolic 5 mg at bedtime with parameters to hold for HR [heart rate] less than 50...RA: Restarted Plaquenil 200 mg Sunday, Tuesday, Thursday, and Saturday and 400 mg Monday, Wednesday, and Friday as well as Celebrex 200 mg daily...Continue Oramorph SR 15 mg bid, and change Percocet 10/325 mg from q 6 h prn to scheduled QID to adhere to home regimen at request of [DPOA #1]...Constipation...Resume home regimen of Miralax daily and Colace [docusate sodium] 100 mg at bedtime...GERD...Takes Prilosec at home, change to formulary equivalent Protonix [pantoprazole] 40 mg daily..."

There was no documentation these medications (except Bystolic and Percocet) were reviewed and reconciled by a physician/LIP until 3/31/2022. There was no documentation the facility included DPOA #1 in the decision to continue, discontinue, or hold these medications as part of Patient #1's plan of care. Bystolic and Percocet were restarted on 3/22/2022, but the medications were not ordered to be administered at the times they were given at home. There was no documentation the medical providers discussed the administration times of these two medications with DPOA #1. There was no documentation the Emergency Department staff provided the printed list given to them by DPOA #1 which listed the medications and administration times to the nursing staff on the floor.

3. During a phone interview on 4/11/2022 at 8:50 AM, DPOA #1 stated she gave the emergency department a list of Patient #1's medications with dosages and administration times upon presentation to the ED on 3/21/2022. DPOA #1 confirmed that she was not told Patient #1 was not started back on Wellbutrin, Plaquenil, Celebrex, or Prilosec until 3/31/2022. DPOA #1 confirmed she was not told that the medications Bystolic and Percocet were not administered at the times of the home schedule until 3/31/2022.

During an interview on 4/12/2022 at 11:31 AM, Nurse Practitioner #2 stated, "...We want to get meds [medications] reconciled as soon as possible...typically it's the attending physician's responsibility [to reconcile home medications]...we [medical team] defer to psychiatry unless consulted specifically for medications...and pain medications..."

During a phone interview on 4/12/2022 at 12:07 PM, Nurse Practitioner #1 stated, "...We [medical team] are a consultant...Psychiatry is the attending...I got an email from [Physician #1]...clarified out role that it's not our responsibility to restart home meds...it's the responsibility of the attending physician..."

During an interview on 4/13/2022 at 9:26 AM, Psychiatrist #1 stated she would look at a patient's home medication on the computer in a specific program, but then have to go to another program to order what medications she wanted. Psychiatrist #1 stated she was unable to check the medications on the home medication list in the computer to continue, discontinue, or hold the medication. Psychiatrist #1 stated she decided not to restart Patient #1's Wellbutrin because it was an activating antidepressant. Psychiatrist #1 stated she did not check the Wellbutrin in the computer to discontinue the medication. Psychiatrist #1 stated the medical team managed the patient's medications for rheumatoid arthritis. Psychiatrist #1 stated she spoke with the Medical Director of Psychiatry about the delay in restarting the medications. Psychiatrist #1 stated she received an email informing her that it was the responsibility of psychiatry to restart all home medications.

During a phone interview on 4/13/2022 at 10:29 AM, Nurse Practitioner #3 stated it was ultimately the responsibility of the psychiatry attending physician to reconcile a patient's home medications.

During an interview on 4/13/2022 at 10:46 AM, the Medical Director of Psychiatry stated it was the responsibility of the attending physician (psychiatry) to continue or discontinue home medications. The Medical Director of Psychiatry stated they were in process of reviewing this case. The Medical Director of Psychiatry stated the first concern recognized was medications that needed to be continued were not for Patient #1.