HospitalInspections.org

Based on review of hospital policy, outside medical record review, facility medical record review, internal document review, and staff and physician interviews, facility staff failed to accurately reconcile a patient's medications at admission and discharge for one of 10 patients reviewed (Patient #4).

The findings included:

Review of the policy "Assessment, Plan of Care, and Documentation" approved date 05/2017 revealed, "PURPOSE: ...To define the data to be gathered on admission to (Named facility) inpatient or outpatient settings. Staff will perform an interdisciplinary assessment of patients' pre, intra, and post hospital needs. The goal of the assessments is to determine appropriate care, treatment and services to meet the patient's changing needs ...PROCEDURE: ...Initial Assessment-Assessment by the MD (physician) or RN (registered nurse) that occurs upon entry into the (Named) system and occurs prior to the writing of orders as well as upon arrival to the patient care unit ...Assessment and reassessment is a continuous process of data collection, analysis and decision-making about treatments and care ..."

Review of the policy "Assessment and Reassessment" approved date 03/2017 revealed, "PURPOSE: To provide a continuum of ongoing assessment and reassessment while receiving interventions in the emergency department. PROCEDURE: ...Secondary Survey: ...The secondary survey may occur at triage or at the bedside ...Current medications. A complete list of patients' medications including over the counter & herbal natural remedies should be included on the medication reconciliation form ..."

Review of the policy "Medication Reconciliation" approved date 08/2017 revealed, "PURPOSE: To define the roles and responsibilities of the healthcare team, and explain the process of reconciling medications for inpatients and outpatients at (Named facility). PROCEDURE: I. Medication Reconciliation for Inpatients A. An interview with the patient and/or family is conducted to obtain the patient's current medication history when the patient enters the hospital ...C. In addition to interviewing the patient and/or family about the patient's medication history, the Licensed Independent Practitioner (LIP) will review the medication history ...2. Once the patient's medication history is known, the LIP will compare the ordered medications and reconcile any discrepancy ...II. Medication Reconciliation upon discharge A. at the time of discharge, the LIP writes a complete list of medications that the patient should take upon leaving the hospital in the discharge summary ...D. The electronic discharge summary is the mechanism for communicating the reconciled medication list to the next provider of care ..."

Review of an outside medication administration record (MAR) from the assisted living facility which had sent Patient #4 to the hospital revealed, Patient #4's medications included levothyroxine (medication to treat low thyroid gland function) 75 micrograms (mcg) daily on Tuesday, Thursday, and Saturday, and 50 mcg daily on Monday, Wednesday, Friday and Sunday. Review revealed Patient #4's medications also included three eye medications for treatment of glaucoma (a group of eye conditions resulting from high pressure within the eye). Review revealed the eye medications were: Travatan Z (a medication which lowers pressure within the eye) 0.004%, 1 drop into the left eye at bedtime; dorzolamide 2%-timolol 0.5%, (a combination medication which lowers pressure within the eye) 1 drop into the left eye twice daily; and brimonidine 0.2% (a medication which lowers pressure within the eye) 1 drop into the left eye twice daily.

Review of the facility's medical record revealed Patient #4 was an 81 year old female who arrived via emergency medical services (EMS) from a local assisted facility and was seen in the emergency department (ED) on 12/27/2018 at 1648 for reported weakness, fever, diarrhea, and muscle aches. Review of the medical record revealed Patient #4's disease history included depressed thyroid function, glaucoma (high pressure within the eye), and macular degeneration (vision loss) in her right eye. Review of a "Medication Documentation Review Audit" by registered nurse (RN) #7 dated 12/27/2018 at 1654 revealed the following medications levothyroxine 75 mcg (no frequency information entered), Travatan Z 0.004% instill 1 gtt (drop) into OU (both eyes) QHS (at bedtime), travoprost benzalkonium (a second prescription for Travatan Z) administer 1 drop to both eyes nightly, timolol 0.5% Administer 1 drop to both eyes Two (2) times a day, and brimonidine 0.2% ophthalmic solution Instill one drop in both eyes bid (twice a day). Review of a "Miscellaneous Nursing Order" by MD #3 dated 12/27/2018 at 2358 and acknowledged at 2359 by RN #6 revealed, "Can we please confirm her eye drop regimen or have pharmacy confirm it? Thank you." Review of medication orders revealed levothyroxine 75 mcg daily was ordered during Patient #4's hospitalization, but eye medications were not ordered, and there was no evidence of pharmacy input pertaining to eye medications for Patient #4 during the hospitalization. Review of Patient #4's discharge summary dated 01/07/2019 revealed the following medications were to be ordered at the receiving facility: "levothyroxine 75 mcg tablet, 3 (three) times a week, Travatan Z 0.004% drop, Instill 1 gtt into ou qhs, travoprost benzalkonium ophthalmic solution (a second prescription for Travatan Z), Administer 1 drop to both eyes nightly, timolol 0.5% ophthalmic solution (not dorzolamide 2%-timolol 0.5%), Administer 1 drop to both eyes Two (2) times a day, and brimonidine 0.2% ophthalmic solution Instill 1 drop in both eyes bid (twice a day). Review of a note dated by case manager (CM) #1 on 01/07/2019 at 1107 revealed "Printed a list of Eye (sic) drops and provided to (Named) RN (#5), to ensure these meds were correct on Med rec (medication reconciliation) to send to (Named outside facility) Placed (Named family's) copy of the eye gtts (drops) with the med rec ..." Review revealed Patient #4 was discharged to a skilled nursing facility on 01/07/2019, at 1220. Review revealed no additional amendments to the medication reconciliation form within Patient #4's medical record, and a copy of the list provided to RN #5 was not part of the medical record.

Interview on 05/09/2019 at 0941with RN #7 revealed he had "reconciled" Patient #4's medications using the facility's electronic medication interface which accessed outside medication records in participating entity databases while Patient #4 was in the emergency department. Interview revealed if a patient does not know their medications, or family is not available to confirm medication doses, he put "unknown" in the frequency area of the record and other staff would update the information at a later time, "Ideally to the next nurse, and when they (patients) get admitted." RN #7 did not recall "having a MAR when I did the reconciliation."

Interview on 05/08/2019 at 1440 with MD #3 revealed he recalled Patient #4 and had written her admission orders, but was not involved in her care after that day. During interview, MD #3 stated "When I admit someone it can be (a) pretty chaotic (time)," and "My primary goal is, what does this patient need to have tonight." MD #3 stated he had not ordered the eye medications but requested pharmacy review of the eye medications because he did not frequently order eye medications, and "these types of things get ironed out over the following days."

Interview on 05/09/2019 at 0925 with RN #6 revealed she had admitted Patient #4 from the ED, and did not recall any family accompanying her. RN #6 recalled the patient had been "very tired." Further interview revealed RN #6 did not remember seeing documents from the outside assisted living facility, "but it was probably in the paperwork from the ED. It gets put in the patient's chart and stays there until discharge. A lot of it is found in (Named electronic record) but if you have questions, you have that to go back to." Interview revealed RN #6 did not remember releasing an order from MD #3 requesting clarification of Patient #4's eye medications.

Interview on 05/08/2019 at 1110 with a pharmacist, RPh #1, revealed pharmacy service was not part of the medication reconciliation process, but pharmacists were "on the receiving end" for medication orders entered into the system. Interview revealed no evidence of a request for pharmacy input related to Patient #4's eye medications in the system.

Interview on 05/08/2019 at 1020 with CM #1 revealed Patient #4's family member had texted a copy of the eye medications to her, and CM #1 stated she provided a copy the medications text to the nurse completing the discharge instructions on the day of Patient #4's discharge.

Interview on 05/08/2019 at 1327 with a physician, MD #2 revealed he had taken over care of Patient #4 on 01/02/2019 and remembered Patient #4. Interview revealed MD #2 had spoken with the family member on the telephone and met with her once. Further interview revealed the family member indicated she "was working, and was not available during the day." Interview revealed MD #2 had asked about eye medications and "If she had said only one eye, I would have put only one eye but she didn't say anything about it," and he believed the discharge medication list was correct. Interview revealed MD #2 was unaware an eye medication list had been provided to CM #1 by a family member prior to Patient #4's discharge.

Interview on 05/08/2019 at 1050 with RN #5 revealed she had discharged Patient #4, but only had a vague recollection of the patient. Interview revealed RN #5 did not recall receiving a list of eye medications provided by CM #1.

Based on review of hospital policy, outside facility record review, medical record review, and staff interviews, facility staff failed to initiate an appropriate plan of care on admission for a patient with a skin laceration for one of 10 patients reviewed (Patient #4).

The findings included:

Review of the policy "Assessment, Plan of Care, and Documentation" approved date 05/2017 revealed, "PURPOSE: ...To define the data to be gathered on admission to (Named facility) inpatient or outpatient settings. Staff will perform an interdisciplinary assessment of patients' pre, intra, and post hospital needs. The goal of the assessments is to determine appropriate care, treatment and services to meet the patient's changing needs ...PROCEDURE: ...Initial Assessment-Assessment by the MD (physician) or RN (registered nurse) that occurs upon entry into the (Named) system and occurs prior to the writing of orders as well as upon arrival to the patient care unit ...Assessment and reassessment is a continuous process of data collection, analysis and decision-making about treatments and care ..."

Review of the policy "Skin Assessment" approved date 08/2016 revealed, "PURPOSE: This assessment allows the clinician to identify any present ulcers or areas that have a potential for ulceration ...PROCEDURE: Skin assessment includes: All skin areas: Skin intact. Open areas observed. Old scars, indication of prior surgery(ies) ...Skin assessment will be documented in the electronic medical record ..."

Review an of outside facility medication administration record scanned to Patient #4's record which contained vital signs for 12/27/2018 at 1430 and noted a "laceration back of head w/staples (with staples)" and an occurrence date of 12/23/2018.

Review of the facility's medical record revealed Patient #4 was an 81 year old female who arrived via emergency medical services (EMS) from a local assisted facility and was seen in the emergency department (ED) on 12/27/2018 at 1648 for reported weakness, fever, diarrhea, and muscle aches. Review of an "ED Provider Note" dated 12/27/2018 at 1941 revealed, "...presents to the emergency department for generalized weakness, fever/chills, general malaise (general, nonspecific feeling of discomfort), and myalgias. Patient has had diarrhea for over a week, but diarrhea did seem to stop 2 days ago ...Medical Decision Making ...Patient will be admitted by the hospitalist team for further workup and care/observation ..." Review of a "History & Physical" dated 12/27/2018 at 2351 revealed Patient #4's primary problem was "...FTT(failure to thrive)/dehydration ...She does report feeling fatigued, dizzy with changes in position and that she has fallen at some point recently ...SKIN: warm dry intact ..." Review of a "Nursing Assessment" dated 12/29/2018 at 0930 revealed Patient #4 had "staples to back of head due to fall," staff shift assessments remained consistent through 01/04/2019, and provider notes indicated Patient #4's skin was clean dry and intact during that period. Provider initial H&P review did not reveal any notation related to a head wound. Review of a "Daily Progress Note" dated 01/05/2019 at 1246 revealed "Infected scalp wound - started on Keflex (an antibacterial medication) and will consult surgery ...Scalp wound appears to be infected and gap/ sloughing." Review revealed the scalp wound staples had been removed. Review of a "General Surgery Consult Note" dated 01/05/2019 at 1439 revealed, "I suspect this is a small scalp lac (laceration) that has already started to granulate in but has an overlying clot in this region. Do agree with a p.o. (per orem, oral) course of antibiotics. Will order twice daily wet-to-dry dressings ..." Review of the discharge summary dated 01/07/2019 revealed the oral antibiotic, Keflex, which was begun on 01/04/2019 at 1500, was to continue through 01/12/2019, and an appointment for follow up of the wound was to be scheduled by the receiving facility within one week of discharge. Review revealed Patient # 4 was discharged to a skilled nursing facility on 01/07/2019 at 1220. Review of the initial nursing care plan revealed it did not address care of a scalp wound.

Interview on 05/08/2019 at 0915 with the nurse manager (NM) #1 during tour of the inpatient unit which had housed Patient #4 revealed report was received from ED nurses prior to a patient's arrival, and report was to discuss pertinent aspects of each patient's admission. Interview revealed nurses had also done bedside shift reports since October 2017 in order to better "identify barriers," and areas of concern in a patient's care. Interview revealed a wound should be documented.

Interview on 05/08/2019 at 0928 with a registered nurse (RN) #2 revealed on arrival to the unit, patients undergo a "head to toe" skin assessment as well as falls risk, nutritional needs, social support and discharge planning assessments. RN #2 stated if a previously undocumented wound was observed staff would "notify the physician and get an order" for initial treatment until the physician was able to assess the wound.

Interview on 05/09/2019 at 0925 with RN # 6 revealed she had admitted Patient #4 from the ED, and did not recall any family accompanying her. RN #6 recalled the patient had been "very tired" on arrival and was minimally interactive during the assessment. Interview revealed RN #6 did "not remember noticing a head wound, and I do not remember getting it from the ED RN." Further interview revealed RN #6 did not remember seeing documents from the outside facility, "but it was probably in the paperwork from the ED. It gets put in the patient's chart and stays there until discharge. A lot of it is found in (Named electronic record) but if you have questions, you have that to go back to."

Interview with RN #4 on 05/08/2019 at 1010 revealed she had taken care of Patient #4 early in her stay. During interview RN #4 recalled "she had stitches back there (head)" but there was no dressing and she had changed Patient #4's pillow case a couple of times because "it had blood on it."

Interview on 05/08/2019 at 1327 with a physician, MD #2 revealed he had taken over care of Patient #4 on 01/02/2019 and remembered Patient #4. Interview revealed MD #2 had spoken with a family member who had informed him that Patient #4 had a head wound "which I was not aware of." MD #2 stated he had asked a nurse to put saline on the area to loosen the scab, prescribed antibiotics, and requested a surgical consult the next day. Interview revealed that staples along the wound had been removed the next day, and he had ordered an antibiotic after observing an open gap at the base of the wound.

Interview with the director of nursing (DON) on 05/09/2019 at 1107 revealed there was a wound nurse at the facility who was available for consult, and staff could place a request through the electronic medical record. Interview revealed she expected the presence of a wound should be "brought to the physician's attention immediately and they could address it." Interview revealed it should not have taken seven days from admission for the wound to be addressed, and "an order obtained."

NC00150336