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Based on interview and documentation review it was determined the Hospital had not yet fully implemented preventive actions to ensure all patient's medication reconciliation was consistently performed to ensure the information was accurate.

Findings included:

The Hospital policy that addressed medication reconciliation was reviewed. The policy stated with all admissions the admitting nurse documents the medications the patient was taking just prior to admission, including over the counter and herbal medications. The admitting physician reviews the list and indicates if he/she is continuing or changing the medications based on the patient's current condition. The admitting physician will utilize all of his/her resources to obtain and accurate list. Admission reconciliation of medications will occur within eight hours of the decision to admit the patient to the Hospital.

Medical record review indicated the Patient home medications were not included in ED nursing documentation or in the dictated, typed Attending ED Physician ' s documentation however there was a handwritten list, that did not included a date, time or signature, that listed medications. Included on the list was an entry for Phenobarbital, 100 mg three times a day.

The ED Attending Physician was interviewed in by telephone on 9/13/10, 12:50 PM, with the Risk Manager present. He/She said the initial handwritten list with the Patient ' s medications was in his/her handwriting. He/She said it was not common for him/her to obtain a patient ' s medication history, as it was usually an ED nurse who would do this. His/her usual practice was to get the medication history list from the nurse and then review the medication, dose and dosing schedule with a patient. The ED Attending Physician said he/she did not have a clear recollection of who had provided the Patient medication history.

Review of 7/30/10, 8:30 AM physician orders indicated the Hospitalist wrote medication ordered that included Phenobarbital 100 mg three times a day.

The Risk Manager said the Patient's primary health care provider, who was not on staff at the Hospital, when called after the Patient had been discharged, verified the dosage of Phenobarbital the Patient was taking while at home was 100 mg every day.

Review of the Hospital internal review, which had been performed after receipt of a complaint related to the Patient ' s hospital stay and the care provided, indicated there was no documentation in the medical record of a medication list from a reliable source. In addition there was no documentation of a review of medications on day 1 of the Patient ' s admission, medication reconciliation had only been documented at discharge.

The Quality Management Nurse was interviewed in person on 9/13/10 at 2:10 PM. He/she said the Hospital was always looking for ways to improve the medication reconciliation process and was about to launch a pilot project in the hopes of improving the process. The project involves four of the hospitalists. The hospitalist ' s at the time of admission will compare the reported medications with a patient ' s electronic record, if they had been a patient at the Hospital in the past. The unit coordinator, of the nursing unit a patient has been admitted to, will call the patient ' s primary health care physician the next day to review the reported current medications. If the primary health care physician can not be reached, which might happen on weekends, the patient ' s pharmacy would be called. He/she said the Hospital is trying to identify reliable sources of information to verify an individual ' s current medication regime and develop a standardized process utilizing these sources.

Based on interview and documentation review it was determined the Hospital failed to ensure all medical records entries were dated, timed and authenticated in one of one applicable medical record reviewed.

Findings include:

Medical record review indicated the Patient home medications were not included in nursing documentation or in the dictated and typed Attending ED Physician's documentation however there was a handwritten list, that did not included a date, time or signature, that listed medications.

The ED Attending Physician was interviewed in by telephone on 9/13/10, 12:50 PM, with the Risk Manager present. He/She said the initial handwritten list with the Patient ' s medications was in his/her handwriting.

Continued review of the handwritten list of the Patient ' s medications indicated the original listed medications were revised with the schedule of the Prevacid changed from once a day to twice a day, the Protonix, 40 mg once a day and Lansoprazole, 30 mg once a day had a line draw through them indicating deletion from the list, and following these changes were three new medications added to the list. The three new medications were in a different handwriting from the original list and included iron pill, calcium with vitamin D and Lupron shot. A check mark was made next to all of the medications with the exception of the two with a line drawn through them. Changes made to the list did not included a time, date or signature to identify when and who had made the changes.