HospitalInspections.org

Based on Critical Access Hospital (CAH) policy and procedure, record review and staff interview it was determined in 1 of 10 (Pt #1) medical record reviewed, the CAH failed to ensure medications were reconciled prior to discharge. This has the potential to affect all discharged patients.

Findings include:

1. The CAH policy revision date 8/16, titled, "Patient Discharge Instructions/Discharge Procedure" was reviewed on 11/15/16 at 1:00 PM. Under "PROCEDURE: 1. Review the physician order and medication reconciliation for specific discharge instructions (example: follow-up appointments, medications, etc.)".

2. The medical record of Pt #1 was reviewed on 11/14/16 and 11/15/16. Pt #1 was admitted through the Emergency Department (ED) on 9/16/16 at 1318 for chief complaint of same level fall with head injury. Pt #1 was treated and admitted for overnight observation. The current physician medication orders did not have Depo-Provera included. Pt #1 was discharged on 9/17/16 at 1317. Discharge instructions given to Pt #1's caregiver indicated Pt #1 was ordered Depo-Provera 150 mg IM as directed.

3. On 11/14/16 an interview was conducted with the Risk Manager (E#3). E#3 reviewed Pt #1's medical record and stated "The patient was on Depo-Provera from a prior stay awhile back. The computer program automatically brings it over, unless we go in and change it. It didn't get reviewed and deleted from the medication list from the prior stay."