HospitalInspections.org

Based on policy review, medical record review, and interview, the facility failed to ensure care was provided in a safe setting related to medication management for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the facility's "MEDICATION RECONCILIATION" policy revealed, "...Clinical staff will make a good faith effort to obtain a list of all medications used by each patient who enters...as soon as possible...when the home medication list is completed, the medication list will be reviewed and compared with current admission medication orders...The physician will determine which home medications will be continued during admission within 24 hours..."

2. Medical record review revealed Patient #1 was admitted to the hospital on 4/17/18 with diagnoses of Right Acetabular Fractures, Severe Carotid Stenoses, Parkinson Disease, Multiple Transient Ischemic Attacks, Hypertension, and Benign Prostatic Hyperplasia.

3. Review of the Emergency Department Disposition Summary dated 4/18/18 at 12:35 AM revealed Patient #1 was admitted to a in-patient room at the hospital.

Review of the "Nursing Info and History Adult (Part 1)..." dated 4/18/18 at 1:11 AM revealed Registered Nurse (RN) #1 entered "Yes", she had reviewed Patient #1's home medications.

Review of a Physician's Progress Note dated 4/18/18 at 10:22 AM revealed Patient #1 was on the following home medications:
atorvastatin 20 mg (milligram) daily.
carbidopa/levodopa/entacapone 25 mg-100 mg-200 mg , 1 tablet 6 x (times) per day.
carvedilol 6.25 mg, 1 tablet twice daily.
duloxetine 60 mg, 2 capsules (120 mg) once daily.
finasteride 5 mg, 1 tablet daily.
losartan 50 mg, 1 tablet twice daily.
Plavix 75 mg, 1 tablet daily.
potassium chloride 20 mEq (milliequivalents), 1 tablet daily.
Rapaflo 8 mg, 1 capsule daily.

The only home medications listed under Patient #1's Inpatient medication list were the losartan and potassium chloride.

Review of the Medication Administration Record revealed that Patient #1 did not receive his atorvastatin, carbidopa/levodopa/entacapone, carvedilol, duloxetine, finasteride, clopidogrel (Plavix), and tamsulosin (in place of Rapaflo) until 4/19/18 at 8:32 AM.

4. During an interview on 7/11/18 at 1:03 PM, in the conference room, the Quality Coordinator verified that Patient #1's home medications were not reconciled by a physician within 24 hours.