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Based on review of medical records, review of medical staff bylaws, rules and regulations, and staff interview it was determined the facility failed to ensure medical staff enforced responsibilities of the medical staff for one (#1) of four patients reviewed.

Findings included:

Review of the medical staff rules and regulations, pages 13 - 14, section titled "Discharge Summary," stated a complete discharge summary shall be electronically dictated on all medical records of patients hospitalized over 48 hours with outcome of hospitalization, disposition of case and provisions for follow-up care. Final diagnosis shall be recorded within the discharge summary. On page 16, section titled "Record Completion," stated the medical record should be completed within thirty (30) days following discharge.

Review of the medical record for patient #1 revealed the patient was admitted to the facility on 10/20/2021 and expired on 10/31/2021. Review of the record revealed the physician assessed the patient on 10/30/2021 with documentation which included an overall prognosis as guarded with a diagnosis which included bilateral pneumonia possible aspiration. Review of the note did not reflect the outcome of hospitalization or disposition of the case.

Interview with the Vice President of Quality and Patient Safety on 12/15/2021 at 1:40 pm confirmed the above findings.

Based on review of the medical records, review of policy and procedures and staff interview it was determined the facility failed to ensure nursing staff evaluated the patient's medication history according to facility policy for one (#1) of four patients sampled.

Findings included:

Review of the policy and procedure titled, "Medication Reconciliation," #302-MM-103, on page 2, Admission Reconciliation, Medication History stated the nurse will collect the list of medications as known or reported by the patient or caregiver and file in the Meditech system. The nurse will confirm or reaffirm the medication history with the patient or information provider and document the source of information. If the nurse is unable to complete the medication list, he/she will indicate this by highlighting unknown info as a flag for on coming shift.

Review of the medical record for patient #1 revealed the patient was admitted on 10/20/2021. The nursing and physician assessments revealed the patient had altered cognitive function and was oriented to person only. Review of the admission medication reconciliation revealed the RN (Registered Nurse) reconciled the patient's medications on 10/21/2021 at 6:49 pm. The review revealed no evidence for the source of information. Review of the nursing and physician progress notes revealed the patient had a health care surrogate involved in the patient's plan of care. There was no evidence the patient's health care surrogate was the source of information for the patient's current medication history.

Interview with the Vice President of Quality and Patient Safety and the Director of Pharmacy on 12/14/2021 at 3:50 pm confirmed the above findings.