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Based on review of documents, medical records and staff interview, it was determined the hospital failed to ensure nursing accurately documented the home medications of patient's on the medication reconciliation form in one (1) of one (1) medical records (#2) reviewed for medical reconciliation. This has the potential to negatively affect all patients by all home medications not being added to the home medication list, thus not being continued while in-patient.

Finding include:

1. Hospital policy titled "Medication Reconciliation", last reviewed 7/11, states in part: "A good faith effort must be made to obtain complete and current information from the patient and/or other sources....For those transfers who do not have a medication list, a phone call may be made by the receiving nurse to that facility to obtain the current list of medications. Contact the Pharmacy that the patient uses for a current medication list.

2. Patient #2 was admitted to the hospital 1/21/13 and discharged 1/25/13. Nursing failed to record three (3) home medications the patient was receiving on the ADMIT/HOME medication reconciliation order form. The patient did not receive these three (3) medications during his in-patient stay. The patient was given the discharge home medication list upon discharge with a note at the bottom which stated "Any meds you have at home that is not on this list, please stop taking until you speak with your family physician." Again, these three (3) home medications were not listed.

3. During an interview with the Charge Nurse of 4 South on 3/19/13 at 1400, she agreed these medications were missing from the medication reconciliation form. She also stated nursing does not have to document how they obtained the information or from who they obtained the information to complete the medication reconciliation form.

4. An interview was conducted with the Physician Care Module Analyst (PCMA) on 3/20/13 at 0800 he revealed once a patient has been admitted to the hospital, the electronic medical record will automatically populate the medication reconciliation form from a previous admission, even if the admission had occurred five (5) or more years ago.

Based on review of documents, medical records, and staff interview it was determined the hospital failed to ensure that adequate discharge planning was completed for one (1) of one (1) medical records (#2). This has the potential to negatively affect all patients in the facility in that a re-evaluation of the patient needs to be completed to ensure that the patient's post-hospital needs are addressed.

Findings include:

1. Hospital policy entitled "Discharge Planning" states, in part, "All patients will be re-evaluated as needed but no longer than every 3 days while in the facility to ensure an appropriate and timely discharge." Additionally, the policy states, in part, "Discharge needs (i.e., home health, DME, community services) will be arranged by the case managers/social workers...".

2. There was no evidence found in the medical record to indicate that patient #2 was re-evaluated prior to discharge nor was any arrangement made by the case manager to address the patient's need for home health following discharge for the administration of subcutaneous Lovenox injections.

3. During an interview with the Charge Nurse of the 4 South nursing unit on 03/19/2013 at 1400, the medical record was reviewed and she concurred with the findings.

Based on review of documents, medical records and staff interview it was determined the hospital failed to ensure that reassessment of discharge planning needs are completed as changes in patients post-hospital care needs arise in one (1) of one (1) medical records reviewed (patient #2). This has the potential to negatively affect all patients of the facility in need of discharge planning in that continuity of care is interrupted.

Findings include:

1. Hospital policy titled, "Discharge Planning", effective February 2013, states in part, "The patient/family will be assisted in development of a realistic post-hospital plan of care that allows for the patient to be discharged safely." Additionally, the policy states, "Evaluation of the patient's home situation, as well as an assessment of the resources available and the ability of those who will care for the patient at home, will be completed through discussion with the patient and family."

2. Patient #2 was admitted on 01/21/2013 and discharged on 01/25/2013. Discharge orders were for the patient to receive subcutaneous Lovenox injections every twelve (12) hours. No documentation was found in the medical record to indicate any patient/family education related to the medication, nor was any documentation found to indicate any reassessment was done relative to post-hospital care needs.

3. During an interview with the Charge Nurse of the 4 South nursing unit on 03/19/2013 at 1400, the medical record was reviewed and she confirmed these findings.