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Based on review of policy and procedure, review of medical staff bylaws and rules and regulations, record review, and staff interview, the Hospital failed to follow their bylaws ensuring enforcement of its rules and regulations within the hospital by failing to perform an accurate medication regimen review upon admission and throughout a patient's hospital stay for 1 of 12 closed patient (Patient #9) records reviewed. The failure to identify and document an accurate list of patient medications caused Patient #9 to not receive current prescribed medications for the patient's chronic conditions of hypertension (high blood pressure), angina (chest discomfort), diabetes, hypercholesterolemia (high cholesterol), pain, and depression throughout Patient #9's hospital stay. The omission of these medications placed Patient #9 at risk of adverse clinical outcomes.

Findings include:

Review of the "Medical Staff Bylaws Part I: Governance" occurred on January 29-30, 2013. The bylaws, dated 01/23/12, page 5, stated, ". . . Section 6. Responsibilities of Each Medical Staff Member: . . . 6.5 Each staff member must abide by the bylaws, rules and regulations, and other policies, procedures, and plans of the hospital and the medical staff . . ."

Review of the "Rules and Regulations of the Medical Staff" occurred on January 29-30, 2013. The rules and regulations, dated 01/23/12, section number 606, stated, "Subject: Medication Management: Medication management will be performed in the following situations: 1. Upon any admission to the facility (e.g. EOD [emergency outpatient department], . . . inpatient . . . etc.); 2. Upon transfer from these areas: Surgery, SCCU [surgical critical care unit] . . ."

Review of the policy "Medication Management Process CPOE [unable to define initials]" occurred on 01/30/13. This policy, revised February 2011, stated, "PURPOSE/GOAL: 1. The organization, with patient's involvement, creates a complete list of the patient's current medications (prior to admission medications) at each appropriate encounter. 2. The medications ordered for . . . the patient . . . are compared to the ones on the list and any discrepancies (omissions, duplications, potential interactions) are resolved. . . . 3. The patient's accurate medication list is communicated to the next provider of service . . . 4. The next provider of service checks the medication list to make sure it is accurate and in concert with any new medications to be ordered/prescribed. . . . Admission to Hospital/EOD . . . admission: Admitting Nurse will verify home medications in PTA [prior to admission] section and marks 'taking' or 'not taking' or flags for removal. In the note (paper icon) documenting the reason for removal. The nurse will take the snapshot of the home medication list. The nurse will review, release, and acknowledge orders as appropriate. The Provider will review medications, 'order', 'replace', 'don't order', or 'discontinue' and enter new medications as appropriate and should address flag for removal med at this time. . . . Transfer: The Provider will review PTA Medications and all active orders, choosing to 'continue', 'discontinue', or 'modify' and enter new orders in system as appropriate. The nurse will review, release, and acknowledge orders as appropriate. ***The transfer med management process will take place from these areas: Patient coming out of surgery, patient coming out of SCCU . . ."

Review of the policy "Medication Reconciliation" occurred on 01/30/13. This policy, effective 09/19/11, stated, ". . . A. . . . Documentation: The fact that medication reconciliation has taken place is documented by: 1. the existence of a prior to admission (PTA) medication list in the patient's medical record in a timely manner. 2. an updated, combined list of prior admission . . . medication at the conclusion of care. . . . B. . . . Medication reconciliation takes place at up to three (3) points: 1. upon entry, 2. upon some transfers within the hospital . . . Reconciliation upon entry: A list of prior to admission . . . medications is obtained from the patient. The list should be as complete as possible, i.e., it should include prescription medications, over-the-counter medications, herbal remedies, etc. . . . Transfers: The transfer med management process will take place from these areas: Patients coming out of surgery, patient coming out of SCCU . . ."

Review of Patient #9's closed medical record occurred on 01/30/13 and identified the Hospital admitted the patient to the emergency department (ED) on 09/14/12 at 12:45 a.m. via ambulance from another hospital. A nurse note, dated 09/14/12 at 1:05 a.m., stated, "Patient arrived from [name of transferring hospital] by ambulance. Patient presents with abdominal pain and back pain. . . . Patient alert and oriented only to person, confused to time, situation, and place." Patient #9's record contained scanned documents including an ambulance report and patient information from the transferring hospital which included a transfer form and a monthly medication administration record (MAR) for September 2012 (a type of facility form which lacked a title, but contained a label from the transferring hospital including information about Patient #9, such as date of birth, date of admission, medical record number, etc.). The ambulance report, dated 09/13/12 at 11:18 p.m., listed Patient #9's medications as glimiperide (for diabetes), multivitamin, Vicodin (for pain), Norvasc (for high blood pressure), hydrochlorothiazide (HCTZ) (for high blood pressure or to decrease fluid), isosorbide (for angina), Synthroid (for thyroid), Tricor (for cholesterol), metformin (for diabetes), mirtazapine (for depression), and Namenda (for Alzheimer's dementia). The report included two additional medications which could not be legibly identified.

Review of the transfer form, dated 09/13/12 at 11:25 p.m., indicated a medication list accompanied Patient #9 upon transfer and stated, ". . . Medications: list sent [with] as well as meds . . ." The MAR from the transferring hospital identified patient medications and listed the following:
- sertraline 50 milligrams (mg) take one tab by mouth daily for depression.
- isosorbide mononitrate CR 30 mg take a half tab by mouth daily for angina.
- levothyroxine 100 micrograms (mcg) take one tab by mouth daily for hypothyroidism.
- Tricor 48 mg take one tab by mouth daily for high cholesterol.
- metformin 500 mg take one tab by mouth each night at bedtime for diabetes.
- mirtazapine 30 mg take one tab by mouth each night at bedtime for depression.
- Namenda 10 mg take one tab by mouth two times a day for dementia.
- glimepiride 4 mg take one tab by mouth daily for diabetes.
- hydrocodone-acetaminophen 5-325 mg take one tab by mouth each morning for pain.
- Daily vites take one tab by mouth daily for vitamin deficiency.
- D 1000 unit take one capsule by mouth daily for calcium absorption.
- losartan potassium HCTZ 100-12.5 mg take one tab by mouth daily for hypertension.
- Norvasc 10 mg take one tab by mouth daily for hypertension.
- Tylenol take one tab by mouth three times daily as needed for pain.

Review of Patient #9's "Prior to Admission Meds Rx form" (a medication list history or medication documentation review) showed a Hospital ED nurse reviewed medications on 09/14/12 at 1:05 a.m. and listed the following:
- Tylenol 325 mg tab, take 650 mg daily.
- Namenda 5 mg tablet, take 10 mg two times a day.
- Armour (for thyroid) 180 mg tablet, take 90 mg daily
- donepezil (for Alzheimer's dementia) 5 mg tab, take two tabs daily.
- levothyroxine 100 mcg tablet, take 100 mcg daily.
- Vitamin B-12 1000 mcg tablet, take 1000 mcg daily.
- Multiple Vitamin tab, take one tab daily.
- Ginkgo Biloba (herbal remedy for memory) 40 mg tab, take 60 mg nightly.

Review of an ED physician note, dated 09/14/12, stated, ". . . HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old . . . with a known history of diabetes and Alzheimer's who presents to the emergency department as a transfer with ongoing abdominal pain. . . . She was subsequently transferred down here for further evaluation. The patient is demented and cannot give me any history and is not a good historian. REVIEW OF SYSTEMS: Cannot be obtained because the patient has dementia. PAST MEDICAL HISTORY: From chart review, includes: 1. Diabetes. 2. Chronic kidney disease. MEDICATIONS AND ALLERGIES: Both reviewed. . . . HOSPITAL COURSE: Patient admitted to the department and examined by myself. . . . She is going to require exploratory laparotomy. I coordinated care . . . [name of surgeon] came and evaluated the patient. . . . The patient was transferred to the operating room in serious condition. . . ."

A general surgery consultation note, dated 09/14/12 at 1:32 a.m., stated, ". . . [history] obtained from chart, transferring doctors, accepting physician. . . . MEDICATIONS: No current facility-administered medications on file prior to encounter. Current Outpatient Prescriptions on File Prior to Encounter . . . levothyroxine . . . Take 100 mcg by mouth daily. vitamin B-12 . . . Take 1,000 mcg by mouth daily. Multiple Vitamin Tabs Take 1 Tab by mouth daily. Ginkgo Biloba 40 MG TABS Take 60 mg by mouth nightly. donepezil . . . 5 MG tablet Take 2 Tabs by mouth daily. acetaminophen . . . 325 MG tablet Take 650 mg by mouth daily. memantine . . . 5 MG tablet Take 10 mg by mouth 2 times daily. thyroid . . . 180 MG tablet Take 90 mg by mouth daily. . . . REVIEW OF SYSTEMS: History obtained from [sic] unobtainable from patient due to mental status . . . PLAN: . . . Patient incompetent for consent. Obtained consent from sister over the phone after unsuccessful attempts to contact her husband."

Upon Patient #9's admission to the Hospital, the ED nurse documented a list of medications which did not match or compare with the medications identified on the patient's ambulance report and MAR from the transferring facility and showed several discrepancies. The record failed to include reasons for the discrepancies. The ED physician documented "medications reviewed", but did not specify which medications, and the general surgeon listed the same medications documented by the ED nurse. Patient #9's record failed to include evidence staff recognized the discrepancies.

Patient #9 transferred from the ED to surgery on 09/14/12 at 2:15 a.m. where the patient underwent an exploratory laparotomy, and transferred from surgery to the SCCU at 5:46 a.m. Review of physician orders identified Patient #9 as NPO (nothing to eat or drink by mouth) on 09/14/12 at 5:10 a.m., able to start sips of water and popsicles on 09/16/12 at 9:20 a.m., and placed on a mechanical soft diet on 09/17/12 at 6:36 a.m. Review of medication orders and medication administration records from September 14-17, 2012, showed Patient #9 only received intravenous (IV) medications including insulin, heparin (used to prevent blood clots), Protonix (used to decrease stomach acid), levothyroxine, acetaminophen, fentanyl (used for pain), lactated ringers (fluid for electrolyte replacement), potassium phosphate/chlorate, Invanz (an antibiotic), dextrose (for blood sugar), Ativan (used for anxiety/restlessness), Haldol (used for anxiety/restlessness), and glucagon (for blood sugar). Patient #9 resumed oral medications after advancement of her diet on 09/17/12. Physician orders for oral medications included the following:
On 09/17/12 at 7:14 a.m., acetaminophen 650 mg every four hours as needed.
On 09/17/12 at 9:20 a.m., levothyroxine 100 mcg every morning.
On 09/18/12 at 6:37 a.m., Tylenol #3 300-30 mg every four hours as needed.
On 09/20/12 at 6:51 a.m., Diflucan (used to treat infection) 200 mg daily for seven days.

A social worker/case management note, dated 09/21/12 at 5:12 p.m. stated, "The family decided that they would rather have the [patient] return to the [name of facility]. Discharge was set up for tomorrow but had to be put on hold until Monday as her medication list needs to be reviewed and likely changed. She was on medications at home that she had not had while here and also were not ordered for her [discharge]. . . ."

During an interview on 01/29/13 at 10:15 a.m., a staff nurse (#4) stated nursing staff reviewed medications with the patient upon admission and documented the medications in the electronic medical record (EMR). She stated if staff had treated the patient within the hospital prior, the EMR automatically generated a list of medications from the previous encounter and nursing staff would then compare medications the patient currently took with the list. The nurse (#4) stated once nursing staff documented an accurate list of medications, the patient's physician indicated which medications to order or continue.

An interview took place on 01/30/13 at 1:40 p.m. with two nursing staff members (#2 and #3) who confirmed the above nurse's (#4) interview. A nurse (#2) stated transfer forms with pertinent patient information, such as medications, typically accompanied a patient upon transfer to the Hospital from another facility or via fax upon admission. The nurse (#2) stated this information remained a part of the patient's medical record while hospitalized and stated medical record staff scanned the information and all other pertinent paper documentation into the patient's EMR upon discharge. A nurse (#3) stated staff must review medications listed on the transfer form upon admission, verify the medications with the patient if able, and document an accurate medication list for the patient's physician to review and approve. The nurse (#3) stated if questions arose from review of the transfer form or if the patient is unable to provide input, the nurse is expected to call the transferring facility and/or the patient's family for clarification.

Hospital staff failed to identify and document an accurate list of medications for Patient #9 upon her admission to the ED, transfers within the Hospital, and upon resumption of oral medications. Patient #9's medical record lacked evidence Hospital staff recognized the patient's medical provider had not implemented medications for the patient's chronic medical conditions.