HospitalInspections.org

Based on interview and documentation review the Hospital (Hospital #1) failed to ensure that a complaint was properly investigated for 1 of 4 applicable patients (Patient #1).

Findings included:

Medical record documentation, dated 11/12/10, indicated that Patient #1 was admitted to Unit #5 (a cardiac unit). A valuables list was completed that indicated Patient #1 brought a bag of medications to Hospital #1.

A tour of Unit #5 and the Pharmacy were conducted on 12/17/10 with the Director of Nursing Practice and the Director of Cardiology present. During the tours it was determined that the practice regarding home medications was as follows: if there were any narcotics with the home medications then the medications were brought to the pharmacy by the nurse. The medications were identified and counted; the information was documented on a blue form signed by the pharmacist and nurse. The medications were then brought back to the unit by either the nurse or a pharmacy technician. The medications and blue form were stored in a designated drawer in the automated medication dispensing system. It was up to the nurse to ensure that the medications were removed from the system and returned to the patient upon discharge. Medications not given to patients upon discharge were eventually removed by the pharmacy, stored in a vault for approximately 7 days, and if not claimed were destroyed.

Nurses who cared for Patient #1 were interviewed as follows:

Nurse #1, assigned to Patient #1 at the time of admission, and was interviewed in person on 12/17/10 at 1:15 P.M. Nurse #1 said Nurse #1 was going to complete the medication reconciliation process and asked Patient #1 about home medications. Nurse #1 said Patient #1 asked for the purse and pulled out the bag of medications. Nurse #1 said the medications included a narcotic. Nurse #1 said after recording the medications Nurse #1 left the medications with Patient #1 and told the oncoming nurse (Nurse #2) about the medications. Nurse #1 said Nurse #2 said the medications had to be locked up for safety. Nurse #1 said Nurse #1 went back to Patient #1, told Patient #1 the medications had to be locked up, and removed the medications. Nurse #1 said Nurse #2 took the medications to the Pharmacy.

Nurse #3, assigned to Patient #1 at the time of discharge was interviewed in person on 12/17/10 at 1:05 P.M. Nurse #3 said Nurse #3 did not remember anything about medications at discharge.

The Director of Patient Relations was interviewed in person on 12/17/10 at 7:45 A.M. The Director said that after Patient #1 was discharged a telephone call was received regarding Patient #1's 11/12/10 to 11/15/10 stay at Hospital #1. The Director said the call was very nonspecific and mentioned that medications had been lost. The Director said there was no evidence in the medical record that medications had been brought in.

Review of the verbal complaint, called in on 11/18/10, indicated that the complaint included concerns with not being seen by a physician and medications brought in from home being lost. The complaint indicated that the conversation was disjointed and difficult to follow.

Review of the actions taken indicated that Patient #1's medical record was reviewed and there was documentation indicating Patient #1 was seen by physician(s) while hospitalized. Documentation indicated they were unable to find any verification that medications were brought to Hospital #1.

The Director said the plan was to follow-up to determine the medication needs of Patient #1 and to arrange for prescriptions, if necessary. The Director said Patient #1 was spoken to via the telephone and was not happy with the action. The Director said Patient #1 ' s primary care physician was contacted and the Director was told that Patient #1 had an appointment on that day.

During the onsite survey on 12/17/10 the Pharmacy located the medications in the Pharmacy vault. Observation of the Patient ' s Own Medications Destruction Log indicated that Patient #1 ' s medications remained in Unit #5 ' s automated dispensing system unnoticed until 12/17/10 at which time they were removed and brought to the Pharmacy.

The initial investigation did not identify that there was documented evidence medications were brought to Hospital #1 and therefore a thorough investigation could not be conducted.

Review of documentation provided by Hospital #1 indicated that another complaint was filed, this time in writing. An initial letter of response was sent indicating the concerns were going to be investigated and at the time of the survey the investigation was pending.

Based on interviews and documentation review Hospital #1 failed to ensure that medical record documentation was complete for 4 of 11 applicable patients (Patients #1; #5; #7, and #10)

Findings included:

1) The Manager of Case Management was interviewed on 12/21/10 at 10:30 A.M. The Manager said the form, An Important Message From Medicare (IM), was presented to patients by either the nurse of clerk on admission. The Manager said the form was signed upon admission and 24-48 hours prior to discharge.

Review of medical records for Patient #1, Patient #7, and Patient #10 indicated that although they signed the IM form on admission; the forms were not signed prior to discharge.

2) Review of the Policy/Procedure titled Medication Reconciliation, effective 3/24/08, the memo, dated 12/15/09, and the Medication Reconciliation Form indicated that patients home medications were identified at the point of entry (such as the ED or nursing unit if a direct admit) and documented on paper or entered into the medication profile (a computerized profile). The name of the medication, dosage and frequency was listed on the form. The source of the information was identified (such as a list, patient or medical record). If the patient was unable to provide information regarding medications, it was noted on the reconciliation form.

A tour of the Emergency Department (ED), conducted on 12/17/10, and Unit #5 and review of medical record documentation, determined that medication reconciliation was documented in paper form in the ED and documented electronically on Unit #5.

Review of medical records determined the following:

Patient #1:
Patient #1 was admitted through the ED on 11/12/10. Patient #1 was alert and oriented and brought a bag of medications from home.

Review of the hand written medication reconciliation form indicated that it did not contain the dose, frequency, or source of information.

Patient #5:
Patient #5 was admitted through the ED on 11/27/10. Patient #5 was alert and oriented.

Review of the hand written medication reconciliation form indicated that it did not contain the dose, frequency, or source of information.

Patient #10:
Patient #10 was admitted through the ED on 11/21/10. Patient #10 was alert and oriented.

Review of the hand written medication reconciliation form indicated that it did not contain the dose, frequency, or source of information.

3) Review of Case Management documentation for Patient #1, dated 11/12/10, indicated that an initial discharge assessment was performed and arrangements were made for a visiting nurse post-discharge.

Review of the order sheets indicated that there was a nurse to nurse communication asking that post-hospital visiting nurse services be added to the discharge instructions.

Review of the Patient Instructions for Discharge, dated 11/15/10, indicated that there was no written documentation regarding visiting nurse services.

Based on documentation review Hospital #1 failed to ensure that 1 of 8 applicable patients (Patient #11) received/signed An Important Message From Medicare, Know Your Rights (IM) form.

Findings included:

Review of medical record documentation indicated that Patient #11 was 75+ years of age and was covered by Medicare and private insurance. Patient #11 was admitted to Hospital #1 on 12/9/10 with chest pain and was alert and oriented. Patient #11 signed all consent and instructional forms by self.

The Manager of Case Management was interviewed on 12/21/10 at 10:30 A.M. The Manager said the IM form was presented to patients by either the nurse of clerk on admission and was maintained in the medical record.

Review of the medical record indicated that there was no evidence an IM form was given to Patient #11 to sign.