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Based on record review, interview, and policy review, the provider failed to complete medication reconciliation for one of two patients (2) medication regiments reviewed. Findings include:

1. Review of patient 2's medical chart revealed he was admitted on 4/22/11.

Review of patient 2's admission medication reconciliation report dated 4/22/11 revealed an:
*Order for budesonide (Pulmicort) 0.25 milligram(mg)/2 milliliter(ml) inhalation solution twice a day.
*Order for hydroxyzine hydrochloride (HCL) (Atarax) 10 mg as needed.

Review of patient 2's Medication Administration Report dated 4/25/11 revealed:
*Budesonide (Pulmicort) 0.5 mg/2ml inhalation solution twice a day.
*No order for hydroxyzine HCL (Atarax).

Review of patient 2's medical chart revealed a facsimile form dated 4/22/11 from the provider's pharmacy service center attached to the front of the chart stated "Please check the vistaril (Atarax) with MD. It looks like your pharmacy does not carry a 10 mg product. Seems like they may carry a 25 mg capsule."

Interview on 4/25/11 at 2:50 p.m. with registered nurse (RN) B confirmed:
*Patient 2 had been receiving budesonide (Pulmicort) 0.5 mg/2 ml inhalation solution twice a day since his admission
*The order for hydroxyzine HCL (Atarax) was an as needed medication.
*Patient 2 had not received hydroxyzine HCL (Atarax).
*The hydroxyzine HCL (Atarax) ordered had not been clarified with the physician.

Interview on 4/25/11 at 3:30 p.m. with clinical coordinator A revealed:
*Patient 2 had received the wrong dose of budesonide (Pulmicort).
*The hydroxyzine HCL (Atarax) order should have been clarified.
*She did not know why the hydroxyzine HCL (Atarax) order had not been handled for three days.

Review of the provider's Medication Reconciliation Form/Orders policy revised 1/17/08 revealed:
*Medication reconciliation would be performed to clarify any discrepancies between the patient's actual medication regime and the most recent record of prescribed medications.
*Patients would have all medications reconciled within 24 hours of admission.

Based on interview, record review, and policy review, the provider failed to ensure comprehensive pre-operative and pre-procedure nursing assessments were documented for three of five sampled same-day surgical/procedure patients (16, 17, and 18). Findings include:

1. Review of patients 16, 17, and 18's entire medical records revealed the only nursing assessments documented prior to patient:
*16's colonoscopy procedure were vital signs and pain.
*17's foot surgery was vital signs.
*18's Porta-cath insertion procedure was vital signs.

Interview on 4/26/11 at 1:15 p.m. with clinical coordinator A and the director of nursing revealed:
*Full nursing assessments were never completed for patients having colonoscopy procedures.
*Patients 17 and 18 should have had full nursing assessments prior to their surgeries and procedures.
*Both agreed comprehensive pre-operative and pre-procedure nursing assessments were important parts of nursing care.
*Both agreed cardiac, neurological, respiratory, and gastrointestinal nursing assessments were important pre-operative and pre-procedure nursing assessment components.

Review of the provider's 4/30/99 documentation policy revealed same-day surgery and gastrointestinal patients were to have nursing assessments documented so the appropriateness of the proposed surgery/procedure could have been evaluated.