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Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure one (1) patient out of twelve (12) sampled patients received medications as ordered (Patient #1). The facility failed to administer two (2) different ordered eye drops for Patient #1 according to Physician's order.

The finding includes:

Review of the facility's policy titled "Medication Reconciliation", with a revised date of 04/07, revealed when all medications have been verified and reconciled by the licensed medical provider they should be faxed to Pharmacy. The pharmacist will do computer entry of reconciled medication as indicated on the form.

Record review revealed Patient #1 was admitted to the facility on 09/07/12 through the emergency department with the diagnoses which included Pneumonia, Gaucome and Cateracts. Further record review revealed Patient #1 had been a resident at a local Long Term Care Facility (LTCF). Review of Patient #1's clinical record revealed a Medication Administration Record (MAR) from the LTCF for the month of September 2012. Review of the MAR from the LTCF and the facility's admission medication reconciliation forms revealed the medications corresponded with each other. Review of the facility's medication reconciliation form and the facility's MAR from 09/07/12 through 09/20/12 revealed the ordered eye drops did not correspond. On 09/20/12 the Restasis (one of the ordered eye drops) was corrected to one (1) drop to both eyes at hour of sleep and the Brimonidine 0.1 percent eye drop was not corrected prior to Patient #1's discharge..

Interview with Patient #1's daughter, on 09/26/12 at 4:15 PM, revealed she told the nurses Patient #1's eye drops were not being given correctly. She stated the nurses would give the eye medication the way she told them they were ordered to be given when she was there, but at night or when she was not there, the eye drops were given incorrectly.

Interview with the Pharmacist, on 10/02/12 at 11:00 AM, revealed when the admission medication reconciliation process was completed, the eye drops were entered incorrectly on the facility's MAR. He stated the process was to enter the orders correctly to the MAR. He also stated if there is a discrepancy the nurse would usually call pharmacy to report it or they correct the MAR themselves. He stated he did not know if the MAR was sent to pharmacy and the order was not corrected or if the pharmacy did not receive the MAR.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure one (1) patient out of twelve (12) sampled patients (Patient #1) received the diet ordered by the Physician. Patient #1 was ordered a pureed diet, but received mechanical soft items on the tray as well.

The findings include:

Review of the facility's policy, "Interpretation of Diet Orders", dated 01/10, revealed diets were prescribed by the Physician; the purpose was to ensure accurate diet orders for our patients. Review of the facility's policy, "Tray Identification", dated 01/10, revealed each patient tray was identified by a menu and/or tray ticket. The purpose was to ensure that each patient received the correct diet and to provide a means of tray identification for patients.

Record review revealed Patient #1 was admitted to the facility on 09/07/12 with a diagnosis of Pneumonia, other diagnosis include Parkinson's disease, Cerebrovascular Attack and Diabetes Mellitus. Review of his/her admission orders revealed an order for a pureed diet. Further record review revealed Patient 31 was discharged on 09/21/12.

During the interview with Patient #1's daughter, on 09/26/12 at 4:15 PM, she stated Patient #1's diet was supposed to be pureed and he/she was on swallowing precautions. She stated she had also requested gravy with each meal, because that helped Patient #1 swallow easier. The daughter stated sometimes they would send it and sometimes they would not. She stated Patient #1 received items that were not on the pureed diet. She stated one (1) dietary employee was rude to her sister when she told him an item on the tray was not pureed.

Interview with the Clinical Nutritional Manager and the Patient Service Manager, on 10/02/12 at 11:30 AM, revealed there had been issues with the diet. They stated on 09/11/12 the diet had been changed to mechanical soft/pureed and that was not a diet that was reconized by the facility. They stated the diet should have been clarified on that date. They further stated after a meeting with Patient #1's daughter, on 09/13/12, the diet was changed back to pureed. They stated on 09/13/12, Patient #1 had received ground meat and on 09/16/12 a vegetable was sent to the patient that was not pureed.