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Based on interview, record review and review of facility policy, it was determined the facility failed to ensure the transferring facility's medication record was reviewed to ascertain current medications were ordered for one (1) of ten (10) sampled patients, Patient #1.

Patient #1 was admitted to the facility on 05/19/19 and upon admission staff failed to accurately authenticate/reconcile the medication list from the transferring facility's medication list. This resulted in Physician's orders being obtained for Meclizine and Lexapro medications, which were not on the current medication list sent from the transferring facility. Patient #1 received Meclizine 25 milligrams (mg) on 05/19/19 at 9:50 AM and 10:15 PM and Lexapro 10 mg on 05/20/19 at 4:00 PM as per the Hospital Physician's Orders. After the error was identified, the medications were discontinued on 05/20/19.

The findings include:

Review of the facility "Medication Reconciliation" Policy, Policy: IDD-22I, last revised 02/2017, revealed upon admission, the nurse would use the transferring facility's medication list to enter current medications. The process then guides the nurse to authenticate/reconcile the medication list. The Admission Medication Reconciliation Form provides all of the patients current transferring medications. Completion of the Admission Medication Reconciliation Form creates inpatient orders for the Physician to verify and pharmacy to fill for use.

Review of Patient #1's medical record revealed the facility admitted the resident on 05/19/19 at 12:19 AM, with diagnoses including Generalized Anxiety Disorder, and Major Depressive Disorder.

Interview with Patient #1's Daughter, on 07/22/19, at 3:08 PM, revealed she had concerns related to the the patient's medications during hospitalization.

Review of Patient #1's transferring facility's (Long Term Care Facility) medication list, dated 05/18/19, revealed no Physician's Orders for Meclizine or Lexapro medications.

Review of Physician's Orders dated 05/19/19, revealed orders including: Meclizine 25 mg three (3) times a day (medication to treat dizziness) and Lexapro 10 mg daily (antidepressant medication). Further review revealed Physician's Orders dated 05/20/19, to discontinue the Meclizine and Lexapro on 05/20/19.

Review of the Medication Administration Record (MAR) for Patient #1, dated May 2019, revealed the patient received Meclizine 25 milligrams (mg) on 05/19/19 at 9:50 AM and 10:15 PM and Lexapro 10 mg on 05/20/19 at 4:00 PM.

Interview on 07/23/19, at 10:27 AM, with Registered Nurse (RN) #5, who worked on the 6th floor where Patient #1 was admitted on 05/19/19, revealed during the admission process the current medication list from the transferring facility was to be utilized in order for the Hospital Physician to order in-patient medications. However, she stated she did not remember Patient #1 or any concerns related to the patient's medications.

Interview with Registered Nurse (RN) #4, who was the 6th Floor Supervisor, on 07/23/19, at 9:08 AM, revealed she was not aware of any concerns related to Patient #1's medications. Per interview, during the admission process the patient's current medication list from home or the transferring facility was to be to be authenticated/reconciled by the admission nurse and the list of medications was to be transferred to the Medication Reconciliation Form for the Hospital Physician to utilize when ordering medications.

Interview with the Director of Nursing, on 07/23/19, at 9:29 AM, revealed she was unaware of any concerns related to Patient #1's admission medications until this Survey. Further interview revealed Patient #1's medication list from the transferring facility should have been reviewed for discrepancies against what the Hospital had on file, from previous visits/admissions, and an accurate medication list should have been formulated for the Physician to be utilized in ordering the in-patient medications. Further interview revealed since Patient #1's Meclizine and Lexapro medication was discontinued on 05/20/19, the nursing staff must have identified the error; however, there was no documented evidence of an Occurrence Report initiated when the error was identified. Per interview, re-education would take place regarding the steps of the admission process.