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Based on medical record review and interviews, it was determined that the hospital failed to provided 24 hour nursing services as required for 1 of 10 patients reviewed (P1). Staff failed to conduct a full medication reconciliation, and order and administer P1's current home medications, including cardiac medications, following P1's transfer from the Emergency Department (ED) and admission to the hospital's medical-surgical unit. The hospital was not found in substantial compliance with the Condition of Participation of Nursing Services at 42 CFR 482.23.

Findings include:

The hospital failed to complete a full and timely medication reconciliation per hospital policy and order and administer all of P1's current in home medications, including cardiac medications, at the time of P1's admission to the hospital. P1 did not receive his/her routine heart medications on the day of admission to the hospital's medical-surgical unit. The following day, 11/16/17, the patient was observed to be in atrial fibrillation (very rapid heart rate) with a rapid ventricular response (RVR) resulting from the omission of P1's heart medications. P1 was transferred to the Special Care Unit (SCU) on 11/16/17 for follow-up treatment related to P1's condition. Refer to the deficiency issued at A405.

Based on medical record review and interviews, the hospital failed to complete a full medication reconciliation upon admission and order and administer in a timely manner all current home medications in accordance with approved medical staff and hospital policies and procedures for 1 of 10 patients (P1) reviewed.

Findings include:

P1's hospital record was reviewed and indicated P1 has a history of hypertension, diabetes mellitus, coronary artery disease, myocardial infarction, chronic kidney disease, heart failure, stroke, atrial fibrillation and an old clavicle fracture. P1 presented to the ED during the late evening of 11/14/17 with complaints of severe left shoulder and neck pain. Family member (K) provided Registered Nurse (RN) (F) with P1's home medication list, which included cardiac medications, at the time of the ED visit. The record indicated RN (F) conducted his/her part of the medication reconciliation process and reviewed and documented the review of P1's home medication list. An x-ray of P1's shoulder was completed, and the x-ray did not reveal the presence of an acute fracture or dislocation. P1 was provided pain medication during the ED visit and no additional medications were ordered for P1 during the ED visit. The record indicated P1 was discharged home with services on 11/21/17.

A history and physical completed by physician/hospitalist (E) on 11/14/17 at 11:45 p.m.was reviewed. It stated P1 received three medications for pain control while in the ED and was advised to wear a shoulder immobilizer to help reduce the pain. P1 displayed a very elevated blood pressure during the examination. The history and physical indicated P1 would be admitted for observation and transferred to the medical-surgical unit. Physician (E) indicated the plan would be to continue P1's home medications and pain control medications. However, physician (E) did not complete a medication reconciliation and did not order the continuation of P1's home medications, including cardiac medications, following P1's 11/15/17 at 12:15 a.m. admission to the hospital.

An 11/16/17 at 7:35 a.m. physician progress note indicated staff responded to a thirty-five minute critical code rapid response because P1 developed shortness of breath with tachycardia while on the medical surgical unit. P1's heart rate was between 150-160, and P1's blood pressure was elevated. An electrocardiogram, chest x-ray, and echocardiogram were conducted. The event was determined to be a hypertensive emergency. P1 was administered Lasix 20 milligram (mg) (diuretic), IV Metoprolol (cardiac/beta blocker) and IV drip Cardizem (cardiac/anti-hypertensive). P1 was transferred to the Special Care Unit (SCU) for further care at 8:30 a.m. on 11/16/17 and remained on the SCU until 10:30 a.m. on 11/17/17 when s/he was transferred back to the medical-surgical unit following improvement of his/her heart rate.

An 11/16/17 at 10:19 a.m. physician progress note completed by physician/hospitalist (J) was reviewed. It indicated P1's atrial fibrillation with rapid ventricular response (RVR) was probably caused by P1's shoulder pain and not receiving his/her beta blocker medication (cardiac) while at the hospital. The plan was for P1's home medications regimen (heart rate control) to be resumed during the hospitalization, and physician (J) completed P1's medication reconciliation and wrote the orders for P1's home medications during P1's hospital stay.

An 11/16/17 patient/visitor safety report was reviewed. It described in detail the hospital's failure to conduct P1's full medication reconciliation at the time of P1's admission to the hospital's medical-surgical unit on 11/15/17. The report stated family member (K) provided RN (F) with a complete list of P1's home medications, including P1's cardiac medications, when P1 was seen in the ED on 11/14/17. The report indicated P1 went into an atrial fibrillation with rapid ventricular response rhythm on 11/16/17 due to not receiving his/her home medications following admission to the hospital on 11/15/17. In addition, the report indicated P1's increased heart rate event could have been prevented if P1's medication reconciliation had been completed in a correct and timely manner when P1 was admitted to the hospital.

An interview with RN (F ) was conducted on 1/5/18 at 8:15 a.m. RN (F) stated she reviewed the home medication list that P1's family member provided to her in the ED on 11/14/17, and she entered "nursing in process" on P1's medication reconciliation record in the computer. This is a trigger for the physician to review the patient's home medications and order the in-patient medications accordingly. She stated she completed her part of P1's medication reconciliation, but P1's home medications were not ordered by night physician (E) or day physician (H) following P1's admission to the hospital.

An interview with physician/hospitalist (E) was conducted on 1/4/18 at 9:30 a.m. Physician (E) stated he was working the night shift on 11/14/17 into 11/15/17 and he stated he admitted P1 to the medical-surgical unit for observation related to P1's left shoulder pain. Physician (E) stated he only addresses acute problems on the night shift and refers patients' medication reconciliation to the physicians who are working on the day shift. Physician (E) stated he thought physician (H) would review P1's home medications on the 11/15/17 day shift and order P1's cardiac medications. Physician (E) stated he did not conduct P1's medication reconciliation during P1's hospital visit.

An interview with physician/hospitalist (H) was conducted on 1/5/18 at 10:25 a.m. Physician (H) stated she provided care to P1 from 8:00 a.m. to 12:00 p.m. on 11/15/17. Physician (H) said physician (E) admitted P1, and physician (E's) night shift ended at 7:00 a.m. on 11/15/17. Normally the admitting physician is expected to complete a patient's medication reconciliation. Physician (E) did not complete P1's medication reconciliation and did not order P1's home medications that P1 should have received during her inpatient stay. Physician (H) stated neither physician (E) nor any other staff told her that P1's medication reconciliation had not been completed and that P1's home medications had not been ordered. Physician (H) stated that prior to the end of her shift at 12:00 p.m. on 11/15/17, she wrote an order for P1 to be discharged on 11/15/17.

An interview with P1 was conducted on 1/9/18 at 9:00 a.m. P1 stated she went to the ED on the evening of 11/14/17 because she was having neck pain. P1 stated she provided the ED with a list of her current medications on 11/14/17. P1 said she was admitted to the hospital related to the pain. The staff only gave her pain medications, and even though she requested her heart medications and other medications, staff did not administer them to her. P1 stated she developed an atrial fibrillation rhythm and was transferred to the Special Care Unit (SCU) for treatment. P1 stated her condition has improved, and she moved into an assisted living facility on 12/5/17.

The facility policy titled Medication Reconciliation, with an origination date of October 2012 and an effective date of June 2016, was reviewed. The policy addresses the process of resolving medication discrepancies and making final decisions on continued medication use, including home medications that are taken by the patient at scheduled times prior to admission to the hospital. The policy indicates the medication reconciliation is to be completed on hospital admission and at discharge. The admission medication reconciliation for inpatient and observation status patients is to be documented within 24 hours. A full medication reconciliation is required on all inpatient and observation status patients. The collect and clarify portion (list of medications) of the process is to be completed by a nurse or a pharmacist, and the reconciliation (decisions related to ordering or not ordering medications) is to be completed by the physician/provider.