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Based on document review and interview, facility nursing services nursing failed to notify a provider of a patient medication concern in a timely manner and failed to document home medications received and returned to a patient for 1 of 10 medical records revived. (P1)

The cumulative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review and interview, facility nursing services nursing failed to notify a provider of a patient daily medication concern in a timely manner and failed to document home medications received and returned to a patient for 1 of 10 medical records reviewed. (P1)

Findings include:

1. Facility policy titled,"Medication Reconciliation", PolicyStat ID 17964504, last revised 04/2025, indicated under PROCEDURE: 1. When a patient is admitted to the hospital, a registered nurse (RN), pharmacist, or pharmacy technician completes the admission section of the Physician/s Admission Orders - Medication Reconciliation in the electronic medical record. This includes a list of the most current medications the patient is taking prior to admission. 2. The Physician will authenticate the admission reconciliation orders either directly to an RN, via telephone order that has been read back and verified, or via HCS.

2. Facility policy titled, "Patient's Own Medications (POM)", Policy Stat ID 17879439, last revised 04/2025, indicated under A. PATIENT HOME MEDICATION (PHM) SUPPLY AND STORAGE: 2. Intake /admission places all medication in a sealed security bag labeled, Patients Medication Inventory. a. Intake/admission requirements for home medications noted. b. Patient name is to be written on bag or patient label applied. c. Bag is to be marked with date and name of medication. d. Bag is sealed using security seal. 6. Once orders are entered into HCS for the admitted patient, pharmacy staff will determine the need, if any, for the patient home medication. a. Medications brought to the facility after intake/admission process if completed. i. The front desk staff will identify patient has a ROI. ii. House supervisor is notified the patient has received home medications and follow the Patient Home Medications supply and storage requirements.

3. Review of P1's MR (Medical Record) from H2 (Psychiatric Hospital) indicated:
a. Intake assessment documentation dated 4/28/25 at 2:20 pm indicated P1 had a history of congestive heart failure, atrial fibrillation, and hypertension. P1 was a direct admission from H1 (Acute Care Hospital). P1 was noted to have heart surgery for congestive heart failure in 2018. Admission documentation indicated P1 was admitted to H2 on 4/28/25 at approximately 2:30 pm.

b. Nursing note entered by N3 (Registered Nurse) dated 4/28/25 at 9:00 pm indicated P1 had no scheduled medications. Nursing note documentation lacked physician notification related to scheduled home medications.

c. Admission home medication orders dated 4/29/25 at 10:25 am indicated MD1 (Medical Doctor) ordered the continuation of P1's home medications that included jardiance, Amiodarone, and Torsemide.

d. P1's MR lacked documentation of provider notification by nursing staff of patient's required daily cardiac medications at the time of admission or after on dates 4/28/25 and 4/29/25.

e. P1 was emergently transferred to H3 (Acute Care Hospital) on 4/29/25 at approximately 3:30 pm with a heart rate of 145 beats per minute and complaints of atrial fibrillation reported by P1.

f. Medication Order documentation dated 4/30/2025 at 9:00 a.m. indicated P1's home medications: Amiodarone 200 mg tablet to be given orally daily, Torsemide 60 mg given orally twice daily, and Jardiance 10 mg tablet given orally daily were to be started on 4/30/2025. The patient was no longer at H2 when these orders were written.

g. MR lacked documentation of receiving and/or returning home medications.


4. Review of P1's MR from H3 indicated the following:
a. EKG (Electrocardiogram) documentation dated 4/29/25 at 4:21 pm indicated P1 had a heart rate of 116 beats per minute. P1's cardiac rhythm was atrial fibrillation with rapid ventricular response.

b. Provider note documentation dated 4/29/25 at 6:51 pm indicated P1 underwent unsynchronized cardioversion with sedation.


5. Incident report documentation dated 4/29/25 at 3:25 pm indicated P1 was emergently sent to H3 with cardiac related concerns for atrial fibrillation, an increased heart rate of 145 beats per minute, and a blood pressure of 147/110 mmHg.

6. Complaint documentation for P1 dated 5/2/25 indicated P1 had concerns that H2 did not return all of the home medications brought to the facility on 4/29/25 by his/her parent. Complaint investigation indicated P1's misplaced home medication was returned to the patient 5/1/2025 by H2 staff.

7. In interview on 6/9/25 at approximately 12:30 pm with A3 (Director of Nursing) confirmed nursing staff did not follow the home medications policy when receiving or returning P1's home medications and did not escalate medication reconciliation concerns r/t (related/to) P1's cardiac medications to a provider at the time of admission or during hospitalization but should have. A3 also confirmed nursing staff did not follow the home medications policy when receiving or returning P1's home medications, but should have.