HospitalInspections.org

Based on a review of facility policy, documentation, medical records and interview with staff it was determined the facility failed to follow current standards of practice to ensure the safety and well-being of a patient for one of one medical record reviewed. (MR1).

Findings include:

A review of the facility policy "Patient Rights and Responsibilities" last revised March 2013 revealed, "You have the right to: ... Receive efficient and quality care with high professional standards that are continually maintained and reviewed. ... ."

1) A review on January 8, 2014, of the patient's Emergency Department medical record for December 24, 2013, revealed no documentation of Diltiazem Hydrochloride as a medication the patient had taken at home. The historian listed was the patient.
A review on January 8, 2014, of the patient's inpatient medical record for the December 24, 2013, admission revealed physician's orders for Telemetry unit written by EMP2 on December 24, 2013, at 1:00 PM which included Metoprolol, but not Diltiazem Hydrochloride.
An interview conducted on January 8, 2013, at 1:00 PM with EMP2 confirmed that they looked at the home medication list documented in the patient's Emergency Department medical record when writing the admission orders in the Emergency Department. EMP2 stated that they did not remember reviewing the Medication Reconciliation form completed on the telemetry unit after they had written the admission orders. Further interview confirmed that EMP2 was not made aware of the omission of an order for Diltiazem by the admitting nurse who completed the Medication Reconciliation form.
2) A review on January 8, 2014, of the "Medication Coordination Booklet Home Medications" completed by EMP4 on December 24, 2013, at 2:50 PM on the telemetry unit revealed "Diltiazem 240 mg orally daily".

A telephone interview conducted on January 8, 2014, at 1:30 PM with EMP4 confirmed that they had completed the Medication Reconciliation form with the patient's input while admitting the patient to the telemetry unit and the list included Diltiazem. Further interview with EMP4 revealed that they saw the admission order for Metoprolol (Lopressor) for blood pressure and surmised that the doctor ordered it in place of the Diltiazem and therefore did not feel the need to notify the admitting doctor of the discrepancies between the medication history and the physician's admitting orders.

3) A review on January 8, 2014, of facility policy "Medication Reconciliation" last reviewed June 2013, revealed, "A. Inpatients: Admissions 3. All medication taken prior to admission will be listed... . 4. The Medication Coordination Booklet will be kept in front of the physician orders sheets in the medical record for physician review. 5. The admitting registered nurse will reconcile the medication history with the admitting medication orders. 6. The admitting registered nurse will address any discrepancies between the medication history and the physician's admitting orders with the physician. ... . 9. The nurse who receives the inpatient admission orders and completes the admission process will complete the reconciliation process. ... ."

An interview conducted on January 8, 2014, at 2:00 PM with EMP8 confirmed, "It is the doctor's responsibility to review the Medication Reconciliation form information. We would expect the nurse who signed off the medication orders would have compared the meds ordered with the Medication Reconciliation information. Then the nurse should have notified the doctor of the discrepancy upon discovery as per their policy. EMP8 stated that this judgement call made by the nurse was not hers to make."
An interview conducted on January 8, 2014, at 2:15 PM with EMP1 confirmed that the admitting doctor did not check the medication reconciliation record, as per their policy. Neither did the admitting nurse report the medication discrepancies found between the medication reconciliation form medication list and the admission medications ordered. EMP1 confirmed that neither the nurse nor the physician followed the facility policy for medication reconciliation.