HospitalInspections.org

Based on survey activities on September 6 and 7, 2017, including a review of seven open medical records, five closed medical records and other pertinent documents, it was determined that the hospital failed to ensure timely and accurate medication reconciliation was provided to the receiving facility at the time of discharge for one of ten patients reviewed.

In a review of the closed medical record for Patient #2, it was revealed the receiving rehabilitation facility did not receive an updated version of Patient #2's medication reconciliation, prompting a re-admission to the hospital. In Patient #2's medical record history and physical, the physician noted the change in Patient #2's medications from the previous admission which was "apparently not conveyed to the rehab facility, therefore the patient was still receiving those medications". The referenced medications noted in Patient #2's medical record that were discontinued included oxycontin, gabapentin and ativan. Patient #2 was re-admitted to the hospital for "acute opioid intoxication" three days after discharge from the same hospital as a direct result of the inaccurate medication reconciliation provided to the receiving rehabilitation facility by the hospital.

While it was evident the hospital conducted quality assessments and tracked metrics involving the medication reconciliation process, and based on staff statements in an interview, provided direct education to the medical staff on the sequence of steps for an accurate medication reconciliation in the discharge process, gaps remain in safety measures to ensure accurate medication reconciliation data is provided for patients who are transferred or discharged.

The system in place does not provide for a process to ensure updated and accurate medication reconciliation data is populated into the discharge summary and forwarded to the receiving facility when the discharge summary is completed and signed prior to completion of the discharge medication reconciliation.