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Based on review of facility documents, medical records (MR) and staff interviews (EMP), it was determined the facility failed to ensure medication reconciliation was completed per policy for one of nine medical records reviewed (MR1).

Findings include:

Review on November 6, 2017, of the facility's "Medication Reconciliation," policy last revised January 2017, revealed "I. Purpose: The purpose of this policy is to establish a process to reconcile medications for patients undergoing treatment at Wilkes Barre General Hospital. Medication Reconciliation is the process of comparing a patient's most current list of medications with those medication prescribed for the patient while under the care of the organization. The purpose of reconciling medications is to ensure patient safety by avoiding medication omissions, duplications, incorrect dosing and drug interactions via the medication reconciliation process. II. Policy: A. Inpatient Medication Reconciliation 1. Upon admission to the organization the registered nurse will make a good faith effort to obtain a list of current medications being taken by the patient. Sources to include when obtaining a list of current medications may include but are not limited to the patient, the patient's family/POA, the patient's pharmacy, and the electronic external medication history available via the electronic medical record. This current medication list is to include the name, dosage, frequency and route of all prescribed medications, over the counter medications/herbals and, medications taken on an as needed basis. 2. The current medication list will be made available to all members of the healthcare team via the patient's medical record. 3. The current medication list will be made available to all prescribing practitioners for reference when ordering medications. 4. Any recognized discrepancies including omissions, duplications, contraindications, and unclear orders will be brought to the attention of the prescribing practitioner and clarified by the individual who discovers the omission (i.e., attending nurse, pharmacist, or other healthcare provider). ... 6. The attending physician is ultimately responsible to complete the medication reconciliation process by electronically signing the medication list in the electronic medical record. This electronic sign off will occur each time medication reconciliation is required as stated in this policy (i.e., upon admission, at transfer in level of care, at discharge) ..."

Review on November 6, 2017, of MR1 revealed the patient was admitted on October 7, 2017 for weakness, diarrhea, decreased appetite, a fall the previous night and a positive troponin. There was documentation the medication history was obtained in the emergency department (ED) by PF1. PF1 documented the following medications: Aspirin 81 mg, oral daily; Claritin 10 mg, oral daily; Sinemet 25/100 mg, oral TID; Lopressor 25 mg, oral twice a day (BID); Sinemet 25/250 mg, oral TID; ciprofloxacin 250mg 1 tablet two times daily; Vitamin B12; and Abilify oral daily.

Interview on November 6, 2017, at approximately 10:00 AM with EMP1 and EMP6 revealed MR1's family provided a written home medication list. The written list included the following medications: Lopressor 25 mg BID, Sinemet 25/100 TID, Aspirin 162 mg daily, Claritin 10 mg daily, Vitamin B12 1000 mg IM every month, Abilify 1.25 mg every night.

EMP1 and EMP6 confirmed the medication history PF1 documented contained Sinemet 25/100 mg TID and Sinemet 25/250 mg TID.

EMP6 revealed PF1 did not complete MR1's current medication list per facility policy. EMP6 stated PF1 used the electronic external medication history and did not reference MR1's current medication list provided by MR1's family.

Continued review on November 6, 2017, of MR1 revealed OTH2 ordered Sinemet 25/100 mg 1 tab, oral, once, STAT [immediately] at 15:45 on October 7, 2017. There was no documentation MR1 received the Sinemet 25/100 mg on October 7, 2017.

OTH1 discontinued the order for Sinemet 25/100 mg and ordered Sinemet 25/250 mg 1 tab, oral, TID at 15:58 on October 7, 2017. There was documentation MR1 received Sinemet 25/250 mg on October 7, 2017, at 21:48 and October 8, 2017, at 09:31.

Interview on November 6, 2017, at approximately 10:30 AM with EMP1 and EMP6 confirmed OTH2 ordered MR1's current dose of Sinemet, and OTH1 discontinued MR1's current dose of Sinemet and ordered Sinemet 25/250 mg TID. EMP1 and EMP6 confirmed MR1 did not receive Sinemet 25/100 mg, and MR1 received Sinemet 25/250 mg on October 7, 2017, at 21:48 and on October 8, 2017, at 09:31.