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Based on interview and record review, the hospital failed to ensure the RN (Registered Nurse) supervised and evaluated the nursing care of each patient. Nursing staff failed to ensure a complete and accurate medication reconciliation was performed on one of one patient (patient #1) as required by hospital policy.

Findings included:

Patient #1 was admitted to the facility on 07/31/2023 for a Right Hip infection and underwent a surgical debridement on 07/31/2023 and 08/02/2023.

Record review of patient #1 medical record reflected the home medication list "current as of 07/27/2023 3:25 PM Carbidopa 200mg one tablet four times a day for the treatment of Parkinson's".

Record review of patient #1 medical record reflected Personnel #1 during a pre-surgical assessment on 07/27/2023 entered the medication, Carbamazepine 200mg one tablet four times a day. Patient #1 was not currently being prescribed Carbamazepine.

Record review of patient #1 Medication Administration Log for 07/31/2023 to 08/15/2023 reflected Carbamazepine 200mg, one tablet four a day was ordered by Physician #14 on 07/31/2023 at 10:49 AM.

Record review of Provider #8 progress notes dated 07/31/2023, 08/01/2023, 08/02/2023, 08/03/2023, 08/04/2023, 08/07/2023, 08/08/2023, 08/09/2023, 08/10/2023, 08/11/2023, 08/12/2023, 08/14/2023, 08/15/2023 reflected the treatment plan for Bipolar Disease was Prozac 40 mg daily and Zyprexa 5 mg HS. There was no mention in the progress note Carbamazepine was ordered for the treatment of Bipolar disease.

Record review of patient #1 medical record reflected Provider #8 progress notes dated 07/31/2023, 08/01/2023, 08/02/2023, 08/03/2023, 08/04/2023, 08/07/2023, 08/08/2023, 08/09/2023, 08/10/2023, 08/11/2023, 08/12/2023, 08/14/2023, 08/15/2023 did not evidence a treatment plan for Parkinson's Disease.

During an interview with Personnel #4 on 04/24/2024 stated, "the pharmacy department does not currently review medication lists for patients that are admitted through our outpatient department. The nurse and the physician are expected to perform the medication reconciliation. The patients home medication list was scanned to the medical record on 07/27/2023. The staff nurse entered Carbamazepine rather than Carbidopa and the order was verified by Provider #8 and Provider #14. Carbidopa and Carbamazepine are not interchangeable. Carbidopa is prescribed for the treatment of Parkinson's and Carbamazepine is for the treatment of seizures.

During an interview with Personnel #8 on 04/24/2024 stated he performs a medication reconciliation based off the medications that are entered in the electronic medical record and does not routinely verify medications against a home medication list. Provider #8 confirmed there is no documentation in the medical record confirming Carbamazepine was ordered for treatment of bipolar disorder. Provider #8 confirmed the patient was not receiving any medications for his Parkinson's Disease. Provider #8 also confirmed there is no documentation in the medical record reflecting Carbidopa was to be discontinued or placed on hold.

During an interview with Personnel #6 on 04/24/2024 confirmed the home medication list reflected patient #1 was currently prescribed Carbidopa 200mg one tablet four times a day. Personnel #6 confirmed Carbamazepine 200mg one tablet four times a day was not listed as a current medication. Personnel #6 does not recall having the home medication list when entering the medications into the patient's profile. Personnel #6 stated when entering medications into a patients' profile, we enter the first 3-4 letters of the medication and a list of medications will populate. For example, when I enter "Carb" all medications that begin with "Carb" populate. Personnel #6 confirmed Carbamazepine populates before Carbidopa, and stated it is possible I could have clicked on Carbamazepine instead of Carbidopa.
During an interview with Personnel #1 on 04/24/2024 confirmed a medication reconciliation was not performed.

Record review of Policy and Procedure titled Medication Reconciliation Process, effective 10/20/2009, last revision 06/17/2020 ..."Purpose: 1. Medication reconciliation is an interdisciplinary process between Nursing, Medical Staff, and Pharmacy that compares the patient's most current list of home medications against the physician's orders upon admission, transfer, and discharge, addressing discrepancies, thereby decreasing potential Adverse Drug Events (ADEs) and omissions of medication therapy ...Policy: 1. It is the Methodist Health System (MHS) policy that medication reconciliation will occur at all levels and transitions of the health care continuum. 2. This applies to all care settings (inpatient and outpatient) and services that administer medication or otherwise manage a patient's medication regimen. GUIDELINES: 1.Reconciliation occurs upon hospitalization, change in level of care, and at discharge. B. Nursing/Pharmacy should undertake a good faith effort to obtain a complete list of medication that a patient is currently taking when admitted for inpatient care or see in an Outpatient setting (emergency department, clinics, primary care, outpatient radiology, ambulatory surgery, diagnostic settings, etc. G. The physician should review ...home medication list ... and reconcile that list with admitting medication orders.