HospitalInspections.org

Based on a review of documentation and the clinical record, the nursing director failed to direct and monitor the nursing care furnished, as facility policy regarding medication reconcilation was not followed.

Findings were:

Patient #1 was admitted to the facility on 12-29-20. An order for Invega Sustenna® was written on 1-25-21, to be started the same day. The order stated that the patient was to receive Invega Sustenna® 234 mg intramuscularly on 1-25-21, 156 mg intramuscularly on 1-30-21, 234 mg on 2-28-21 and 234 mg every 28 days after the dose on 2-28-21.

A review of the medication administration record and nursing documentation revealed that patient #1 refused to consent to the Invega Sustenna® and never received the initial dose. The patient was discharged on 1-27-21. The discharge medication reconciliation form stated that the patient was to receive Invega Sustenna® 156 mg on 1-30-21 and Invega Sustenna® 234 mg on 2-28-21 (although she had never received the initial dose, to be administered on 1-25-21).

Facility policy MM-14 titled "Reconciled Medications" stated, in part:
"Purpose:
Medication reconcilation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors or derug interactions. It should be done at every transition of care in which new medications are ordered or existing orders rewritten...
...
Procedure:
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Upon Discharge:
1. The complete list of the patient's medications will be communicated to the next provider of service when the patient is referred or transferred to another setting.
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3. The nurse will review discharge medication reconciliation list with the physician/NPP against the MAR [medication administration record] and other physician order sheets."

The above was confirmed in a telephone interview with the CEO on 3-2-21.