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Based on interview and record review the facility failed to ensure their QAPI (Quality Assessment and Performance Improvement) program fully implemented and monitored an action plan following an adverse event (unexpected occurrence) that placed 1 patient (#1) at serious risk for physical injury. Not ensuring that the adverse event was thoroughly investigated, performance improvements implemented and to ensure the process was reevaluated for effectiveness placed other patients at risk for experiencing similar adverse events. Findings:


Patient #1


Record review on 2/21/13 revealed Patient #1 was admitted to the hospital on 12/14/12 with admitting diagnoses of dyspnea (shortness of breath) and confusion. During the hospital stay the Patient received antibiotic treatment for a urinary tract infection. The Patient's confusion cleared up after the urinary tract infection was treated. The Patient had multiple chronic medical conditions that active treatment was not being provided for during the 12/14-20/12 hospital stay. However, the Patient took multiple medications on a daily basis to treat these other medical conditions.


Further record review revealed at the time of discharged the physician wrote an order to "continue previous medications". On a 12/20/12 computer generated discharge summary the physician assistant (PA) included the medication list from admission with current medication changes.


The nurse's discharge medication list did not include the changes that the physician ordered for the patient on the dictated discharge summary. As a result, the Patient was sent home with orders to take Lasix (a diuretic) two times a day instead of PRN (as necessary). The Patient was also instructed to take two medications that had been discontinued, Flexeril (a medication for muscle spasms) three times a day and Amniodorone (a medication fors heart arrhythmias) two times a day. Known side effects when taking Amniodorone include but are not limited to: "Neurologic problems are extremely common, occurring in 20% to 40% of patients and including malaise and fatigue, tremor and involuntary movements, poor coordination and gait, and peripheral neuropathy".


On 12/20/2012 the PA's dictated discharge summary had not yet been transcribed so when the nurse wrote out the medications on the discharge instructions she included the medications on the medication list that was brought in by the family at admission and the additional medications ordered while in the hospital.


Additional record review revealed the Patient was readmitted on 12/31/2012 because he was experiencing weakness, decreased ability to walk, confusion, and frequent falls. The family felt it was because of some kind of adverse reaction to the medications that the Patient was sent home on.


During an interview with the Director of Nurses (DON) on 2/21/2013 at 11:30 am, she provided the surveyor written information that identified the hospital's awareness of the wrong medication orders being given to the Patient's family at discharge on 12/20/2012. According to the assisted living home (ALF) caregiver and the Patient's POA (Power Of Attorney), "The Patient was becoming increasingly weak at the assisted living ... [name omitted] from the ALF had spoken to [name omitted] the SSW [Social Worker] at the hospital to question the medications prior to the Dec 27 doctor visit who spoke with the Dr. on duty. That doctor never called them back. [name omitted] said that as she arranged to get medisets through Geneva Woods that the med lists from Dr. [name omitted], Dr. [name omitted] and the discharge instructions [did not match]. At some point she got a hold of [name omitted] who told the patient to come in."


When the surveyor questioned the DON on what the hospital had put into place to address the identified adverse event, the DON said the QAPI director had started her investigation and had started putting a plan of action into place in late December, but recently the QAPI director had resigned and the plan of action for addressing the medication reconciliation problem had been put on hold. The DON was asked what measures had taken place to ensure nursing staff did not continue to pull from the wrong medication list while discharging patients. The DON said the manager on the Medical Surgical (Med/Surg) unit had discussed the adverse event during staff nursing meetings and that the Med/Surg manager had pulled together a task force group of NPs (Nurse Practitioners) and Physician Assistants and Doctors to address the issue.


During an interview with the Nurse Manager on 2/21/2012 at 1:00 pm the manager confirmed the DON's information.


When the surveyor asked to review the nursing staff meeting minutes to ensure the staff nurses had discussed the medication reconciliation issues a written note was provided that discussed the hospital ' s activities in reviewing the requirements for medication reconciliation with the nursing staff, however, the documentation revealed "There were a lot of nurses that did not attend the refresher classes."


The DON also disclosed the nursing department had started printing out the medication list of each Med/Surg patient every morning. The DON said after the list were printed it was the Med/Surg manager and the patients' primary nurse's responsibility to review the list and clarify any discrepancy. The interventions put in place were for medication reconciliation while in the hospital, not for issues associated with medication reconciliation at the time of discharge.


The surveyor asked the DON to explain how the medication reconciliation process worked when a patient was admitted to time of discharge. The DON explained that the hospital actually worked off from several different computer systems. She said when a patient came into the Emergency Department (ED) for treatment that medications were listed in the "ProMed" system. The ProMed system was said to have limitations because it only allowed for a total of 18 medications or fewer if you listed dosage and time taken.


The DON admitted because of the limitations in the computer system there was always a potential for the medication list to be incomplete. In addition to the space limitations in ProMed there was also the fact that the ProMed ER computer system was not accessible to any of the inpatient nursing staff. The ER computer system was a completely separate system from the inpatient computer system. So when a patient was admitted to the hospital through the ER the medication list had to be printed and put into the inpatient hospital record.


When the Surveyor asked if the ProMed medication list was printed and put into the inpatient transfer paperwork the DON disclosed not on a consistent basis.


The DON said that sometimes during the initial inpatient nursing assessment when patients medications were reviewed that the Patient's medication list brought from home was no longer available because the family members had already left or the patient was too sick or tired to provide that information.


A third way the hospital obtained information concerning patients' medications was to utilize the community "Health Care System". This system was connected into local pharmacies. When admitted, the hospital could run the patient's name through the system and if the local pharmacy was signed up with the community health care system they could see what current medications the patient had been obtaining from that pharmacy. The DON said this was not a conclusive list and that the list was to be used for information only; that when a patient was discharged the Patient's physician was required to put in a written order of what medications the patient was to take, their dosages and the timing of when they were to be taken.


In the case of Patient #1 the DON confirmed that the discharge written medication orders had not been done according to hospital policy.


The DON further stated that the hospital had not taken all the appropriate actions needed to address the known deficient practices related to the medication reconciliation. She said areas that still needed followed-up were the outcome from the Medical Board peer review; the completion of the training for nursing staff concerning medication reconciliation at the time of patient discharge; for the QAPI committee to include the issue as a line item in the QAPI monthly meetings; and a complete analysis of the information collected on the compliance rate for medication reconciliation for the nursing staff needed to be trended and goals set for improvement.


In conclusion, the Surveyor asked if the DON thought there was still a potential risk for patients being discharged from the hospital to be sent home on the wrong medications with the hospital's current process, the DON stated "yes" there still was a possibility that could happen.


Current policies reviewed for Discharge Planning revealed each patient or patient's representative were to have discharge instructions which included their medication review.