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Based on medical record review and staff interview by surveyor #29972, the hospital failed to document nursing interventions and patient's response in 4 of 10 medical records reviewed.

Review of the Patient Medication Reconciliation Policy dated February 2010, beginning 11/10/11 at 9:00 am revealed the following:

Subject: Discharge Medication Teaching

Policy Statement: Discharge medication teaching will be provided.
Purpose:
- To increase patient understanding and compliance with the medication regimen upon discharge. Medication teaching may include drug action, drug interactions, common side effects, advice as to what to do if a dose is missed, drug-food interactions, and general information in regard to the storage and handling of drugs.
- To identify the potentially high risk or non-compliant patient population for early and effective intervention.

Guideline:
1. All patients will have medication teaching by their date of discharge.
2. The interdisciplinary team will assess the variables affecting medication compliance and noncompliance behavior in order to recognize and support positive coping skills and achieve participation and cooperation in medication taking.
3. Teaching will be documented in the chart.

Review of Medication Management Policy dated December 2010, beginning on 11/10/11 at 9:30 am reveals the following:

Subject: Patient Medication Education

Policy Statement: Education on medication shall be provided to the patient and/or party responsible for administration of medications.

Purpose: To increase understanding and compliance with medication therapy.
Guidelines:
1. Individuals administering a medication will be aware of its purpose, action, usual dosage and untoward reactions. This information will be shared with patient.
2. Medication education shall be documented in the medical record.
3. All patients will have medication teaching completed by their date of discharge or will be referred for follow-up education.
4. A Discharge Take Home Medication Report will be prepared electronically by the physician during the discharge medication reconciliation. The RN will verify that this has been completed and then print. Alternately, Form F-108, Discharge Medication Teaching Sheet, will be completed by Nursing and will include the name of the drug, dosage and frequency of administration in terms understood by the patient and/or party responsible for administration of the medications. A COPY of either form will be given to the patient at the time of discharge. A COPY will be retained in the medical record.


Review of the Nursing Process and Documentation Policy dated October 2009,
on 11/10/11 at 9:45 pm reveals the following:
The discharge instructions will include: Reinforcement and/or review of all
discharge medication teaching and documentation of patient understanding.

Review of Pt #1's physician order sheet beginning 11/9/11 at 2:00 pm revealed the following orders:

9/17/11 10:27 am: Cardizem CD 120 mg daily (a calcium channel blocker, it works by relaxing the blood vessels in the body and heart so blood can flow more easily).
9/17/11 10:27 am: Gabapentin 200 mg twice daily (used to relieve nerve pain-burning, stabbing pain)
9/15/11 9:30 am: Digoxin 0.125 mg daily (used to strengthen the force of the heart muscle's contractions, helps restore a normal steady heart rhythm and improved blood circulation).

Review of Pt #1's Patient Education Record reveals the following documentation under " Education Content " :

9/17/11- " IPOC Medications "
9/24/11- " Medications "
9/25/11- " Meds "
10/1/11- " Meds "

Pt #1's nurse's discharge note dated 10/7/11 10:20 am states the following: "discharged to home accompanied by spouse. Patient provided with the following education materials upon discharge: patient health profile, valuables and belongings sent with patient. Nursing Discharge summary, Discharge Instructions, Discharge Medication Teaching Sheet and Follow-up appointments reviewed with patient and family member. "

Per interview with staff B (VP of Quality) on 11/10/11 at 11:30 am, "Discharge Medication Teaching Sheet " is the same as the " Discharge Take Home Medication Report " which lists all the patients discharge medications and dose, remaining doses day of discharge and the time the next doses are due.
Per review of Pt #1's Discharge Take Home Medication Report all medication columns pertaining to time of next dose are blank, instructions and/or comments for all discharge medications are blank, and the " remaining doses day of discharge " section is blank.

Reviewed Pt # 1's electronic medical record (EMR) with Staff D (RN Clinical Systems App Coordinator) on 11/9/11 at 3:50 pm, found no documentation of patient education done for Cardizem, Digoxin, or Gabapentin.

Pt #7's medical record reviewed beginning on 11/9/11 at 3:45 pm revealed the following: Physician order for Coumadin (blood thinner) dated 9/21/11 at 11:00 am. Patient Education Record for Coumadin--"Knowledge/skills related to Anticoagulant Therapy" is not completed/filled in. Review of electronic medical records with Staff D (RN Clinical Apps Coordinator) on 11/9/11 at 2:10 pm showed no evidence or documentation of nursing interventions providing medication teaching or patient response to teaching.

Pt #8's medical record reviewed beginning on 11/10/11 at 10:00 am revealed the following:
Physician order for Keppra 750 mg twice daily (anti-seizure) dated 8/29/11 at 6:15 pm and Depakote 250 mg twice daily (anti-seizure). Patient Education Record does not indicate specific education on these medications. Review of the electronic medical record with Staff D on 11/10/11 beginning at 12:00pm showed no record or documentation of nursing interventions to provide patient teaching for new medications. Pt #8's Discharge Take Home Medications Report/ Teaching Medication Sheet is not completed/filled in as to what medication discharge plan/teaching was given to patient.

Pt #9's medical record reviewed beginning on 11/10/11 at 10:30 am revealed the following:
Physician order dated 9/21/11 for Amoxicillin (antibiotic) 500 mg 3 times daily for 7 days begin at discharge. Patient Education Record shows no documentation of Amoxicillin medication teaching. Review of the electronic medical record with Staff D beginning at 12:00 pm showed no record or documentation of nursing interventions providing patient teaching for new medications. Pt #9's Discharge Take home Medication Report/Teaching Medication Sheet is not completed/filled in as to what medication discharge teaching was given, and Amoxicillin is not listed on the Discharge Take Home Medication Report.

The above information was verified during interview with Staff B (VP of Quality) and Staff C (VP of Patient Services) on 11/10/11 at 3:45 pm.

Based on record review and interview by surveyor #29972, the hospital does not ensure medical records are complete in 7 out of 10 records reviewed (Pt #1, 4, 5, 6, 8, 9, 10).

Per interview with Staff B (VP of Quality) and Staff C (VP of Patient Care) on 11/10/11 at 11:30 am, and in accordance with the Patient Medication Education Policy reviewed, the Discharge Take Home Medication Report also called the Medication Teaching Sheet is prepared electronically by the physician during the discharge medication reconciliation. The RN will then verify this is completed and then print. This formed is then to be completed by the RN with any additional instructions/comments, remaining doses day of discharge, and time of next dose(s) for each discharge medication listed. A copy of the form is then given to the patient at discharge, and a copy is retained in the medical record.

Per record review by surveyor #29972 between 11/9/11 and 11/10/11, for Pt #1, 4, 5, 6, 8, 9, 10 the Discharge Take Home Medication Report / Medication Teaching Sheet does not contain any additional instructions/comments, remaining doses day of discharge, or the time of next dose(s) for any of the discharge medications listed. Pt #1 has a list of 30 discharge medications, Pt #4 has 17 discharge medications, Pt #5 has 22 discharge medications, Pt #6 has 21 discharge medications, Pt #8 has 21 discharge meds, Pt #9 has 13 discharge meds, Pt #10 has 13 discharge meds.