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Based on the review of medical records , interviews with staff and review of policies and procedures it was determined that the hospital failed to perform an effective medication reconciliation for patient #1 resulting in the patient receiving medications post discharge that were not required for his medical conditions, and which subsequently resulted in a hospital readmission.

Patient #1 was a 29 year old male who presented to the Emergency Department from home on January 22, 2015 due to nausea and vomiting. His past medical history included; Multiple Sclerosis, asthma, migraines, chronic pain, abdominal adhesions, degenerative disk disease, irritable bowel, diplegic cerebral palsy, bronchitis. Spastic paraplegia, congenital imperforate anus, chronic constipation, and Ileostomy. According to the review of policies and medical records and interviews with staff, a reconciliation of patient #1's medications was done at admission. Medication reconciliation is the process of identifying the most current list of all medications the patient is taking, including name, dosage, frequency, and route. This is done through comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider. The medication reconciliation stated that patient # 1 could only remember one of the medications that he was taking at home, and that he did not have a list of medications with him. The hospital staff who performed the medication reconciliation included the patient's list of medications from his previous admissions to the hospital from 8/4/14 and 10/25/15 on the admission medication reconciliation. There was no documentation that the hospital staff took any further action to reconcile his current medications. These medications did not correlate to any clinical diagnoses identified on this admission, and there were no identified rationales for retaining the listed medications in the current and active clinical record.

The medications that lacked indications were Hydrochlorothiazide (HCTZ), Isosorbide Mononitrate (Imdur), Lisinopril, Ranolazine (Ranexa), Arixtra, Pepcid, and Terazosin (Hytrin).

Patient #1 had no diagnosis of hypertension upon admission, or during the inpatient stay . However, medications that included Lisinopril and HCTZ prescribed for this condition were listed on his medication list.

Isosorbide Mononitrate and Ranolazine are used for angina, and patient #1 did not have a diagnosis of angina to support this medication.

Arixtra is an anticoagulant used frequently for deep vein thrombosis prophylaxis (DVT), patient #1 had no history of DVTs or other conditions requiring anticoagulation.

Pepcid is used for GERD or acid reflux which was never diagnosed for patient #1.

Terazosin is used to treat benign prostatic hyperplasia or hypertension which also was not diagnosed for Patient #1.

It was noted that these medications were never ordered for the patient during his inpatient admission to the hospital from January 22, 2015 to January 29, 2015.

The hospital process for discharge included medication reconciliation in accordance with a medication reconciliation policy. However, staff failed to identify the inconsistencies in patient #1's records at the time of his discharge. The discharge summary dated January 29, 2015 for patient #1 identified the same list of unnecessary medications that were included on the admission medication reconciliation list. Again there were no documented clinical diagnoses and no other rationale supporting the medications that were listed in the discharge summary.

The discharge medication reconciliation was done by a nurse practitioner who was not the patient's attending. When interviewed on April 6, 2015 she stated that since the attending knew this patient well, she believed the list of medications to be accurate.

The discharge summary listing the patient's medications was sent to the long term care facility that was providing post hospitalization care to patient #1 at the time of his discharge on 1/29/2015. The long-term care physician prescribed these medications to the patient.

Patient #1 was readmitted to the hospital on February 10, 2015 with a diagnosis of acute renal failure, hyperkalemia and viral gastroenteritis with dehydration. The discharge summary communication from the hospital to the long term care facility contributed to medication errors reaching the patient and to his related acute renal failure and hyperkalemia.

Based on the review of 5 open and 7 closed medical records, it was determined that the hospital failed to maintain an accurate and complete medical record for patient #1 over multiple admissions to the hospital. The findings include:

Review of the medical records for patient #1 revealed that he presented to this hospital with multiple admissions that included multiple diagnoses over the past year.

On August 8, 2014 patient #1 presented to the Emergency Department with fever/chills, nausea, vomiting, cough, diarrhea, and confusion. His past medical history included; Multiple sclerosis, asthma, migraines, chronic pain, abdominal adhesions, degenerative disk disease, irritable bowel, diplegic cerebral palsy, bronchitis. Spastic paraplegia, congenital imperforate anus, chronic constipation, and Ileostomy. During the inpatient stay the patient was given a diagnosis of hypertension. However, the documentation did not show that Patient #1 was discharged with that diagnosis.

On October 25, 2015 patient #1 presented to the Emergency Department with progressive focal motor weakness. His past medical history on this admission included; neurogenic bladder, urinary urgency with occasional incontinence that was dated to have been diagnosed from April of 2014. The diagnosis of hypertension was not carried over to this admission.

On January 22, 2015 patient #1 presented to the Emergency department for vomiting and nausea. Patient stated that he was on blood pressure and angina medications. However, the patient's previous medical records did not support that medical history. The patient did not receive medications for high blood pressure or angina during this admission.

The discharge summary dated January 29, 2015 (January 22 admission) inaccurately indicated that patient #1 was on Hydrochlorothiazide, Isosorbide Mononitrate, Arixtra, Ranolazine, and Lisinopril. The list of medications in the discharge summary did not include a rationale or clinical diagnosis for those medications but the patient was discharged to a long term care facility with these medications listed.

On February 10, 2015 , the patient was sent to the Emergency Department from the long-term care facility with acute renal failure, hyperkalemia and viral gastroenteritis with dehydration. The patient's past medical history then included mitral valve prolapse which was not identified on the previous admissions. During the course of the February 10, 2015 admission the medical record was not changed and updated to provide the adequate and necessary information pertaining to patient #1's current and past medical history.

Based on staff interviews, and review of medical records, policies and procedures it was determined that Condition of Discharge Planning was not met due to the the hospital's failure to provide accurate information for patient #1 at discharge resulting in the patient's readmission with acute renal failure and hyperkalemia subsequent to the adminsitration of the incorrect medications at his long term care facility.

Patient #1 was a 29 year old male who presented to the Emergency Department from home on January 22, 2015 due to nausea and vomiting. Staff interviews and review of medical records and hospital policies revealed that a reconciliation of patient #1's medication was done at admission. The medication reconciliation stated that patient # 1 could only remember one of the medications that he was taking at home, and that he did not have a list of medications with him. The hospital staff who performed the medication reconciliation then included the patient's list of medications from his previous admissions to the hospital (from 8/4/14 and 10/25/15) on the admission medication reconciliation. Seven medications were listed in the admission reconciliation that were not supported by any clinical diagnoses or other rationale (Hydrochlorothiazide (HCTZ), Isosorbide Mononitrate (Imdur), Lisinopril, Ranolazine (Ranexa), Arixtra, Pepcid, and Terazosin (Hytrin).) These seven medications were never ordered for, or administered to, patient #1 during his inpatient admission to the hospital from January 22, 2015 to January 29, 2015.

The discharge medication reconciliation was done by a nurse practitioner who was not the patient's attending. When interviewed on April 6, 2015 she stated that since the attending knew this patient well she believed the list of medications to be accurate. The discharge summary dated January 29, 2015 for patient #1 included these same seven medications that had been included on the admission medication reconciliation list and they were still not supported by any clinical diagnoses or other rationale.

The discharge summary listing the patient's medications was sent to the long term care facility that was providing post hospital care. The long-term care physician prescribed these medications to the patient. The patient was sent back to the hospital on February 10, 2015 with a diagnosis of acute renal failure, hyperkalemia and viral gastroenteritis with dehydration. The hospital failed to provide accurate information for the safe discharge of patient #1. See the deficency cited at A0837 .

Based on the review of 5 open and 7 closed medical records, review of hospital policy and interviews with staff, it was determined that the hospital failed to provide necessary and accurate information for a safe transfer of patient #1 to a long term care facility.

Patient #1 was a 29 year old male who presented to the Emergency Department from home on January 22, 2015 due to nausea and vomiting.

According to the review of policies and medical records and interviews of staff, a reconciliation of patient #1's medication was done at admission. The medication reconciliation stated that patient # 1 could only remember one of the medications that he was taking at home, and that he did not have a list of medications with him. The hospital staff who performed the medication reconciliation included the patient's list of medications from his previous admissions to the hospital (8/4/14 and 10/25/15) on the admission medication reconciliation. Seven listed medications were listed but not supported by any clinical diagnoses or other identified rationale. The medications were Hydrochlorothiazide (HCTZ), Isosorbide Mononitrate (Imdur), Lisinopril, Ranolazine (Ranexa), Arixtra, Pepcid, and Terazosin (hytrin).

Patient #1 had no diagnoses of hypertension upon admission, or during the inpatient stay. However, medications that included Lisinopril and HCTZ prescribed for this condition were listed on his medication list.

Isosorbide Mononitrate and Ranolazine are used for angina, and patient #1 did not have a diagnosis of angina to support this medication.

Arixtra is a anticoagulant frequently used for deep vein thrombosis prophylaxis (DVT), patient #1 had no history of DVTs or other indications supporting use of an anticoagulant.

Pepcid is used for GERD or acid reflux which was never diagnosed for patient #1.

Terazosin is used to treat benign prostatic hyperplasia or hypertension which also was not diagnosed for Patient #1.

It was noted that these medications were never ordered for the patient during his inpatient admission to the hospital from January 22, 2015 to January 29, 2015.

The hospital's discharge process includes medication reconciliation, in accordance with a medication reconciliation policy which was reviewed by the surveyor. Interviews and record documentation revealed that the discharge summary dated January 29, 2015 for patient #1 identified the same list of medications that were included on the admission medication reconciliation list. There were no clinical diagnoses that correlated with the the medications that were listed in the discharge summary nor was there any rationale for patient #1 to take the identified medications.

The discharge medication reconciliation was done by a nurse practitioner who was not the patient's attending. When interviewed on April 6, 2015 she stated that since the attending knew this patient well she believed the list of medications to be accurate. The discharge summary listing the patient's medications was sent with the patient on 1/29/15 to the long term care facility that was providing post hospital care to patient #1. The long-term care physician prescribed the unnecessary medications to the patient. The patient was sent back to the hospital on February 10, 2015 with diagnoses including acute renal failure, hyperkalemia and viral gastroenteritis with dehydration. The administration of incorrect and unnecessary medications reported to the long term care facility by the hospital, contributed to the patient's acute renal failure and hyperkalemia.