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Based on medical record review, document review and interview, the facility failed to ensure a comprehensive and accurate history and physical examination for Patient #1. Specifically, the facility failed to conduct verification of the patient's home medications, including Keppra (antiseizure drug), in accordance with its policy and procedure. A serious adverse outcome occurred as a result of the identified noncompliance, which may have resulted in an episode of status epilepticus (seizure) of Patient #1, and may place other patients at risk for adverse outcome.


Findings include:


Review of Patient #1's EPIC (Electronic Medical Record System) Medical Record (MR) identified the following information:
On 03/21/2022 at 4:23 PM, a patient presented by ambulance to the Emergency Department (ED) with complaint of fatigue, and a previous medical history of subarachnoid hemorrhage (SAH, brain hemorrhage), ruptured aneurysm (a burst of a blood vessel) Ventriculoperitoneal shunt (VP shunt, a plastic tube placed to drain extra fluid from the brain), recent altered mental status, and urinary tract infection.
Medication Reconciliation documentation by the ED provider did not include Keppra.

The patient did not receive Keppra from admission of 03/21/2022 at 4:23 PM, until 03/24/2023 at 1:00 AM when patient had seizures.


See Tag A 358.

Based on medical record review, document review and interview, in one (1) of nine (9) medical records reviewed, the facility failed to ensure a comprehensive and accurate history and physical examination for a patient. Specifically, the facility failed to conduct verification of the patient's home medications, including Keppra (antiseizure drug), in accordance with its policy and procedure. (Patient #1)


Findings include:


Review of the Prehospital Care Report Summary (FDNY-Fire Department of New York, Ambulance), dated 03/21/2022, documented patient current medications included Keppra.

Review of Patient #1's Medical Record identified the following information:
On 3/21/2022 at 1623 (4:23 PM), the ED Provider noted, "Chief complaint: fatigue (patient daughter reported increased lethargy and poor appetite for more than a week); history of present illness (history provided by relative); Past Medical History; Past Surgical History; Physical Exam: Review of System (ROS); Unable to perform with mental status change."

Physical Exam: ill-appearing elderly female. Neurological: Mental status: Disoriented; Motor: Weakness present; Comments AAO (Awake, alert, and oriented) x1(to person).

Medication reconciliation documented the following drugs: Norvasc (treat high blood pressure), Losartan (high blood pressure), Protonix (treat certain stomach and esophagus problems), Pravastatin (treat high cholesterol), and Senokot (laxative). No Keppra was documented.

There was no documented evidence the Prehospital Care Summary Report (Ambulance FDNY) of 3/21/2022, which listed Keppra as one of patient's home medications, was acknowledged, addressed, and ordered for safe patient care management and to prevent an adverse outcome.

On 3/21/2022 at 2022 (8:22 PM), the patient disposition was admitted to Telemetry.

On 03/22/2022 at 0047 (12:47 AM), the History and Physical documented by the Attending physician, included a review of systems, review of past medical history, and medication reconciliation. Review of systems: Neurological and Mental Status: Patient is disoriented; Motor: Weakness present; Comments AAOx1 (Awake, Alert, and Oriented to person).
Documented medication reconciliation did not include Keppra.

On 3/24/22 at 03:33 AM, Neurology Consult Note: "Code 66 (Seizure) was activated at 1:00 AM when patient was noted to be having twitching to her upper extremities and face with blood coming from the mouth. Ativan 4 mg x2 were administered with no resolution of movements ...Stroke Code was then activated for question of a possible intracranial bleed. On arrival, writer noted patient had left gaze deviation with twitching movements to the face and jerking movements to the upper extremities ...Patient had received second dose of Ativan 4 mg. Loading dose of Keppra 4.5 g was ordered. Patient did not return to her baseline and
continued to have twitching and jerking movements. Code 88 was activated for airway protection in the setting of status epilepticus. Patient received Rocuronium (muscle relaxant), Lidocaine (regulates heart beats and anesthetic) and Propofol (anesthesia) and was intubated. Seizure-like activity resolved. Keppra 4.5 g was also administered."

Neuro ICU was consulted, and patient was transferred to the Neuro ICU. No further seizure-like activity was noted. Patient was intubated for airway management.

On 3/27/2022 at 1423 (2:23 PM), Attending Neuro Intensivist (Staff F) documentation noted patient was on Keppra at home.

On 4/15/2022 upon family's request, patient was transferred to another facility and remained intubated at the time of transfer.



Additional review of Patient #1's EMR in EPIC documentation revealed the patient had previous admissions at another NYC Health and Hospitals Facility (on 4/2021 and 5/2021) which documented the patient was on Keppra.


The facility provided a written procedure for medication reconciliation titled, "NYC Health + Hospitals Inpatient Physician-Medication Reconciliation." The written procedure was undated, unsigned with no proof of approval from the Governing Body, and not site specific. The written procedure documented the following:

"Introduction to medication reconciliation. Medication Reconciliation (med rec) is the process of comparing a patient's current orders with new orders you're writing. To maintain a complete and accurate list of medication, reconcile medications at the following times:
-Upon admission
-Before transferring a patient to another
inpatient unit with a different level of care
-Upon discharge.

2. Review Home Medications:
Admitting provider review and update as needed. Review and update home medications as you verify them with the patient or their care giver(s).
Prescriptions from previous visits and patient-reported medications appear here.
Many Patients will have medication information from outside sources. This information from other Epic sites through Care Everywhere or through Subscripts hub from the patient's pharmacy benefit manager (PBM)."

The facility did not ensure its "Medication Reconciliation" policy and procedure was followed.


During interview with Staff Q, Director of Regulatory, on 03/16/2023 at 10:09 AM, Staff Q verified its Medication Reconciliation policy and procedure. Staff Q acknowledged the policy was undated, unsigned by Governing Body, and not site specific.

During interview on 3/17/2023 at 11:18 AM, Staff F, Attending Neurointensivist, was asked where he obtained the information that the patient was on Keppra at home. Staff F opened the EMR system where the patient's previous admissions in 4/2021 and 5/2021, at another NYC Health and Hospital facility documented that the patient was on Keppra.
Staff F explained for medication reconciliation, medical staff get information from the patient, family, pharmacy, and prior records of admissions.

During interview with the patient's relative on 3/20/2023 at 11:30 AM, the relative
acknowledged being present with the patient during the ED admission, and that the physician was informed the patient was on Keppra at home.