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Based on record review and interview the facility failed to follow the facilities policy and procedures to ensure complete evaluation of patient's discharge needs by failing to provide 3 of 10 patients (Patient #1 Patient #4 and Patient #7) complete education of their medications, accurately documented in their after visit summary instructions in a total of 10 medical records reviewed.

Findings include:

Review of policy "Medication Reconciliation" dated 5/06/2019, under Hospital Registered Nurse's scope of practice "#3 revealed "At the time of patient discharge, the home medication list is reviewed and reconciled. The patient/family are provided with a complete list of medications to be continued at home. At discharge, explain the importance of managing medication information to the patient/family and document the medication education was completed."

Review of policy "Discharge of a Patient from the Hospital, EDTC (Emergency Department Trauma Care), or Day Surgery" dated 11/07/2017 VIII. Registered Nurse Responsibilities for Patient Discharge, E. After Visit Summary (AVS) 4. "Hospital will print one copy of the AVS. a. Review the AVS with the Family. b. Obtain the signature of the parent or authorized adult. c. Made a copy of the signed AVS... to be scanned into the EHR (electronic health record) by Medical Records post-discharge."

Patient #1's medical record was reviewed and revealed Patient #1 was admitted from the clinic on 9/16/19 with enteral colitis versus bacterial overgrowth. Medication reconciliation was completed on admission 9/16/19 by Certified Pharmacy Tech (CPhT) P 9/16/19 and revealed three medications listed under "Home Medications", Tylenol, Flagyl (antibiotic) and pediatric multivitamin with iron. Patient #1 was treated with intravenous (IV) Zosyn (antibiotic) and discharged 9/19/2019. The after visit summary (AVS) "Medication List TAKE these medications" listing Tylenol, "START" under an arrow by "ferrous sulfate" (iron tablet), multivitamin with iron, "START" under an arrow by "rifAXIMin" (antibiotic), and "STOP" under X by "FLAGYL (antibiotic). Under "Where to pick up your medications", listed the pharmacy, pharmacy address, and two medications "ferrous sulfate" & "rifAXIMin." There is no medication education on rifaximin documented in the medical record. There is no documentation in the medical record that rifaximin was denied by the insurance company prior to discharge and flagyl was given instead.

Patient #1 was readmitted on 9/23/19 thorough the Emergency Department with abdominal pain, vomiting, and temperature of 102 degrees. Medication reconciliation was completed by CPhT I 9/24/19 and revealed 4 medications listed under "Home Medications", Tylenol, ferrous sulfate, pediatric multivitamin with iron and rifaximin with a note under rifaximin "Pt (patient) has not started this medication at home yet." Flagyl was not listed under "Home Medications" in the medication reconciliation list. History and physical dated 9/23/2019 at 8:50 PM under social history revealed "Insurance denied rifaximin so [s/he] has been taking oral flagyl." Patient #1 was treated with IV Zosyn, transitioned to Rifaximin by mouth, and discharged 9/26/2019. AVS printed 9/26/2019 at 10:50 AM under "Medication List" revealed Tylenol, ferrous sulfate, pediatric multivitamin with iron, and rifaximin "Last given 9 AM on 9/26. Next dose can be given at 3PM." Under "Where to pick up your medications", listed the pharmacy, pharmacy address, and one medication "rifAXIMin." There is no medication education on rifaximin documented in the medical record. There was no documentation in the medical record that the provider was notified Patient #1 did not receive the rifaximin on discharge.

Patient #1 was transferred to the Intensive Care Unit at this facility on 9/28/19 from another acute hospital where s/he was intubated with severe sepsis in septic shock. The Critical Care History and Physical dated 9/28/2019 at 10:11 AM by Physician K revealed "Per chart review, [Patient #1] was doing okay at home following discharge. [S/he] did continue to have intermittent fevers, but antibiotics had not been continued - there were problems with insurance approving the medication." Critical Care Progress note by Physician K on 9/28/2019 at 11:33 AM revealed "[S/he] was supposed to be on rifaximin post discharge but due to insurance not approving it [s/he] has been without antibiotics x 2 days." Admission medication reconciliation started 9/28/2019 at 11:19 am, completed by Physician L 9/28/2019 at 2:23 PM, revealed four medications listed under "Home Meds Already Reconciled", Tylenol, ferrous sulfate, pediatric multivitamin with iron and rifaximin. Patient #1 was treated with IV antibiotics and transitioned to Rifaximin by mouth 10/02/2019. Patient #1 was discharged 10/07/2019 with instructions that rifaximin had been approved by insurance with number and names of who to contact.

Patient #4's medical record was reviewed and revealed Patient #4 was a 1 year, 11 month old admitted 9/04/2019 through the Emergency Department Trauma Center (EDTC) with a history of Hirschsprung disease admitted for rectal examination, rectal, and mucosus fistula biopies, and a contrast study of the gastrointestinal tract. "Pharmacy Medication Reconciliation" was completed 9/05/2019 at 10:53 AM by Certified Pharmacy Tech I revealing one medication,"pediatric multivitamin." After visit summary (AVS) Medication List revealed "Unreviewed medications - please ask your doctor about these medications" listing Ciprofloxacin and Flagyl. There was no medication education documented in the medical record on the medications on the AVS or a signature indicating parent had received the list of home medications.

Patient #7's medical record was reviewed and revealed Patient #7 was a 15-year-old admitted 7/01/2019 through the emergency room with left hand cellulitis and received IV cefepime and vancomycin. Medication reconciliation was completed by CPhT Q 7/01/2019 and revealed 1 medication listed under "Home Medications", ibuprofen. Patient #7 was discharged 7/02/2019. AVS printed 7/02/2019 under "Medication List" revealed "START" under an arrow by "amoxicillin." There was no medication education of amoxicillin documented in the medical record.

On 10/31/2019 at 2:05 PM during an interview with Clinical Nurse Specialist (CNS) D while reviewing Patient #1's medical record, inpatient admission 9/16/ to 9/19/2019, CNS D stated "the [parent]said [s/he] was taking the Flagyl" at discharge but confirmed there was no documentation of this in Patient #1's medical record.

On 10/31/2019 at 2:15 PM during an interview with Case Management Manager F, Manager F stated that the rifaximin medication that was ordered on discharge was denied by the insurance company. Manager F stated denial of the rifaximin was documented in the case management notes and confirmed it was not documented in Patient #1's medical record.

On 11/01/2019 at 9:45 AM during an interview with Registered Nurse Orientee (RN) O, RN O stated the medication list on the AVS was verified and reviewed with the patient/parent at discharge. RN O stated that any discrepancies are verified with the physician and documented in the AVS. RN O stated "I don't remember" what medications Patient #1 was to take at discharge, stating "it would have been documented in the AVS."

On 11/01/2019 at l:02 PM during an interview with CNS D, CNS D stated the registered nurse was responsible for documenting that they completed education on any new medications. CNS D confirmed there was no documentation of medication education on rifaximin documented during Patient #1's hospitalizations on 9/16 to 9/19/2019 and 9/23 to 9/26/2019, there was no medication education documentation of Ciprofloxacin or Flagyl documented in Patient #4's hospitalization on 9/04 to 9/05/2019, and no documentation of medication education on amoxicillin done on Patient #7's hospitalization on 7/01 to 7/02/2019.

Based on record review and interview the facility failed to identify factors that contribute to preventable readmissions by failing to conduct an in depth review of their readmissions in one of one hospital QAPI program.

Findings include:

Review of "Scope of Service Hospital Case Management" dated 11-30-2018 revealed "Utilization Management Specialists are RNs (registered nurses) whose activities include concurrent and retroactive reviews, ongoing level of care, as well as assessment and appeal of concurrent and retrospective clinical denials."

On 10/31/2019 at 3:10 PM during an interview with Regulatory Specialist C, C stated they did review their readmissions two years ago, did not find anything in their reviews, but they continue to report out the number of readmissions quarterly, confirming "we do not do review of our individual readmissions anymore."