HospitalInspections.org

Based on policy review, record review, and interview, the hospital failed to ensure nursing staff completed the process of medication reconciliation for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. The hospital policy "MEDICATION RECONCILIATION/INVENTORY" approved 5/2016 and reviewed 4/2020 revealed, "... It is the policy of the center to reconcile medications upon admission...Medication reconciliation is a process that provides an accurate list of current medications from one provider to the next... for continuity of care... at the time of admission, the admitting nurse will reconcile the medication and doses... provided by patient recollection... patient medication list, or patient/family record... The form should be sent with the admission physician orders..."

2. Medical record review revealed Patient #1 was admitted to the hospital on 1/3/2023 with diagnoses which included Major Depressive Disorder, Recurrent Severe. Patient #1 had a past medical history of Hypertension (HTN), Cardiovascular Accident, and Congestive Heart Failure (CHF).

The EMTALA (Emergency Medical Treatment & Labor Act) Medical Screening Exam dated 1/3/2023 at 1:34 PM, revealed Patient #1's blood pressure (BP) was 180/94. The patient reported she took her BP medications about an hour prior. The physician was consulted, and admission continued.

The Admission Physician orders were taken by a verbal order on 1/3/2023 at 3:42 PM and signed by the physician on 1/4/2023 at 11:00 AM.

Review of the "MEDICATION RECONCILIATION ORDERS" dated 1/3/2023 at 7:30 PM, by the Registered Nurse (RN) revealed Patient #1 had taken the following medications prior to admission: Lisinopril 20 milligrams (mg) by mouth (po) daily for hypertension (HTN), Norvasc 10 mg po daily for HTN, Clonidine 0.1 mg po daily for HTN, Spironolactone 25 mg po daily for HTN/CHF, and Lasix 20 mg po daily for HTN/CHF. The form was signed by the Nurse Practitioner on 1/4/2023 at 3:20 PM. The medications are "checked" to be ordered in the hospital. The Clonidine was changed to 0.1 mg as needed (PRN) for BP greater than (>) 160/90.

The Progress Note dated 1/4/2023 at 3:00 PM revealed, "... contacted NP due to...blood pressure being 185/139...one time dose of Norvasc 5mg since pt [patient] was taking this med [medication] at home. Pt blood pressure was rechecked at 1800 [6:00 PM] and it was 195/118. Gave a one time dose of Clonidine..."

A physician's order dated 1/4/2023 at 3:03 PM revealed, "...Norvasc...5 mg po daily/ STAT [immediately] x 1...high blood pressure..."

A physician's order dated 1/4/2023 at 6:00 PM revealed, "...Clonidine 0.1 mg STAT x1...elevated blood pressure..."

Review of the "ROUTINE MEDICATION RECORD" revealed, Patient #1 received her 1st dose of routine daily medications Lisinopril 20 mg, Norvasc 10 mg, Lasix 20 mg, and Spironolactone 25 mg, on 1/5/2023 at 9:00 AM: 41 hours and 18 minutes after admission to the facility.

Patient #1 was discharged home on 1/6/2023.

3. In an interview in the conference room on 1/17/2023 at 1:01 PM, the Chief Nursing Officer verified the nursing staff was expected to contact the provider to review and obtain orders for the medications after the Medication Reconciliation form was complete.