HospitalInspections.org

Based on policy and procedure, record review and staff interview it was determined in 1 of 10 (Pt. #1) medical records reviewed the CAH failed to ensure medication reconciliation policies were followed to ensure the accuracy of patient's current medications.
Finding includes:

1. The CAH policy dated 6/5/13, titled, "Medication Reconciliation" was reviewed on 6/5/13. Under "Introduction to Medication Reconciliation" para. 1 "Medication Reconciliation allows you to view a comprehensive list of all medications that a patient is on and ensure the accurate transfer of medication information across all levels of transitions of care."

2. The medical record of Pt. #1 was reviewed on 6/5/13. Pt. #1 was admitted to the ED on 4/14/13 at 1349 with diagnoses of Nausea, Diarrhea, and Abdominal Pain. Documentation indicated Pt. #1 brought a hand-written list of medications to the ED. Documentation indicated the medications brought in by Pt. #1 did not match the CAH's electronic medical record list of home medications. There was no documentation to indicate a discussion with Pt. #1 regarding the discrepancy or physician notification.

3. During an interview with the CNO on 6/5/13 at 1:00 PM, the CNO stated "the patients are encouraged to bring all of their medicines with them to the hospital so we know exactly what they are taking." The CNO confirmed the discrepancy in medications from the Pt. #1's handwritten list and the hospital's list and that all medications are to be reconciled upon admission.