HospitalInspections.org

Based on interviews, and record reviews, the hospital failed to ensure its medical staff by laws/rules/regulations/policies on medication reconciliation were followed in 1 on 1 (patient #1) in that:

The facility failed to administer a physician recommended medication to patient #1 for 7 days.

The facility physicians documented in their progress notes Patient #1 was on gabapentin medication for peripheral neuropathy though no medication administration records showed its administration.

Findings included:

Patient # 1 was an 87-year-old African American female with past medical history including hypertension, diabetes, CVA, chronic kidney disease and a history of peripheral neuropathy. Patient #1 was admitted to the facility on 07/17/2019 at 1920 with a chief complaint of generalized weakness and left flank pain.

Admission History and Physical record dated 07/17/2019 reviewed on 01/06/2020 at 10:45 a.m. revealed patient #1 was on home medication gabapentin 300 mg by mouth twice daily among other medications. Physician #1 in her assessment recommended continuation of her home medication (gabapentin) due to the patient's history of peripheral neuropathy.

Physician progress note signed and dated 07/18/19 by physician #2 indicated (on assessment and plan) that "history of peripheral neuropathy, on gabapentin." Progressive physician notes from 19th to 24th indicated patient #1 "still complains of significant bilateral heel pain on gabapentin." This was despite the patient not being on any gabapentin medication.

Medication records reviewed did not indicate patient # 1 was on any gabapentin from 07/17/19 up to 07/24/19.

Physician order reviewed indicated patient #1 was put on Gabapentin 300mg by mouth three times daily on 07/25/19.

Interview with Personnel # 1 on 01/06/2020 at 12:30 p.m. confirmed physician recommendation to continue gabapentin was not followed. Subsequent physician assessment and plan revealed patient was thought to be on the medication up to 07/25/19 when an order was written. Personnel #1 reported "nurses are to check on H&P and should notify the physician for any discrepancies .... Pharmacists are not involved in medication reconciliation. The patient or patient family notifies the nurse the medications the patient was taking at home. The physician decides what medication to continue or discontinue."

Review of hospital policy ref #716-049, entitled: "Medication Reconciliation" stated in its definition: "Medication reconciliation is an interdisciplinary process of identifying the most accurate and complete list of medications a patient is taking and using this list to provide correct medications for the patient. Reconciliation involves comparing the patient's current list of medications against the physician's admission, transfer, and/or discharge orders." The policy stated "All admitted patients should have all medications reconciled within 24 hours. Each patient's home medications ...are documented."