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Based on staff interviews and record review, the hospital failed to assure that the medical record for 1 of 10 records reviewed was completely and accurately documented. (Patient #1) Findings include:

Per record review and confirmed by staff interviews, the medical record for Patient #1 contained inaccurate medication reconciliation information and failed to document telephone calls made to a surgeon from another hospital, completed by the Emergency Room (ER) Provider during the patient's visit on 6/1/11.

Per a telephone interview on 1/7/11 at 12:30 PM, the patient's family member stated that they had provided the medications the patient was taking from home for review by the Emergency Room nurse upon admission to the ER on 6/1/11 and had informed the nurse that only brand name medications were to be administered to the patient due to adverse side effects. The family stated that medications listed/ordered inpatient were incorrect. The family stated that staff were informed that the medication Celecoxib was ordered in error and nurses failed to note this fact and bring it to the physician's attention to be discontinued and the correct medication ordered. Per review of the MAR for the 2 days of the inpatient stay (6/2/11 - 6/3/11), the incorrect medication remained on the MAR until discharge 6/3/11. Nurses documented the patient's refusal of Celecoxib in the medical record for 6/2/11 and 6/3/11, however, they failed to document why. During interview on 1/10/12 at 3:20 PM, the President of Patient Services confirmed that nurses should have documented why Patient # 1 refused to take the medication(s) ordered during the hospital stay.

During interview on 1/10/12 at 1:20 PM, the Physician Assistant (PA) who provided the medical exam to the patient in the ER, confirmed that he/she had failed to document telephone conversations with the patient's surgeon from a procedure performed at an out of state hospital the preceding week. He/she confirmed that they did consult together via telephone but there is no evidence of that in the ER medical record for 6/1/11.