The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

UC SAN DIEGO HEALTH HILLCREST - HILLCREST MED CTR 200 WEST ARBOR DRIVE SAN DIEGO, CA 92103 May 24, 2012
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on interview and record review, the hospital failed to ensure that it's policy and procedure pertaining to patient complaints and grievances was implemented, for 1 of 8 complaints and grievances reviewed (Patient 2).

Findings:
On 5/23/12 at 11:00 A.M., a joint interview and review of the hospital's complaint and grievance process, as it pertained to 8 patient complaints and grievances, was conducted with the Director of Patient Relations (DPR) and 3 patient relations staff members.

According to a complaint log, on 2/9/12, Patient 2 filed a complaint regarding the care and services she received in the Emergency Department (ED) at Hospital A. Per the log, the patient complained about ED staff rudeness and "being placed in an unsafe, vulnerable position by an ED nurse." The patient complained that she should have been given a taxi voucher to get home, rather than a bus pass.

On 5/23/12, the hospital's policy and procedure entitled "Patient Experience/Complaints/Grievances Policy," dated 8/19/10, was reviewed. Per the policy, a "grievance" differed from a "complaint" when it was a problem or concern that could not be resolved to the patient's satisfaction after undergoing initial review and resolution. In addition, a "grievance" required that the patient receive a written notice via mail or e-mail within 7 business days of the grievance date that provided the following: a. steps taken on behalf of the patient to investigate the grievance, b. identified timeframe patient can expect a resolution or update on the progress of the investigation, c. the name and number of the hospital's contact person coordinating the investigation.

Patient Relations Staff (PRS) 3 was assigned to Patient 2's complaint. Per PRS 3 the patient's complaint was "unresolved." Per PRS 3's incident documentation report, Patient 2's complaint was categorized as a "complaint" not a grievance. According to PRS 3 the patient's complaint was unresolved because PRS 3 had not heard back from all of the ED staff. PRS 3 stated that after the initial investigation, she spoke with the patient, and the patient was not satisfied with the response. There was no evidence that the patient's complaint had been then acknowledged as a grievance, per the policy. There was no evidence that a letter was sent to the patient as required by hospital policy. There was no evidence of any further follow-up by PRS 3 on Patient 2's behalf.

On 5/23/12 at 12:05 P.M., an interview was conducted with the DPR. The DPR acknowledged that Patient 2's "complaint" should have been viewed as a grievance. The DPR acknowledged that Patient 2's complaint or grievance had not been resolved in a reasonable timeframe and that the hospital's policy and procedure was not implemented by PRS 3.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to identify opportunities for improvement following the death of Patient 1 at Hospital A. When Patient 1 eloped and was later found pulseless, in the Emergency Department (ED) waiting room bathroom, a post event analysis failed to identify opportunities for improvement pertaining to staff response after patient elopement, patient assessment and reassessment, and medication reconciliation. In addition, the hospital failed to monitor the medication reconciliation process in the Emergency Departments (ED), Operating Room (OR), and other procedural areas at Hospital A and B, to ensure that the process was consistently performed and completed, in accordance with the hospital's policy. The hospital failed to identify opportunities for improvement when medication reconciliation data from these areas was not collected.

Findings:

1. An investigation and electronic record review was initiated on 4/5/12 at 8:20 A.M., as a result of a complaint which alleged that on 2/21/12, during the course of being treated for alcohol intoxication in the ED, Patient 1 "disappeared" from the ED, ingested something he found in the ED waiting room, and was later found pulseless in the waiting room bathroom. Patient 1 became brain dead and died sometime thereafter.

On 4/5/12 at 8:35 A.M., a review of the ED's registry log revealed that Patient 1's name was entered into the log twice, once at 12:55 P.M. for "ETOH" (ethyl alcohol), and then at 6:15 P.M. for "CPR" (cardiopulmonary resuscitation).

Patient 1 presented to the Emergency Department (ED) via paramedics on 2/21/12 at 12:55 P.M., with a chief complaint of "ETOH" use.
Per the Triage Nurse notes, Patient 1 presented with "heavy ETOH," intermittent level of consciousness, "fell out of his wheelchair and urinated on the waiting room floor." The triage nurse documented that the patient had "chronic ETOH," and was seen at the hospital within the last few days "for same." His past medical history included diagnoses of chronic depressive person, schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and alcoholism. Per the Triage Record, Patient 1's medications included Abilify (an antipsychotic and antidepressant medication) and Seroquel (antipsychotic medication used in treatment of schizophrenia). The entries in the electronic record pertaining to the dosages and frequencies of those medications contained "N/A" (not assessed).
Per the ED record, Patient 1 was placed in a room on 2/21/12 at 12:55 P.M., and assessed by Registered Nurse (RN) 1 at 1:00 P.M. RN 1's documented neurological assessment of the patient was "alert but confused" and verbal responses were "incomprehensible." RN 1 documented that the patient expressed no suicidal ideation/intent. RN 1 documented that the patient had not attempted suicide in the past. Patient 1 was placed on a heart monitor. Per RN 1 the patient has sinus tachycardia (fast heart rate) with a rate of 101.
Per an entry made in the record at 1:12 P.M., the patient's breathalyzer (device for estimating blood alcohol content (BAC-milligrams (mg) of alcohol per 100 mg. of blood, from a breath sample) result was 0.278. Per RN 1's notes, the patient followed simple commands and mumbled with slurred speech.
At 3:10 P.M., RN 1 documented that Patient 1 was sleeping, but aroused easily, denied pain and had slurred speech. He remained on a heart monitor.
At 4:40 P.M., RN 1 documented "pt. (patient) awake and alert pulled off monitor leads and attempted to walk out of hospital. pt. returned to rm. (room) and put shirt on. ambulates steady gait. denies pain admits to ETOH. slow to respond unable to state year. knows name, president and that he as at (name of hospital). pt. calm and cooperative, will wait for discharge re-evaluated by (names of Medical Doctor (MD) 2 and MD 1- the attending physician)."
At 4:56 P.M., RN 2 documented that Patient 1 decided to walk out of the ED, and that "MD 2 aware."
On 4/5/12 at 10:00 A.M., a joint interview was conducted with the Nursing Director of the ED (NDED) and the Licensing and Certification Principal Consultant (LCPC). Per the NDED, on 2/21/12, Patient 1 apparently eloped and was found down in a locked ED waiting room bathroom. Per the NDED, Patient 1 had numerous visits to the ED within the past year related to alcohol use. The LCPC stated that, per a quality variance report, it was presumed that Patient 1 drank a bottle of hand sanitizer gel, as an empty bottle of hand sanitizer gel was found next to the patient's body and some of the gel was on the patient's face. Patient 1 was in full cardiac arrest when he was found, and emergency resuscitative measures were implemented. On 2/21/12 at 6:15 P.M., Patient 1 was re-triaged into the ED and admitted into the Intensive Care Unit (ICU) for further management.
Per a physician's ICU progress note, dated 2/28/12, Patient 1 was made a DNR (do not resuscitate) with comfort care status, after his clinical status and poor prognosis was reviewed with the patient's family member. Compassionate extubation protocol was implemented and Patient 1 expired on [DATE] at 12:28 P.M.
On 4/13/12 at 9:30 A.M., an interview was conducted with RN 1. RN 1 stated that she was unaware of Patient 1's history of depression and schizophrenia. RN 1 confirmed that her assessment pertaining to the patient's risk for suicide was completed when the patient was intoxicated from alcohol. RN 1 acknowledged that she should have reassessed the patient for being a danger to himself as he was becoming more coherent and less intoxicated. RN 1 stated that she didn't think about a reassessment of the patient from a psychosocial standpoint or requesting a referral for a social worker consult. RN 1 stated that she did not look for Patient 1 or inform the Charge Nurse that he had left without notification.
On 4/13/12, the ED Standards of Patient Care were reviewed. Per the Standards, potential indications for Social Work Services or Case Management referrals included patients who made frequent visits to the ED. In addition, patients who had problems with alcohol or psychiatric issues should be considered for counseling referrals.
On 4/13/12, a review was conducted of the hospital's policy entitled "Patient Leaving Against Medical Advice (AMA) and Patient Elopement," dated 7/19/07. The policy defined "elopement" as "when a patient leaves the hospital without notification to the treating physician or hospital staff." The policy defined "decisional capacity" as when a patient "can understand the condition and the risk and benefits of the recommended treatment and available alternatives and make a choice." Per the policy, in the event of an elopement of a patient that lacks decision making capacity, but not assessed as a flight risk, "the nurse caring for the patient shall notify the physician, the nursing supervisor and or the unit manager/designee immediately upon finding the patient's absence." Per the policy, the nursing supervisor was required to notify hospital security.
Further review of the record, revealed no documented evidence that RN 1 or RN 2 attempted to locate Patient 1 after he left. There was no documented evidence that the Charge Nurse or hospital security was informed of the patient's unexpected departure, so that a diligent search could be performed for the patient in an effort to ensure that he was safe and expressed an understanding of his condition, need for follow up care, and discharge instructions.
On 4/13/12 at 12:15 P.M., an interview was conducted with the Associate Medical Director of the ED, MD 4. Per MD 4, a patient's decisional capacity and safety should be determined during reassessment of the patient before they are discharged . MD 4 stated that decisional capacity is determined by talking to the patient and assessment of orientation. MD 4 acknowledged that during the discharge process determination of decisional capacity is often made when the patient can verbalize understanding about their medical condition, treatment options, and discharge instructions. MD 4 acknowledged that Patient 1 left prior to being formally discharged and receiving discharge instructions. MD 4 acknowledged that there was no documented evidence in the record concerning Patient 1's decision capacity other than he was awake and oriented to person, place, month, and knew who the President was.
On 4/24/12 at 1:45 P.M., an interview was conducted with MD 1. MD 1 stated that she reassessed Patient 1 as he metabolized. She said her usual process for a patient who entered the ED with alcohol intoxication was to talk with the patient about detoxification and plans for entering a detox center. MD 1 acknowledged that she didn't ask Patient 1 about his medications or compliance. MD 1 stated that she only asked the patient if he needed his medications and the patient replied that "he didn't need them."
Per the hospital's "Medication Reconciliation" policy, dated 11/18/10, the purpose of medication reconciliations were to decrease the number of medication errors, provide and sustain a continuity of care with regard to a patient's medication regimen, minimize complications of the patient's health that are related to changing a patient's medications and to promote communication between and among healthcare providers with regard to changes made to a patient's medication regimen. "All patients with an emergency department encounter with an Emergency Department Licensed Independent Provider will have their home medication....information collected and documented."
An interview with the Director of Pharmacy (DOP) was conducted during a Quality Assessment and Performance Improvement (QAPI) group interview on 5/23/12 at 2:08 P.M. The DOP stated that medication reconciliation was important for patient safety and medication efficacy purposes.
There was no documented evidence in the record that ED staff performed the medication reconciliation process during Patient 1's visit to the ED.
On 4/13/12 at 2:30 P.M., an interview was conducted with the hospital's Sentinel Event Specialist (SES). Per the SES, an investigation concerning Patient 1's death was conducted and completed. The SES was asked if opportunities for improvement had been identified by the hospital and if any subsequent actions were taken as a result. The SES shared the action plan which consisted of 2 follow up actions: 1. all hand sanitizer free-standing bottles were removed from the ED waiting room at Hospital A. and 2. location of the keys for the ED waiting room bathroom was evaluated. The SES stated that she had reviewed Patient 1's medical record. The SES stated that she did not consider Patient 1's disappearance an "elopement" scenario because the patient was not a custodial patient "under guard." The SES stated that she had not reviewed the hospital's policy concerning elopement when the event was analyzed. The hospital's definition of elopement, per the policy was reviewed with the SES. The policy's definition of elopement was not consistent with what the SES verbalized.
Following Patient 1's death, the hospital failed to identify opportunities for improvement pertaining to staff response to the patient's elopement, nursing assessments and reassessments, and the medication reconciliation process in the ED, when it conducted an analysis of the event.





2. A review of ED medical records were conducted beginning on 5/21/12 at 1:25 P.M. The medical records showed that the medication reconciliation process was not performed and completed in accordance with the hospital's policy.

A review of the hospital's policy entitled "Medication Reconciliation," effective date of 11/18/10, was conducted. The purpose of medication reconciliations were to decrease the number of medication errors, provide and sustain a continuity of care with regard to a patient's medication regimen, minimize complications of the patient's health that are related to changing a patient's medications and to promote communication between and among healthcare providers with regard to changes made to a patient's medication regimen. "All patients with an emergency department encounter with an Emergency Department Licensed Independent Provider will have their home medication....information collected and documented."

An interview with the ED nurse manager (EDNM) was conducted on 5/22/12 at 1:18 P.M. The EDNM acknowledged that multiple nursing staff in the ED did not consistently verbalize or demonstrate the hospital's medication reconciliation process. Registered Nurse (RN 41) stated that the physician was ultimately responsible for the completion of a patient's medication reconciliation. RN 42, RN 43 and RN 44 stated that the medication reconciliation process began with the triage nurse and then it was the primary nurses responsibility to complete the medication reconciliation section. RN 42 and RN 44 both stated that the medication reconciliation will be completed prior to the patients' discharge from the ED. He acknowledged that the medication reconciliation process was inconsistently performed and the documentation was incomplete because most of the records reviewed revealed that the dosage and duration were filled in with "N/A" (not assessed per the hospital).

An interview with the Director of Pharmacy (DOP) was conducted during a Quality Assessment and Performance Improvement (QAPI) group interview on 5/23/12 at 2:08 P.M. The DOP stated that medication reconciliation was important for patient safety and medication efficacy purposes. He stated that the pharmacy was not monitoring the medication reconciliation process in the EDs at Hospital A and B. He acknowledged that there was no pharmacy oversight in the EDs on this process to ensure that it was performed and completed in accordance with the hospital's policy. In addition, the DOP acknowledged that pharmacy also did not monitor the medication reconciliation process in the OR (operating room) and special procedure areas such as the cardiac catheterization lab, GI (gastrointestinal) and IR (interventional radiology).

The hospital's Medication Error Reduction Plan (MERP) FY (fiscal year) 2011/2012 was reviewed on 5/24/12 with the DOP.
The MERP's medication safety initiatives did not include the review or monitoring of the hospital's medication reconciliation process in the EDs at Hospital A and B.

An interview with the Director of Quality was conducted on 5/24/12 at 10:45 A.M. The Director of Quality stated that the hospital's Quality Assessment and Performance Improvement (QAPI) program did not monitor the medication reconciliation process in the EDs at both Hospital A and B, to ensure that it was consistently performed and completed in accordance with the hospital's policy. She also acknowledged that this process was not monitored in the OR and special procedure areas such as the cardiac catheterization lab, GI, pulmonary and IR.

3. A review of ED medical records were conducted beginning on 5/21/12 at 1:25 P.M. The medical records showed that the medication reconciliation process was not performed and completed in accordance with the hospital's policy.

Beginning on 5/21/12 through 5/23/12, interviews with ED staff were conducted at Hospital A and B. The ED staff were unable to consistently verbalize or demonstrate the hospital's medication reconciliation process. During a Quality Assessment and Performance Improvement (QAPI) group interview on 5/23/12 at 2:08 P.M., the Chief Nursing Officer, Chief Medical Officer, the Director of Pharmacy, the Nurse Director of the ED (NDED), the Director of Regulatory and the Medical Director of the ED were in attendance. The NDED agreed that the ED staff were not able to consistently verbalize or demonstrate the hospital's medication reconciliation process. She also acknowledged that multiple medical records reviewed from the ED at Hospital A and B showed that the medication reconciliations were not performed or completed in accordance with the hospital's policy.

Per the hospital's "Medication Reconciliation" policy, dated 11/18/10, the purpose of medication reconciliations were to decrease the number of medication errors, provide and sustain a continuity of care with regard to a patient's medication regimen, minimize complications of the patient's health that are related to changing a patient's medications and to promote communication between and among healthcare providers with regard to changes made to a patient's medication regimen. "All patients with an emergency department encounter with an Emergency Department Licensed Independent Provider will have their home medication....information collected and documented."

A review of a hospital form entitled "Emergency Department -Total," dated 1/1/12 - 3/31/12, was conducted on 5/24/12. The form showed the hospital's audit results from various patient safety indicators monitored and tracked in the ED. There was no documented evidence to show that monitoring and tracking of the hospital's medication reconciliation process and its implementation were performed.

A review of a hospital form entitled "Inpatient," dated 1/1/12 - 3/31/12, was conducted on 5/24/12. The form was an audit tool that showed how medication reconciliations were monitored and tracked in the EPIC's (the hospital's electronic medical charting system) inpatient medical record. The audit tool confirmed that the hospital was only monitoring and tracking the medication reconciliation process in inpatient medical records.

There was no documented evidence (data) to show that the hospital's QAPI program monitored or tracked the hospital's medication reconciliation process in the EDs at Hospital A and B.

An interview with the Director of Quality was conducted on 5/24/12, at 10:45 A.M. The Director of Quality stated that the hospital's Quality Assessment and Performance Improvement (QAPI) program did not monitor or track the hospital's medication reconciliation process in the EDs at Hospital A and B. She stated that the hospital's audit forms did not include a review of the medication reconciliation process in the ED's at Hospital A and B. She acknowledged that opportunities for improvement related to medication reconciliation were not identified because the process was not monitored or tracked by the hospital to ensure that the process was performed and completed in accordance with the hospital policy.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure that Registered Nurse (RN) staff implemented the Emergency Department Standards of Patient Care for 1 patient (Patient 1) at Hospital A. There was no documented evidence that RN 1 performed a focused assessment of Patient 1's psychosocial needs or performed a reassessment of the patient as the patient's condition changed.

Findings:

1. An investigation and electronic record review was initiated on 4/5/12 at 8:20 A.M., as a result of a complaint which alleged that on 2/21/12, during the course of being treated for alcohol intoxication in the ED, Patient 1 "disappeared" from the ED, ingested something he found in the ED waiting room, and was later found pulseless in the waiting room bathroom. Patient 1 became brain dead and died sometime thereafter.

On 4/5/12 at 8:35 A.M., a review of the ED's registry log revealed that Patient 1's name was entered into the log twice, once at 12:55 P.M. for "ETOH" (ethyl alcohol), and then at 6:15 P.M. for "CPR" (cardiopulmonary resuscitation).
Patient 1 presented to the Emergency Department (ED) via paramedics on 2/21/12 at 12:55 P.M., with a chief complaint of "ETOH" use.
Per the Triage Nurse notes, Patient 1 presented with "heavy ETOH," intermittent level of consciousness, "fell out of his wheelchair and urinated on the waiting room floor." The triage nurse documented that the patient had "chronic ETOH," and was seen at the hospital within the last few days "for same." His past medical history included diagnoses of chronic depressive person, schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and alcoholism. Per the Triage Record, Patient 1's medications included Abilify (an antipsychotic and antidepressant medication) and Seroquel (antipsychotic medication used in treatment of schizophrenia). The entries in the electronic record pertaining to the dosages and frequencies of those medications contained "N/A" (not assessed).
Per the ED record, Patient 1 was placed in a room on 2/21/12 at 12:55 P.M. and assessed by Registered Nurse (RN) 1 at 1:00 P.M. RN 1's documented neurological assessment of the patient was "alert but confused" and verbal responses were "incomprehensible." RN 1 documented that the patient expressed no suicidal ideation/intent. RN 1 documented that the patient had not attempted suicide in the past. Patient 1 was placed on a heart monitor. Per RN 1 the patient has sinus tachycardia (fast heart rate) with a rate of 101.
Per an entry made in the record at 1:12 P.M., the patient's breathalyzer (device for estimating blood alcohol content (BAC-milligrams (mg) of alcohol per 100 mg. of blood from a breath sample) result was 0.278. Per RN 1's notes, the patient followed simple commands and mumbled with slurred speech.
At 3:10 P.M., RN 1 documented that Patient 1 was sleeping, but aroused easily, denied pain and had slurred speech. He remained on a heart monitor.
At 4:40 P.M., RN 1 documented "pt. (patient) awake and alert pulled off monitor leads and attempted to walk out of hospital. pt. returned to rm. (room) and put shirt on. ambulates steady gait. denies pain admits to ETOH. slow to respond unable to state year. knows name, president and that he as at (name of hospital). pt. calm and cooperative, will wait for discharge re-evaluated by (names of MD 2 and MD 1- the attending physician)."
At 4:56 P.M., RN 2 documented that Patient 1 decided to walk out of the ED, and that "MD 2 aware."
On 4/5/12 at 10:00 A.M., a joint interview was conducted with the Nursing Director of the ED (NDED) and the Licensing and Certification Principal Consultant (LCPC). Per the NDED, on 2/21/12, Patient 1 apparently eloped and was found down in a locked ED waiting room bathroom. Per the NDED, Patient 1 had numerous visits to the ED within the past year related to alcohol use. The LCPC stated that, per a quality variance report, it was presumed that Patient 1 drank a bottle of hand sanitizer gel, as an empty bottle of sanitizer was found next to the patient's body and some of the gel was on the patient's face. Patient 1 was in full cardiac arrest when he was found, and emergency resuscitative measures were implemented. On 2/21/12 at 6:15 P.M., Patient 1 was re-triaged into the ED and admitted into the Intensive Care Unit (ICU) for further management.
Per a physician ICU progress note, dated 2/28/12, Patient 1 was made a DNR (do not resuscitate) comfort care status, after his clinical status and poor prognosis was reviewed with the patient's father. Compassionate extubation protocol was implemented and Patient 1 expired on [DATE] at 12:28 P.M.
On 4/13/12, the ED Standards of Patient Care (EDSPC) were reviewed. Per the Standards, a focused asessment of a patient would be completed within 2 hours of being placed in a patient care delivery area. The focused assessment would include as appropriate the patient's suicide risk, psychological status, social and functional status. In addition, patients were to be reassessed whenever there was a change in the patient's condition or diagnosis. Per the EDSPC, the patient would have their psychological, social and emotional needs met during their ED visit. Potential indications for Social Work Services or Case Management referrals included patients who made frequent visits to the ED. In addition, patients who had problems with alcohol or psychiatric issues should be considered for counseling referrals.
On 4/13/12 at 9:30 A.M. an interview was conducted with RN 1. RN 1 stated that she was unaware of Patient 1's history of depression and schizophrenia. RN 1 confirmed that her assessment pertaining to the patient's risk for suicide was completed when the patient was intoxicated from alcohol. RN 1 acknowledged that she should have reassessed the patient for being a danger to himself as he was becoming more coherent and less intoxicated. RN 1 stated that she didn't think about requesting a referral for a social worker consult.
There was no documentation in the record to reflect that, as Patient 1 became more coherent, RN 1 performed a psychosocial assessment and reassessment of the patient, who had an ongoing history of alchohol abuse, depression, and schizophrenia, and made frequent visits to the ED, to determine relevant needs or possible referrals.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure that Emergency Department (ED) staff at Hospital A implemented its patient elopement policy and procedure and ED Standards of Patient Care. When there was no documented evidence that Patient 1's decisional making capacity had been determined, ED staff failed to notify appropriate personnel and conduct a diligent search of the patient when he eloped (left without notification to staff) and was not formally discharged . Patient 1 was subsequently found pulseless in the ED waiting room bathroom. In addition, there was no documented evidence that nursing staff considered a psychosocial or case managment referral due to the patient's recurring presentation to the ED related to alcohol intoxication.

Findings:

1. An investigation and electronic record review was initiated on 4/5/12 at 8:20 A.M., as a result of a complaint which alleged that, on 2/21/12, during the course of being treated for alcohol intoxication in the ED, Patient 1 "disappeared" from the ED, ingested something he found in the ED waiting room, and was later found pulseless in the waiting room bathroom. Patient 1 became brain dead and died sometime thereafter.

On 4/5/12 at 8:35 A.M., a review of the ED's registry log revealed that Patient 1's name was entered into the log twice, once at 12:55 P.M. for "ETOH" (ethyl alcohol), and then at 6:15 P.M. for "CPR" (cardiopulmonary resuscitation).
Patient 1 presented to the Emergency Department (ED) via paramedics on 2/21/12 at 12:55 P.M., with a chief complaint of "ETOH" use. Patient 1 was triaged as a category "2." Per the Department of Emergency Medicine Triage Guidelines, a category 2 patient was "acute" and 1) had an illness or injury that posed no immediate threat to life or limb, and 2) held a risk for deterioration into critical state without medical attention within hours.
Per the Triage Nurse notes, Patient 1 presented with "heavy ETOH," intermittent level of consciousness, "fell out of his wheelchair and urinated on the waiting room floor." The triage nurse documented that the patient had "chronic ETOH," and was seen at the hospital within the last few days "for same." His past medical history included diagnoses of chronic depressive person, schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and alcoholism. Per the Triage Record, Patient 1's medications included Abilify (an antipsychotic and antidepressant medication) and Seroquel (antipsychotic medication used in treatment of schizophrenia). The entries in the electronic record pertaining to the dosages and frequencies of those medications contained "N/A" (not assessed).
Per the ED record, Patient 1 was placed in a room on 2/21/12 at 12:55 P.M., and assessed by Registered Nurse (RN) 1 at 1:00 P.M. RN 1's documented neurological assessment of the patient was "alert but confused" and verbal responses were "incomprehensible." RN 1 documented that the patient expressed no suicidal ideation/intent. RN 1 documented that the patient had not attempted suicide in the past. Patient 1 was placed on a heart monitor. Per RN 1 the patient has sinus tachycardia (fast heart rate) with a rate of 101.
Per an entry made in the record at 1:12 P.M., the patient's breathalyzer (device for estimating blood alcohol content (BAC-milligrams (mg) of alcohol per 100 mg. of blood, from a breath sample) result was 0.278. Per RN 1's notes, the patient followed simple commands and mumbled with slurred speech.
According to the electronic record, a physician's initial assessment of Patient 1 occurred at 12:56 P.M. At 5:25 P.M., Medical Doctor (MD) 2, fourth year Resident (physician in training), documented the following: "acute etoh intoxication, no e/o (evidence of) trauma, + (positive) elevated breathalyzer, will monitor closely as pt. (patient) metabolizes." At 6:20 P.M., MD 2 entered the physical assessment of Patient 1 into the electronic record. The assessment included a review of vital signs, general appearance, head, ear, nose and throat, chest, cardiac, abdomen, extremities, skin and neurological systems. The neurological exam documented that the patient had slurred speech, was alert and oriented times 1, followed simple commands, and moved all four extremities.
On 2/21/12 the attending physician, MD 1, entered the history and physician (H&P) examination of Patient 1 into the electronic record at 4:02 P.M. MD 1 documented that the patient had multiple visits to the ED due to alcohol intoxication or "alcohol related." Per the H&P, the patient had slurred speech, answered a few yes and no questions only, and opened eyes to voice command. MD 1's plan was to allow Patient 1 to sober and reassess for any additional complaints and proceed with a work up as indicated.
A review of the ED physician treatment orders for Patient 1 was conducted. There were a total of 3 orders. Two orders were entered at 12:57 P.M. The orders prescribed an ETOH breathalyzer and a blood sugar test. The last order entered by a physician was at 7:19 P.M. which stated "gone."
At 3:10 P.M., RN 1 documented that Patient 1 was sleeping, but aroused easily, denied pain and had slurred speech. He remained on a heart monitor.
At 4:40 P.M., RN 1 documented "pt. (patient) awake and alert pulled off monitor leads and attempted to walk out of hospital. pt. returned to rm. (room) and put shirt on. ambulates steady gait. denies pain admits to ETOH. slow to respond unable to state year. knows name, president and that he as at (name of hospital). pt. calm and cooperative, will wait for discharge re-evaluated by (names of MD 2 and MD 1- the attending physician)."
At 4:56 P.M., RN 2 documented that Patient 1 decided to walk out of the ED, and that "MD 2 aware."
Another note by MD 2, also entered into the electronic record at 5:25 P.M., indicated that the patient was re-evaluated (at what specific time that re-evaluation occurred was unclear based on the electronic record which only recorded the time the entry was made by the physician, not the actual bedside evaluation time). Per the second 5:25 P.M. note, Patient 1 ambulated with a steady gait and was in the process of getting ready to discharge when the patient left without waiting for a discharge order and paperwork. There was no documented evidence that, during MD 2's re-evaluation of Patient 1 as he was metabolizing the alcohol, that an assessment of the patient's mental status or decisional making capacity occurred. In addition, there was no documented evidence that an assessment or reassessment occurred relative to the patient's risk to harm himself or others.
On 2/21/12 at 6:34 P.M., MD 1 made 2 entries into the electronic record. MD 1 documented a "delayed note," which indicated that Patient 1 was reassessed and was "metabolizing appropriately." He was "awake, talkative, still with slightly slurred speech, knows name, place, month, unclear of year but knows (NAME) is president." Per the note, the patient wanted to leave and requested a bus token. MD 1 documented that the patient was able to ambulate with a steady gait out of his room and back to his gurney. The patient was instructed to stay in his room and a meal and bus token would be provided. The second note by MD 1 at 6:34 P.M., documented that Patient 1 left the ED without waiting for discharge paperwork and "without official discharge." MD 1 documented that MD 1 looked around the ED for the patient but could not find him. There was no documented evidence that, during MD 1's reassessment of Patient 1, as he was "metabolizing appropriately," an evaluation of the patient's mental status, or decisional making capacity occurred. In addition, there was no documented evidence that an assessment or reassessment occurred relative to the patient's risk to harm himself or others.
On 4/5/12 at 10:00 A.M., a joint interview was conducted with the Nursing Director of the ED (NDED) and the Licensing and Certification Principal Consultant (LCPC). Per the NDED, on 2/21/12, Patient 1 apparently eloped and was found down in a locked ED waiting room bathroom. Per the NDED, Patient 1 had numerous visits to the ED within the past year related to alcohol use. The LCPC stated that, per a quality variance report, it was presumed that Patient 1 drank a bottle of hand sanitizer gel, as an empty bottle of hand sanitizer gel was found next to the patient's body and some of the gel was on the patient's face. Patient 1 was in full cardiac arrest when he was found, and emergency resuscitative measures were implemented. On 2/21/12 at 6:15 P.M., Patient 1 was re-triaged into the ED and admitted into the Intensive Care Unit (ICU) for further management.
Per a H&P, dated 2/21/12 at 8:18 P.M., Patient 1 was in the ICU, intubated and nonresponsive. Per the H&P, the patient had possible ethanol poisoning with a BAL (blood alcohol level) of 0.526, "confounded by his presumed ingestion of hand sanitizer."
Per a physician ICU progress note, dated 2/28/12, Patient 1 was made a DNR (do not resuscitate) comfort care status, after his clinical status and poor prognosis was reviewed with the patient's family member. Compassionate extubation protocol was implemented and Patient 1 expired on [DATE] at 12:28 P.M.
On 4/13/12 at 9:30 A.M., an interview was conducted with RN 1. RN 1 stated that she was unaware of Patient 1's history of depression and schizophrenia. RN 1 confirmed that her assessment pertaining to the patient's risk for suicide was completed when the patient was intoxicated from alcohol. RN 1 acknowledged that she should have reassessed the patient for being a danger to himself as he was becoming more coherent and less intoxicated. RN 1 stated that she didn't think about a reassessment of the patient from a psychosocial standpoint or requesting a referral for a social worker consult. RN 1 stated that she did not look for Patient 1 or inform the Charge Nurse that he had left without notification.
On 4/13/12 the ED Standards of Patient Care were reviewed. Per the Standards, potential indications for Social Work Services or Case Management referrals included patients who made frequent visits to the ED. In addition, patients who had problems with alcohol or psychiatric issues should be considered for counseling referrals.
On 4/13/12, a review was conducted of the hospital's policy entitled "Patient Leaving Against Medical Advice (AMA) and Patient Elopement," dated 7/19/07. The policy defined "elopement" as "when a patient leaves the hospital without notification to the treating physician or hospital staff." The policy defined "decisional capacity" as when a patient "can understand the condition and the risk and benefits of the recommended treatment and available alternatives and make a choice." Per the policy, in the event of an elopement of a patient that lacks decision making capacity, but not assessed as a flight risk, "the nurse caring for the patient shall notify the physician, the nursing supervisor and or the unit manager/designee immediately upon finding the patient's absence." Per the policy, the nursing supervisor was required to notify hospital security.
Further review of the record, revealed no documented evidence that RN 1 or RN 2 attempted to locate Patient 1 after he left. There was no documented evidence that the Charge Nurse or hospital security was informed of the patient's unexpected departure, so that a diligent search could be performed for the patient in an effort to ensure that he was safe and expressed an understanding of his condition, need for follow up care, and discharge instructions.
On 4/13/12 at 11:15 A.M., an interview was conducted with the ED Charge Nurse (EDCN) on 2/21/12. The EDCN stated that she "didn't believe that RN 1 or 2 informed her of Patient 1's elopement." The EDCN stated that if a patient "disappeared and we are worried" we look in the department, call security and sometimes call the police."
On 4/13/12 at 12:15 P.M., an interview was conducted with the Associate Medical Director of the ED, MD 4. Per MD 4, a patient's decisional capacity and safety should be determined during reassessment of the patient before they are discharged . MD 4 stated that decisional capacity is determined by talking to the patient and assessment of orientation. MD 4 acknowledged that during the discharge process determination of decisional capacity is often made when the patient can verbalize understanding about their medical condition, treatment options, and discharge instructions. MD 4 acknowledged that Patient 1 left prior to being formally discharged and receiving discharge instructions. MD 4 acknowledged that there was no documented evidence in the record concerning Patient 1's decision capacity other than he was awake and oriented to person, place, month, and knew who the President was.
On 4/13/12 at 1:20 P.M., an interview was conducted with MD 2. MD 2 stated she was aware of the patient's history of depression and schizophrenia. MD 2 stated that they were planning for Patient 1's discharge when he left. MD 2 stated that a patient was safe to discharge when he had the capacity to make decisions, was no longer intoxicated, could walk, act appropriately, and answer questions. There was no documented evidence in MD 2's reevaluation of Patient 1 relative to his decisional capacity and safety other than he ambulated with a steady gait.
On 4/24/12 at 1:45 P.M., an interview was conducted with MD 1. MD 1 stated she walked around the ED and didnt' see the patient. She stated she also looked out at the bus stop but did not see Patient 1.
When Patient 1 eloped from the ED prior to a formal discharge, nursing staff did not follow policy and procedure and inform appropriate personnel, to include the Charge Nurse and Security, to ensure that a diligent search was conducted in an effort to ensure that Patient 1 was safe and expressed an understanding of his condition, need for follow up care, and discharge instructions. In addition, there was no documented evidence that nursing staff considered a psychosocial consult for Patient 1, who had a known history of alcohol abuse and made frequent visits to the ED related to that issue.
VIOLATION: PHARMACY ADMINISTRATION Tag No: A0491
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, and record review, Hospital A and B failed to ensure that its policy and procedure pertaining to the medication reconciliation process was consistently performed in the Emergency Department (ED), for 13 of 61 sampled patients (1, 3, 4, 24, 33, 34, 35, 37, 40, 41, 42, 61, 62). Non compliance with the medication reconciliation process increased the risk of potential medication errors to patients, as well as the potential for medication incompatabilities and adverse drug reactions. In addition, lack of compliance with the medication reconciliation process did not promote or provide continuity of care concerning patients' medication regimens.

Findings:

1. An investigation and electronic record review was initiated on 4/5/12 at 8:20 A.M. as a result of a complaint which alleged that, on 2/21/12, during the course of being treated for alcohol intoxication in Hospital A's ED, Patient 1 "disappeared" from the ED, ingested something he found in the ED waiting room, and was later found pulseless in the waiting room bathroom. Patient 1 became brain dead and died sometime thereafter.

On 4/5/12 at 8:35 A.M., a review of the ED's registry log revealed that Patient 1's name was entered into the log twice, once at 12:55 P.M. for "ETOH" (ethyl alcohol), and then at 6:15 P.M. for "CPR" (cardiopulmonary resuscitation).
Patient 1 presented to the Emergency Department (ED) via paramedics on 2/21/12 at 12:55 P.M., with a chief complaint of "ETOH" use.
Per the Triage Nurse notes, Patient 1 presented with "heavy ETOH," intermittent level of consciousness, "fell out of his wheelchair and urinated on the waiting room floor." The triage nurse documented that the patient had "chronic ETOH," and was seen at the hospital within the last few days "for same." His past medical history included diagnoses of [DIAGNOSES REDACTED]. The entries in the electronic record pertaining to the dosages and frequencies of those medications contained "N/A" (not assessed).
Per the 2010/2011 Emergency Department Standards of Patient Care, Section 1, paragraph f, the initial assessment must include " current medication history, including over the counter (OTC) medications ... "
On 4/24/12 at 1:45 P.M., an interview was conducted with MD 1. MD 1 stated that she reassessed Patient 1 as he metabolized. She said her usual process for a patient who entered the ED with alcohol intoxication was to talk with the patient about detoxification and plans for entering a detox center. MD 1 acknowledged that she didn't ask Patient 1 about his medications, dosages, or compliance. MD 1 stated that she only asked the patient if he needed his medications refilled and the patient replied that "he didn't need them."
A review of the hospital's policy entitled "Medication Reconciliation," dated 11/18/10, was conducted on 5/22/12. Per the policy, the purpose of the medication reconcilation process was to decrease the number of medication errors, provide and sustain a continuity of care with regard to a patient's medication regimen, minimize complications of the patient's health that are related to changing a patient's medications and promote communication between and among healthcare providers with regard to changes made to a patient's medication regimen. Per the same policy, it stipulated that "All patients with an emergency department encounter with an Emergency Department Licensed Independent Provider will have their home medication and allergy information collected and documented."

An interview with the Director of Pharmacy (DOP) was conducted during a Quality Assessment and Performance Improvement (QAPI) group interview on 5/23/12 at 2:08 P.M. The DOP stated that medication reconciliation was important for patient safety and medication efficacy purposes.

There was no documented evidence in the record that Patient 1's medications were reconciled by licensed staff prior to his departure from the ED.

2. On 5/21/12 at 11:00 A.M., a tour was conducted of the ED at Hospital A. A review of Patient 3's record was initiated. Patient 3 was admitted on [DATE] at 7:11 A.M., with a chief complaint of shortness of breath. Per the Triage record, the patient's medications included steroids (synthetic hormone which treats a variety of illnesses and also has an antiflammatory effect), folic acid (vitamin), and Advair (inhaler for breathing problems). The amounts and frequency of the medications were documented as "N/A," which meant "not assessed," per the ED Nursing Director.

On 5/21/12 at 12:00 P.M., an interview was conducted with Patient 3. Per the patient he came to the ED because he had some breathing problems. Patient 3 stated that the nurse in Triage, Registered Nurse (RN) 4, asked him about his medications and he told RN 4 that he currently took 10 milligrams (mg.) of steroid after being weaned down from a dose of 40 mg. This was not documented in the patient's medical record.

On 5/21/12 at 12:30 P.M., an interview was conducted with RN 4. RN 4 stated that whether or not he documented the names, amounts, and frequencies of the medications that a patient took, depended on how busy he was. RN 4 stated that if the triage nurse did not complete the patient's medication assessment, the primary nurse was responsible to do so.

On 5/21/12 at 12:35 P.M., Patient 3's primary nurse, RN 1, was interviewed. RN 1 stated that sometimes she asked the patients about their medications, dose and frequency, but it was the ED physicians' responsibility to perform the medication reconciliation process.
Per the 2010/2011 Emergency Department Standards of Patient Care, Section 1, paragraph f, the initial assessment must include " current medication history, including over the counter (OTC) medications ... "

On 5/22/12 at 9:00 A.M., Patient 3's ED record was reviewed. The record indicated that the patient was discharged from the ED in stable condition. The section of the ED record entitled "medication reconcilation" contained the names of the Patient 3's medications: steroids, folic acid, and Advair, but the dosages and frequencies remained as "N/A," not assessed.

An interview with the Director of Pharmacy (DOP) was conducted during a Quality Assessment and Performance Improvement (QAPI) group interview on 5/23/12 at 2:08 P.M. The DOP stated that medication reconciliation was important for patient safety and medication efficacy purposes.

A review of the hospital's policy entitled "Medication Rconciliation," dated 11/18/10, was conducted on 5/22/12. Per the policy, the purpose of the medication reconcilation process was to decrease the number of medication errors, provide and sustain a continuity of care with regard to a patient's medication regimen, minimize complications of the patient's health that are related to changing a patient's medications and promote communication between and among healthcare providers with regard to changes made to a patient's medication regimen. Per the same policy, it stipulated that "All patients with an emergency department encounter with an Emergency Department Licensed Independent Provider will have their home medication and allergy information collected and documented."

There was no documented evidence in the record that Patient 3's medications were reconciled by licensed staff prior to his discharge from the ED.

3. On 5/21/12 at 11:00 A.M., a tour was conducted of the ED at Hospital A. A review of Patient 4's clinical record was initiated. Patient 4 (MDS) dated [DATE] at 9:00 A.M. with a chief complaint of alcohol (ETOH) intoxication per the triage record. Per the Triage record, the patient was responsive to painful stimuli only. The patient's medications were documented as "unknown."
Per the 2010/2011 Emergency Department Standards of Patient Care, Section 1, paragraph f, the initial assessment must include " current medication history, including over the counter (OTC) medications ... "
Per an ED physician's note dated 5/21/12 at 9:48 P.M., Patient 4 was reassessed and had "metabolized appropriately." Per the record, the patient was discharged from the ED on 5/21/12 at 9:55 P.M.

The Medication Reconciliation section of the ED record contained documentation that indicated that any medications that the patient took remained "unknown."

An interview with the Director of Pharmacy (DOP) was conducted during a Quality Assessment and Performance Improvement (QAPI) group interview on 5/23/12 at 2:08 P.M. The DOP stated that medication reconciliation was important for patient safety and medication efficacy purposes.

A review of the hospital's policy entitled "Medication Rconciliation," dated 11/18/10, was conducted on 5/22/12. Per the policy, the purpose or the medication reconcilation process was to decrease the number of medication errors, provide and sustain a continuity of care with regard to a patient's medication regimen, minimize complications of the patient's health that are related to changing a patient's medications and promote communication between and among healthcare providers with regard to changes made to a patient's medication regimen. Per the same policy, it stipulated that "All patients with an emergency department encounter with an Emergency Department Licensed Independent Provider will have their home medication and allergy information collected and documented."

There was no documented evidence in the record that Patient 4's medications were reconciled by licensed staff prior to his discharge from the ED.




4. Patient 61's medical record was reviewed on 5/23/12 at 11:20 A.M. Patient 61 was seen at Hospital A's emergency department on 1/17/12, and was discharged on the same day per the emergency room record. Per the same record, the patient went to the hospital's emergency department due to abdominal pain, vomiting and diarrhea.
A review of Patient 61's Triage (the process of determining the priority of patient's treatments based on the severity of their condition) Record indicated that the patient was taking 4 medications which included Lisinopril (blood pressure medication) and Geodon (psychotropic medication). However, under the dosage and frequency for Lisinopril and Geodon, the documentation indicated "N/A" (not assessed).
A review of the emergency room Medication Reconciliation record also indicated that the dosage and frequency for both the Lisinopril and Geodon were "not assessed."
A review of the hospital's policy and procedure (P&P) titled "Medication Reconciliation" was conducted on 5/23/12 at 9:00 A.M. The P&P indicated that, "All patients with an emergency department encounter with an Emergency Department Licensed Independent Provider will have their home medication and allergy information collected and documented. a. (Hospital name) Emergency Departments using the WebCHARTS electronic medical record will document the medication and allergy information in the Medication-Allergy List on the Triage page within the application."
A joint record review and interview with the Director of Regulatory Affairs (DRA) was conducted on 5/23/12 at 1:05 P.M. The DRA stated that the "N/A" documented on both of the medications' dosage and frequency meant "not assessed." The DRA acknowledged that there was no documented evidence that Patient 61's medications were reconciled prior to the patient being discharged from the hospital.
An interview with the Director of Pharmacy (DOP) was conducted during a Quality Assessment and Performance Improvement (QAPI) group interview on 5/23/12 at 2:08 P.M. The DOP stated that medication reconciliation was important for patient safety and medication efficacy purposes.
5. Patient 62's medical record was reviewed on 5/23/12 at 11:40 A.M. Patient 62 was seen at Hospital B's emergency department on 1/2/12, and was discharged on the same day per the emergency room record. Per the same record, the patient went to the emergency room due to low blood pressure and was feeling tired.
A review of Patient 62's Triage Record indicated that the patient was taking multiple medications which included Simvastatin (cholesterol medication), Isosorbide (dilates/opens blood vessels), and NitroQuick (dilates blood vessels). However, under the dosage and frequency for Simvastatin, Geodon, and NitroQuick, the documentation indicated "N/A" (not assessed).
A review of the emergency room Medication Reconciliation record also indicated that the dosage and frequency for Simvastatin, Isosorbide, and NitroQuick were "not assessed."
A review of the hospital's policy and procedure (P&P) titled "Medication Reconciliation" was conducted on 5/23/12 at 9:00 A.M. The P&P indicated that, "All patients with an emergency department encounter with an Emergency Department Licensed Independent Provider will have their home medication and allergy information collected and documented. a. (Hospital name) Emergency Departments using the WebCHARTS electronic medical record will document the medication and allergy information in the Medication-Allergy List on the Triage page within the application."
A joint record review and interview with the Director of Regulatory Affairs (DRA) was conducted on 5/23/12 at 1:05 P.M. The DRA stated that the "N/A" documented on both of the medications' dosage and frequency meant "not assessed." The DRA acknowledged that there was no documented evidence that Patient 62's medications were reconciled prior to the patient being discharged from the hospital.
An interview with the Director of Pharmacy (DOP) was conducted during a Quality Assessment and Performance Improvement (QAPI) group interview on 5/23/12 at 2:08 P.M. The DOP stated that medication reconciliation was important for patient safety and medication efficacy purposes.




6. A review of Patient 41's medical record was conducted on 5/21/12, at 1:25 P.M. Patient 41 was seen in the Emergency Department (ED) at Hospital B on 5/21/12 and was discharged on the same day per the ED record. Per the same record, Patient 41 complained of too much pain in the right flank and wanted a kidney stent (surgical device implanted so urine can flow from the kidneys to the bladder) that was placed in 5/9/12 removed.

Patient 41's Triage Record (priority of treatments based on severity of condition) dated 5/21/12, indicated that Patient 41 was taking the following medications, their dosage and frequency: Synthroid (synthetic [DIAGNOSES REDACTED]), Glipizide (oral antidiabetic drug), Simvastatin (reduces blood cholesterol levels), Prilosec (antacid), Lasix (treats fluid retention), Pyridium (treat urinary tract infections) and ProAir HFA (a quick relief rescue inhaler). The medications were listed but the dosage and frequency columns were filled in with "N/A" (not assessed per the the hospital).

An interview and joint record review with Registered Nurse (RN 41) was conducted on 5/21/12 at 1:35 P.M. RN 41 stated that the medication reconciliation was initiated by the triage nurse and if the patient had a previous visit to the ED, the medications would populate within the triage record, also known as the triage screen. She further explained that ultimately the physician will review the medications with the patient and will complete the medication reconciliation section of the record.

A review of the hospital's policy entitled "Medication Reconciliation," effective date of 11/18/10, was conducted on 5/22/12. The policy indicated that its purpose was to decrease the number of medication errors, provide and sustain a continuity of care with regard to a patient's medication regimen, minimize complications of the patient's health that are related to changing a patient's medications and promote communication between and among healthcare providers with regard to changes made to a patient's medication regimen. Per the same policy, it stipulated that "All patients with an emergency department encounter with an Emergency Department Licensed Independent Provider will have their home medication and allergy information collected and documented." In addition, the policy indicated that "At the conclusion of the emergency department encounter, the patient will receive an updated medication list within the patient discharge instructions which includes any additional or changed medications, as well as instructions to discontinue specific medications, if appropriate."

A follow-up review of Patient 41's ED Medication Reconciliation record was conducted on 5/23/12 at 9:03 A.M. The record showed the same list of medications that Patient 41 was taking upon admission to the ED. The section for dosage, frequency and duration were still marked with "N/A" even after Patient 41's discharge from the ED.

An interview with the Director of Pharmacy (DOP) was conducted during a Quality Assessment and Performance Improvement (QAPI) group interview on 5/23/12 at 2:08 P.M. The DOP stated that medication reconciliation was important for patient safety and medication efficacy purposes.

An interview with the ED nurse manager (EDNM) was conducted on 5/24/12 at 11:25 A.M. The EDNM stated that the best practice was for the RNs to ascertain the medication reconciliation information as quickly as possible but ultimately, the physician was responsible for the completion of the medication reconciliations. He acknowledged that Patient 41's medication reconciliation was not completed in accordance with the hospital's policy.

7. A review of Patient 42's medical record was conducted on 5/21/12 at 1:47 P.M. Patient 42 was seen in the Emergency Department (ED) at Hospital B on 5/21/12 and was discharged on the same day per the ED record. Per the same record, Patient 42 had a chief complaint of a head pain.

Patient 42's Triage Record dated 5/21/12, indicated that Patient 42 was taking the following medications, their dosage and frequency: Omega 3 (fatty acids), Norvasc (for high blood pressure), Actos (for diabetes) and Diovan (for high blood pressure). The medications were listed but the dosage and frequency columns were filled in with "N/A" (not assessed per the the hospital).

An interview with Registered Nurse (RN 42) was conducted on 5/21/12, at 1:47 P.M. RN 42 stated that the triage nurse would start the process of obtaining the information to complete the medication reconciliation section of a patient's record. He stated that the primary nurse would continue the process if the medication reconciliation section was not completed. He stated that the medication reconciliation will be completed by the time patient was discharged from the ED. He explained that part of the discharge process from the ED included a review of medications patient would continue, discontinue or start per physician's order.

A review of the hospital's policy entitled "Medication Reconciliation," effective date of 11/18/10, was conducted on 5/22/12. The policy indicated that its purpose was to decrease the number of medication errors, provide and sustain a continuity of care with regard to a patient's medication regimen, minimize complications of the patient's health that are related to changing a patient's medications and promote communication between and among healthcare providers with regard to changes made to a patient's medication regimen. Per the same policy, it stipulated that "All patients with an emergency department encounter with an Emergency Department Licensed Independent Provider will have their home medication and allergy information collected and documented." In addition, the policy indicated that "At the conclusion of the emergency department encounter, the patient will receive an updated medication list within the patient discharge instructions which includes any additional or changed medications, as well as instructions to discontinue specific medications, if appropriate."

A follow-up review of Patient 42's ED Medication Reconciliation record was conducted on 5/23/12 at 9:03 A.M. The record showed the same list of medications that Patient 41 was taking upon admission to the ED. The section for dosage and frequency were still marked with "N/A" even after Patient 42's discharge from the ED.

An interview with the Director of Pharmacy (DOP) was conducted during a Quality Assessment and Performance Improvement (QAPI) group interview on 5/23/12 at 2:08 P.M. The DOP stated that medication reconciliation was important for patient safety and medication efficacy purposes.

An interview with the ED nurse manager (EDNM) was conducted on 5/24/12 at 11:25 A.M. The EDNM stated that the best practice was for the RNs to ascertain the medication reconciliation information as quickly as possible but ultimately, the physician was responsible for the completion of the medication reconciliations. He acknowledged that Patient 42's medication reconciliation was not completed in accordance with the hospital's policy.





8. Review of the closed record for patient 25 contained a form entitled Triage Record which contained a section at the bottom entitled "Medications." Eleven medications were listed. Of these, only two had the dosage, route and frequency filled out. The information for the rest of the medications was not present. There was no discussion of this list of medications in the physician's H & P (history & physical). Patient 25 was discharged from the ED without completion of the Medication Reconciliation Process.

Six patients (24, 33, 34, 35, 37 and 40) were seen in the ED and then later admitted to the hospital. In these cases, the ED Medication forms were not filled out completely. Some listed medications, with no dosages, route or frequency, others were completely blank, and others had some drug names and some "unknowns." The form was not updated by the time the patients left the ED as per the process described by the Nurse Director of the ED in the findings below.

The Nurse Director of ED (NDED) was interviewed on 5/21/12. At that time, she was questioned about the process for filling out the medical record form for medication reconciliation. The NDED stated that the ED Electronic Medical Record (EMR) is not connected with the inpatient Electronic Record system. However, the ED system will fill in medication fields on the Medication Reconciliation form automatically if that information is available on the ED EMR system from a previous visit. The triage nurse is then responsible for going over the meds with the patient or family and completing the information. Primary ED nurse RN 10 was interviewed on 5/21/12 at 12:15 PM. She was asked about the triage process and medication reconciliation. She stated that the triage nurse would fill in the information to the extent possible. RN 10 stated she would attempt to get the rest of the information but she did not know if all of the other nurses did this.

The Medical Director of the ED was interviewed on 5/24/12 and stated that much of the information on the Triage Record was automatically populated from information obtained at a prior ED visit. He could not explain why the information on current information from the triage form was not reconciled with the information the physician obtained in his H & P.