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WESTCHESTER GENERAL HOSPITAL 2500 SW 75TH AVE MIAMI, FL 33155 Aug. 7, 2012
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
Based on observation, interviews, and record reviews the facility failed to reassess the patient's discharge plan which included the post discharge medications (Ciprofloxacin) which may affect the continuing care needs of one of five sampled patient (SP) #4 .


Findings include:

During an Observation and interview with sampled patient # 4 with the Risk Manager present. The patient stated that she lived in a home (Assisted Living Facility(ALF) where she will return after discharge.

On 8/6/2012 at 2:00pm sampled patient #4 received her discharge instructions from the nurse. The nurse instructed the patient regarding her discharge medications which included a prescription for Ciprofloxacin 500mg [milligrams] by mouth to be taken twice a day.
Review of sampled patient #4 medical record revealed that the patient was admitted with a UTI (urinary tract infection) on 08/03/2012 with a history of a recent Urinary tract infection on a previous admission for observation in July/2012. During the present admission, the physician ordered Ciprofloxacin 400mg IV [intravenous] to be given every 12 hours along with an order for a urine for C/S (culture and sensitivity) which was received on 8/3/2012. According to the nursing notes dated 8/3/2012 at 01:41 AM, sample patient (#4) complained of itching and a rash on the inside of the left forearm. The Physician was called and the Ciprofloxacin was discontinued. There is no evidence in the patient's (#4 ) medical record that the possible allergy was forwarded to the pharmacy department and documented in the patient record.

On 8/4/2012 at 11:30 am an order was received to restart the Ciprofloxacin 500mg by mouth, twice a day. The patient received the medication according to the medication profile report from 8/4/2012 until discharge.
Review of the Urinalysis DIP test dated 08/06/2012 at 13:02 pm prior to the patient's discharge has resulted that the urine appears cloudy, and blood as large. The same results of the urine DIP test completed on 08/02/2012 at 23:14 on admission.

Further record review revealed that the results of the urine culture and sensitivity test collected on 08/03/2012 at 04:32 am and received in the lab on 8/03/12 at 1617 resulted in: Escherichia coli, - CFUnits /ml. The sensitivity revealed that Escherichia coli is resistant to Ciprofloxacin therefore the antibiotic is ineffective against the organism.
During an Interview with the Vice President (VP) of administration on 8/6/2012 at 10:00am she confirmed that the results of the sensitivity revealed that Escherichia coli is resistant to Ciprofloxacin therefore the antibiotic is ineffective.

During an interview with the Director of Pharmacy on 08/06/2012 at 2:30pm, she stated that all of the medications are reviewed for all inpatients prior to discharge. She also verified that the discharged medications for sampled patient #4 were reviewed by the pharmacist prior to discharge. She presented a copy dated 08/06/2012 that was signed by a pharmacist.
Review of the discharge summary dated 08/07/2012 revealed that the physician documented that the patient (#4) was discharged on Ciprofloxacin but we did not receive the results of the urine sensitivity prior to her discharge. He also documented that the patient will be given Nitrofurantoin 100mg twice a day for her slight pyuria (pus in urine). Per the VP of administration in an interview on 08/07/2012 in the afternoon, she stated that the physician will fax the prescription for the new antibiotic to the pharmacy /ALF since the patient was already discharged .

Review of the facility's Medication reconciliation policy revealed that the policy is to minimize the risk of medication errors caused by medications not being continued upon admission to the hospital, transfer between hospital level of care, or discharge from the hospital. The goal include: development of a complete list of the patient's current medication upon admission to the hospital developed with the patient and reconciled during discharge for formal communication to the next provider of care/service. The policy then states that the nursing department will take the lead in the medication reconciliation process. The patient care nurse monitors each step of the process: from admission, changes in acuity of care, through discharge.
There is no evidence that the possible allergy to Ciprofloxacin was formally communicated to the next provider nor any evidence to demonstrate that nursing monitored each step of the process through discharge to ensure the ALF provider was aware of the need to follow up on the results of the urine culture received prior to sample patient #4 discharge.