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MEMORIAL MISSION HOSPITAL AND ASHEVILLE SURGERY CE 509 BILTMORE AVE ASHEVILLE, NC 28801 April 27, 2017
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy, medical records, "Current Summary Medication/Fluid Event Log," Response Timeline, and staff interview, the facility failed to provide and accurately reconciled medication list to the receiving facility upon discharge for 1 of 4 discharged patients (Patient #11).

The findings included:

Review on 04/27/2017 of the facility policy "Medication Management" (Policy: IMM.ADM.0002, Origination Date: 01/17/2017), revealed " ...PROCEDURE: C. Discharge Reconciliation Process - INPATIENT SETTING: 1. Role of Provider - a. Review and reconcile home medications with therapies provided during hospitalization to ensure home list is accurate and updated with no duplications, omissions, incomplete instructions, or unintended prescriptions ..."

Review on 04/26/2017 of Patient #11's medical record revealed a [AGE] year old female was a direct admit to the facility on [DATE], after presenting to the ED (Emergency Department) at an outlying facility. Review of the History and Physical (H & P) upon admission revealed the patient's history of diagnoses included [DIAGNOSES REDACTED][DIAGNOSES REDACTED], and [DIAGNOSES REDACTED] (high cholesterol/lipids). Review of the patient's admission history dated 01/10/2017 at 2344, revealed a medication list with the following home medications: acetaminophen (Tylenol)-oxycodone every six hours PRN (as needed) for severe pain, amantadine (for Parkinson disease), desvenlafaxine (antidepressant), diclofenac topical (non-steroidal anti-inflammatory), fluticasone nasal, PRN ( for allergies levothyroxine (for [DIAGNOSES REDACTED]), lorazepam, PRN (for anxiety), modafinil (reduces sleepiness), ondansetron PRN (for nausea and vomiting), pregabalin (for nerve and muscle pain), ranitidine (for heartburn and reflux), senna (laxative), and simvastatin (treats high cholesterol). Review of the patients "Depart Discharge Summary" dated 01/27/2017, revealed the medications to be taken at home included all of the above medications as well as the following 11 medications: Tylenol (an analgesic for minor aches and pains) PRN (as needed), amitriptyline (for nerve pain and depression), flexeril (a muscle relaxant), Lasix (a diuretic), loratadine (an antihistamine), meclizine PRN (treats motion sickness and vertigo), lopressor (can be used to treat blood pressure, angina and heart failure), biofreeze PRN (a pain relieving gel), a multivitamin, oxycodone (a narcotic for moderate to severe pain), and potassium chloride.

Review on 04/26/2017 of the "Current Summary Medication/Fluid Event Log," initiated by the manager of the neuroscience Unit on 02/02/2017, revealed the patient's family member phoned the unit on 02/02/2017 stating "multiple medications were on [Patient #11's] d/c [discharge] instructions that she was no longer taking. Meds were carried over from a 2010 admission." The family member stated the patient had to be admitted to a hospital. Documentation during the facility's investigation, revealed the 11 additional medications on the patient's discharge summary were from the patient's 2010 discharge instructions. Review revealed the family member inquired about the status of the investigation on 02/17/2017. "Explained that we would like to get information from IT about a possible chart merge prior to sending letter of resolution." The family member "says she appreciates that" however, did not think the patient "should have to pay for her subsequent admission to [outlying facility] due to the nursing home giving her incorrect meds that were on our discharge orders." The family member asked which department she should speak to about this matter and was given the number for Risk Management. Documentation revealed this event "will remain risk file as family's resolution request was reimbursement/compensation."

Review on 04/26/2017 of the Response Timeline revealed on 02/03/2017, the Medication safety team was made aware of the event and on 02/06/2017 the Medication Safety Pharmacist reviewed the event and indicated there appeared to be a "potential profile merge" and requested informatics help audit the chart. On 02/07/2017, "Informatics confirmed this was a profile merge. Informatics, nursing, and pharmacy aware and pulled in Medical Records to map process for merge." A meeting "to map and discuss process and potential interventions" occurred on 02/15/2017. Director of HIM (Health Information Management) requested "a few weeks" to look into this. On 02/20/2017, Neuroscience Unit was "made aware of 'glitch' and as a result of the finding during daily huddles story of merging of records and medication list shared with RNs to be cautious upon discharge." During the month of March, 2017, "Meetings and research completed within HIM conducted by Director to determine and identify best practice with the merging of records/based on open encounters or closed encounter ..." On 04/18/2017, HIM (Health Information Management) requested until "May 1 week to finish data collection, meeting set for May 2." The Medication Safety Team, Registration, Medical Records, and Clinical Informatics met on 04/26/2017, and resulted in the following steps being put into place: Bed control would contact the patient's primary nurse or any NUS (Nursing Unit Supervisor) following a file merger to "redo medication history;" An SBAR (Situation, Background, Assessment, Recommendation. A tool used to facilitate prompt and appropriate communication), was sent out addressing the role of the primary nurse; and a meeting was scheduled for May 2nd "to develop long term automated solution."

Interview on 04/27/2017 at 1022 with the physician who discharged the patient, revealed he "didn't realize" he was re-stating meds the patient had not previously been on and was not aware how the med rec discharge system worked in the electronic medical record program the hospital used. The physician stated he "rarely discharged patients ... At the end of the day, it comes down to me not personally identifying the meds with the patient ... our practice is to make sure the list is correct before sending them out of the hospital." The physician stated he had "assumed" the meds that populated in the chart were a "working list of patient's actual meds ..."

Interview on 04/27/2017 at 1037 with a Patient Registration Representative from Bed Control, revealed when a chart merged, "we always call the floor, and most of the time would speak with the HUC (Health Unit Coordinator) or the RN (Registered Nurse) who has the patient. We are trying to make sure the patient's nurse or nursing supervisor is aware ... We've been doing that for at least a year ... I know to do that, and I'm the trainer for the group ... We had an email sent just this week to re-confirm we do that process ..." The interview revealed Bed Control would speak with the patient's nurse or Unit Supervisor and "specifically remind about med rec."

Interview on 04/26/2017 at 1630 with the Neurosciences Unit Supervisor, revealed staff brought this up in daily huddles, the potential for an EMR (electronic medical record) merge and staff to have "extra awareness ... It may appear nothing has been done, however, we have determined this is a very complicated process involving numerous departments. I think this is what contributes to the time frame. HIM has done the same thing instructing them to wait for merge if you can and also did work with registration people on exhausting several options" before creating a new account... "We haven't just been sitting on this, it's been a thoughtful process."

Interview on 04/27/2017 at 1050 with the Chief Quality Officer, the VP (Vice President for Quality and Safety, the Director of Accreditation, and the Chief Medical Information Officer, revealed they have found there are between 2 and 7 mergers per day, which include trauma patients and newborns. The interview revealed the facility had a "very careful merge overlay process within the universe of merged records." The facility also had "team based care units" with huddles every shift and the RLs are reviewed during the huddles. Interview revealed the Medication Safety Team was working on the med rec and "then realized this was bigger than the med rec - it was part of the merger." The administration and teams were trying to discover the "best practice" and "as the team re-approached this week, we put a new level of awareness with bed control." The administration is "looking at both sides, merging vs not merging, before making a decision on the right thing to do ... We don't want to inadvertently harm someone ... We've looked at tradeoffs and are trying to find the safest approach." Interview revealed the administration "emphasize the importance of med rec all of the time." The interview revealed the facility has not educated "broadly among the medical staff because it would be difficult to say what to do next until we come up with a system..." Interview revealed "implementation of change would be when a broad communication would go out ... the RLs [grievance files] get reviewed every day and this was part of a complex, crazy process we are trying to get right." The administration revealed they knew this was a "pharmacy/IT issue ... We have our process on the front line, then a process for bringing things back to us after review. For some reason, this didn't make it back to us ..."