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.


Based on medical record review, staff interviews, and review of the hospital policy entitled "Medication Reconciliation", it was determined that the hospital failed to transfer relevant sample patient ID #1 to a Rehabilitation facility with the necessary medical information for follow-up care, related to accuracy of medication reconciliation.

Findings are as follows:

A review of the hospital policy entitled "Medication Reconciliation", under "Intent" states: " To accurately and completely reconcile medications across the continuum of care" .

Under Policy, it states: "Medication Reconciliation is an interdisciplinary process between Prescribers, Nursing, and Pharmacy that compares a patient's best known list of current home or Long Term Care Facillty (LTCF) medications against the prescriber's admission, transfer and/or discharge orders".

Under Procedure, it states under "Ambulatory Areas Procedure":

Item a. "It is the responsibility of the appropriate professional in each area to obtain a list of current medications from patient's being treated in ambulatory areas of South County Hospital. This list shall be validated with the patient, whenever possible. The prescriber shall refer to this list when writing orders".

A review of the clinical record for patient ID #1 revealed a [AGE]-year-old admitted to the Emergency Department (ED) on 11/15/10 by rescue accompanied by family. The patient was noted to be confused and hard of hearing, and had fallen at home. The patient was also noted with a history of falls.

On arrival, an EKG (electrocardiogram) revealed [DIAGNOSES REDACTED]with a rate of 70. A nursing note at 0915 revealed that the nurse had confirmed with the patient's Primary Care Physician (PCP) that the patient had been in [DIAGNOSES REDACTED]for 3 years. "Not on Coumadin secondary to family declined".

Electronic documentation of the patient's medication reconciliation revealed, "Simvastin 40 mg (milligram) daily, Tricor 145 mg daily, Metformin HCL 500 mg daily, Lisinopril 10 mg daily, and Aspirin 81 mg daily" .

A Case Management representative noted a discussion with the family regarding agreement for Skilled Nursing Placement of the patient, with the ultimate goal to return home and independent apartment living. A bed was located for Rehabilitation. The patient was transferred that same day with a "Continuity of Care Form" that included physician orders for post discharge medications, after the physician had reviewed the electronic documentation of the patient's medication reconciliation

The patient returned to the ED by rescue from the Rehabilitation facility on 11/17/10. The Rehabilitation facility had noted the patient to be lethargic and flaccid, with a low blood pressure. It was noted that the patient had been receiving Aspirin, Lisinopril, Simvastin, Tricor, Metformin, Insulin, and Lidoderm. Upon arrival to the ED, the patient was noted with a blood pressure of 111/58, and blood glucose of 97. It was determined that the patient had been discharged to the Rehabilitation facility from the hospital ED with inaccurate medication reconciliation on 11/15/10. As a result, the patient was prescribed and dispensed various medications (Simvastin, Tricor, Metformin, Lisinopril, and Aspirin) that were intended for another patient. With the 11/17/10 ED visit, it was also determined that the patient had a urinary tract infection, and had been prescribed the antibiotic Cipro.

During an interview on 1/19/11 at 10:00 AM with the Assistant Director of Emergency Medicine, it was reported that he had been on duty when the patient was brought to the ED on 11/15/10. He had examined the patient and reviewed the EKG, and had concern regarding the [DIAGNOSES REDACTED]noted. He spoke with the patient's daughter, who had made him aware that "the patient was taking no medications as far as she knew". The care of the patient was then transferred to another ED Physician with change of shift. The Assistant Director of Emergency Medicine reported that he made the oncoming physician aware of the medication issue, and that "the PCP should be contacted".

During an interview on 1/25/11 at 8:50 AM with the ED Primary Care Nurse, it was reported that there had been continuous interaction with the family throughout the patient's ED stay, and that this nurse was "well aware" that the patient had been taking no medications at home. This had been communicated to the ED physician. The nurse made the call to the patient's PCP, per the request of the physician. The call resulted in information that the patient had been prescribed Aspirin only, and no Coumadin. This was also communicated to the ED physician. The nurse had no explanation as to why "no home medications" had not been entered into the electronic medical record when the information had been obtained from a reliable source. The nurse was unaware that inaccurate home medications had been entered in the patient's electronic record related to medication reconciliation. When a bed was obtained for rehabilitation, the physician was asked by the Case Manager to complete the Continuity of Care Form for transfer, and the nurse had no involvement with this form completion.

During an interview on 1/19/11 at 10:00 AM with the Clinical Nurse Manager of the ED, she reported that the ED recently began using electronic record documentation (Meditech) in June of 2010 for the initial nursing "Triage assessment and Documentation" and "Medication Reconciliation". The Primary Care Nurse is responsible for entering the medication history in this electronic record. The hospital's investigation into this occurrence concluded that another nurse, attempting to assist the Primary Care Nurse, had likely entered the medications of another patient who had been two doors down in the ED on 11/15/10, into this patient's electronic record.

Although the family reported that the patient had been on no medications, the patient medication reconciliation electronic documentation in the ED had revealed medications. There was no evidence that these medications were verified with the patient/family by the interdisciplinary team per the hospital policy.

In addition, the ED physician failed to communicate with the patient's PCP regarding home medications when he had the opportunity to do so with the nurse placing a call to this PCP while the patient was in the ED. The Primary Care Nurse failed to enter "no home medications" in the patient's electronic record when this had been confirmed by the family. As a result, the patient was transferred to Rehabilitation with a Continuity of Care Form and medication orders that resulted in inaccurate medication reconciliation. Additionally the Rehabilitation facility did not receive the necessary information for follow-up care, resultant in the patient receiving unnecessary medications.