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HARRISON MEDICAL CENTER 2520 CHERRY AVENUE BREMERTON, WA 98310 May 3, 2019
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
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Based on record review and interview, the facility failed to ensure implementation of a system for patients to receive routine medications when they were Emergency Department patients for extended time, including days for 1 of 1 patients.

Failure to do so may result in patient harm due to the patient not receiving prescribed home medications.

Findings:

1.a. Record review of the policy titled, "Medication Reconciliation", Policy # 945.75, Last Revised 09/2016, showed that the purpose of the policy was to obtain a patient's current medication list since last provided, allowing for a way of reconciling medication information from the time of admission throughout the hospital stay and at the time of discharge. The process was to be completed within 12 hours of admission to the hospital.

The policy identified that this process was performed for emergency department (ED) patients and that was the combined work of nursing, pharmacy and providers. It also stated that medication reconciliation was the responsibility of the provider and must be completed in the electronic medical record. The Medication Reconciliation Technician was to verify all reported home doses with a second source independent of the patient/family/caregiver to validate administration history for each medication.

1.b. Record review of the policy titled, "Medication Reconciliation Technician," Policy # 56, Last revised 03/19 stated the all medication histories completed by a Medication Reconciliation Technician (MRT) must be reviewed, reconciled and approved by a pharmacist prior to action being taken by provider(s). It also stated that if the MRT was unable to complete the process prior to admission,due to the patient being unable to participate and the family being unavailable, then the medication list will be marked as "Unable to Assess". It did not state that when "Unable to Assess" was marked the list did not require a pharmacist review.

2. Record review of Patient #1's medical record showed:

a. Patient #1 was evaluated and treated in the Emergency Department on 01/19/19 and the patient was found to have sustained a right wrist fracture (non-displaced) after a fall in the community. The physician placed a volar splint on the date of the evaluation and identified that it was unsafe to discharge her home alone. The patient did not meet criteria to qualify for an inpatient admission.

The hospital did not admit the patient to the hospital during the time searching for non-hospital level care. The patient was housed in the emergency room for 7 days until the search for community care resources was exhausted. The patient became confused during her stay in the Emergency Department. On 01/26/19 (7 days later) the patient was discharged from the ED and admitted to the hospital. During that ED period, there was not a record that the patient's home medications were assessed for administration while in the ED.

b. On 01/26/19 at 9:26 PM, the admission day to the hospital, a MRT assigned to the ED attempted to obtain and record information about "Prior to Admission Medications" for the patient. Through her research (calling pharmacy and a home care agency), she recorded that the patient was taking seven medications. However, she also recorded that she was unable to assess the patient's medication regime.

c. After she recorded that she was unable to assess the medication regime, a pharmacist entered a note at 8:50 AM that she reviewed the medications. Then the MRT entered another note that day at 12:34 PM that she was unable to assess the medication status. There was no documentation of approval by a pharmacist after the final medication reconciliation technician entry.

d. An inpatient physician wrote routine medication orders during the patient's hospital stay. One of the medications prescribed/re-started (an anti-depressant) required a taper, if it was to be discontinued (i.e. patients do not tolerate stopping the medication suddenly without significant side effects).

3. a. On 05/02/19 at 3:40 PM, the surveyor interviewed the Medical Director of the Emergency Department (Staff #1). He stated that physicians in the ED should write orders to ensure that patients with extended ED stays receive routine medications. He acknowledged that "boarding" patients in the ED was a regular occurrence, for a variety of reasons, when patients do not require ongoing inpatient medical and nursing care.

b. On 05/03/19 at 11:00 AM, the surveyor interviewed the Director of the Pharmacy (Staff #2). He identified that patients who had extended stays in the ED should receive routine prescribed medications during that stay. He acknowledged there was not a system to ensure implementation of that care for patients (besides ED providers writing orders) or for implementation of the medication reconciliation system, as ED patients with extended stays were not "admitted " to the hospital.

He also acknowledged that pharmacist review and approval of MRT data gathering was required to occur for ED patients being admitted to the hospital and that pharmacist documentation that occurred after the final MRT entry could not be identified for Patient #1.

c. On 05/03/19 at 8:50 AM, the surveyor interviewed the Nurse Manager of the ED (Staff #3). She stated that the MRTs priorities for medication reconciliation with ED patients who were for those being admitted to the hospital and then for patients with extended ED stays.
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