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|BLOOMINGTON MEADOWS HOSPITAL||3600 N PROW RD BLOOMINGTON, IN 47404||Jan. 23, 2020|
|VIOLATION: MEDICAL STAFF - ACCOUNTABILITY||Tag No: A0049|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on document review and interview the facility failed to ensure medical staff followed their rules and regulations related to the evaluation and monitoring of patient medication therapy in 1 (patient 1) of 10 medical records (MR) reviewed:
1. Patient 1's MR: Review of Discharge Medication Reconciliation Orders (new medications for patient) dated 10/5/19 per medical staff D2 (Physician) indicated: "Cymbalta 60 mg daily for depression. Clonidine 0.1 mg twice daily for hypertension". Review of patient 1's MR indicated he/she was discharged on [DATE]. Review of Medication Administration Record lacked documentation the patient was administered Cymbalta 60 mg and/or Clonidine 0.1 mg prior to discharge.
2. Medical Staff Rules and Regulation, revised/reviewed 1/19, indicated on page 11: "6.12.3. Evaluating the effects of medications are monitored: (i) The Provider shall monitor the patient's response to first dose(s) of a medication new to a patient on the next patient contact, and document in the Daily Physician Progress Note. (ii) The Provider shall monitor effects of medications on the patient to assure that medication therapy is appropriate and minimizes the occurrence of adverse events. The patient's response will be documented in the Daily Physician Progress Note".
3. On 1/23/20 at approximately 1500 hours, staff N7 (Chief Nursing Officer) was interviewed and confirmed patient 1's Discharge Summary indicated the patient was discharged on [DATE] with orders for Cymbalta 60 mg and Clonidine 0.1 mg twice daily. Staff N7 confirmed the patient was not administered those medications prior to discharge and thus was unable to be evaluated and monitored for effectiveness and/or adverse reactions. Staff N7 confirmed Medical Staff Rules and Regulations indicates a provider should evaluate and monitor the effectiveness of medication therapy.