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Based on document review and interview, the hospital failed to ensure medical staff (MS) enforcement of their Bylaws Rules and Regulations requirement for a medical history and physical (H&P) to be completed within 24 hours of admission for 2 of 10 medical records (MR) reviewed (P5 and P8).

Findings include:

1. Review of the MS Bylaws Rules and Regulations, Effective 8/20/15, indicated in 2.4 History and Physical: A complete medical history and physical examination shall be recorded by the Attending Practitioner no earlier than thirty days before or no later than twenty-four (24) hours after Admission. The medical history and physical examination must be placed in the patient's medical record within 24 hours after admission.

2. Review of MRs indicated the following:
A. Patient P5 was admitted 3/12/18 at 1617 hours and the H&P was authored 3/15/18 at 0732 hours.
B. Patient P8 was admitted 2/13/18 at 1335 hours and the H&P was authored 2/15/18 at 2132 hours.

3. On 4/20/18 between approximately 12:00pm and 4:00pm during MR review, A4, Charge Nurse, verified the H&Ps for P5 and P8 had not been completed within 24 hours of admission.

Based on document review and interview, the hospital failed to ensure discharge summaries with final diagnosis were completed within 30 days following discharge for 5 of 10 medical records (MR) reviewed (P1, P2, P3, P4 and P5).

Findings include:

1. Review of Rules and Regulations of the Medical Staff (MS), Effective 8/20/15, indicated in 2.12.1 the following: Discharge Summary. The Attending Practitioner shall prepare a written or dictated discharge summary for all inpatients within thirty (30) days of discharge.

2. Review of patient MRs on 4/19/18 and 4/20/18 indicated the following:
A. P1 was discharged 1/30/18. The MR lacked documentation of a discharge summary (DCS).
B. P2 was discharged 1/31/18. The DCS was dictated 3/20/18.
C. P3 was discharged 3/17/18. The MR lacked documentation of a DCS.
D. P4 was discharged 2/23/18. The MR lacked documentation of a DCS.
E. P5 was discharged 3/6/18. The DCS was dictated 4/15/18.

3. On 4/19/18 between approximately 1:00pm and 4:00pm during MR review, A4, Charge Nurse, verified DCSs for P1, P2, P3 and P4 had not been dictated within 30 days of discharge. On 4/20/18 at approximately 12:30pm, A4 verified the DCS for P5 had not been dictated within 30 days of discharge.

Based on document review and interview, the hospital failed to minimize drug errors by failing to ensure patient medications were adequately reconciled by medical staff (MS) and pharmacy services in accordance with policy and procedure (P&P) for 5 of 10 patient's medical records (MR) reviewed (P1, P4, P5, P6 and P8).

Findings include:

1. Review of the P&P titled Medication Reconciliation, Last Reviewed 2/15/2018, indicated the following:
A. PURPOSE - Medication Reconciliation: process of comparing the medication a patient is taking (and should be taking) with newly ordered medications. The comparison addresses duplications, omissions, and interactions, and the need to continue current medications.
B. POLICY - An interprofessional process will be implemented to ensure that patients receive effective reconciliation of their medication information upon admission, during their stay, and upon discharge.
C. Medication Information from a Transferring Facility: All sources of previous facility medication information should be reviewed. These included the Discharge Medication Summary, transfer orders, and recent MAR (medication administration record).
D. Creating a complete Medication Regimen for a patient upon admission: In determining the initial medication regimen, the following sources of information will be reviewed and considered. 1) Discharge/Transfer medication list from acute care facility (ACF)...
E. Creating an initial Medication Regimen: The physician will determine which orders cannot wait for the full medication reconciliation process to be completed. These orders will be completed upon admission. This process should ensure that all needed doses for the first 24 hours are considered. This will prevent omitted doses to full completion of medication reconciliation.
F. Completing Admission Medication Reconciliation in a timely manner: The admissions medication reconciliation process will be completed within 48 hours of admission. A good faith effort should be made to obtain all sources of medication information. Information regarding the historical medications that were identified should be documented. The physician will evaluate each historical medication and determine which medications to continue (order) during this admissions...
G. PROCEDURE - 1. The admissions liaison team members will obtain information on historical medications prior to admission. 2. The pharmacist, in accordance with hospital policy, will document the medication by history in the electronic medical record (EMR) using the information provided from the admissions liaison and/or other resources. Any discrepancies or irregularities noted will be communicated to the physician at that time.

2. Review of patient MRs indicated the following:
A. P1 was admitted 1/26/18 at 1744 hours. The MR lacked documentation of effective medication reconciliation. The following discrepancies between the Discharge/Transfer medication list from the ACF and hospital physician orders were as follows: The ACF transfer documents indicated the patient was to start taking or continue taking the following medications: Lyrica, allopurinol, atorvastatin, biotene, brinzolamide-brimonidine, calcitonin-salmon, conjugated estrogens vaginal cream, cynocobalamin, famotidine, nitroglycerin, oxybutynin, oxycodone-acetaminophen, pantoprazole, prednisone, Requip, Spiriva Respimat inhaler, sucralfate, vitamin D. The hospital MR lacked documentation of a physician order to continue or discontinue the above medications and lacked documentation of pharmacy comparison with newly ordered medications.
B. P4 was admitted 2/21/18 at 1355 hours. The MR lacked documentation of effective medication reconciliation. The following discrepancies between the Discharge/Transfer medication list from the ACF and physician orders were as follows: The ACF transfer documents indicated the patient was to start taking or continue taking: Nitroglycerin prn (as needed).
C. P5 was admitted 2/20/18 at 1340 hours. The MR lacked documentation of effective medication reconciliation. The following discrepancies between the ACF Discharge/Transfer medication list dated 2/20/18 and physician orders were as follows:
i. Per ACF: Amlodipine-benazepril (Lotrel) 1 daily. Hospital physician ordered amlodipine (Norvasc), start date 3/2/18 0800 hours. The MR lacked documentation of reconciliation of this medication completed within 48 hours.
ii. Per ACF: Dutasteride (Avodart) daily. Hospital physician ordered Avodart daily, start date 3/2/18 0800 hours. The MR lacked documentation of reconciliation of this medication completed within 48 hours.
iii. Per ACF: Metoprolol tartrate 2 times daily (BID). Hospital physician ordered metoprolol BID, start date 2/27/18 at 2000 hours. The MR lacked documentation of reconciliation of this medication completed within 48 hours. The history "Details" indicated a pharmacist entered the medication information into the MR with a requested start date of 2/20/18.
iv. The H&P (History & Physical) dated 2/21/18 at 0648 hours included the following in "Medications (27) Active": Amlodipine daily and metroprolol tartrate BID.
D. P5 was re-admitted 3/12/18 at 1617 hours. The MR lacked documentation of effective medication reconciliation. The following discrepancies between the ACF Discharge/Transfer medication list dated 3/12/18 and hospital physician orders were as follows:
i. Per ACF: Insulin lispro, 3 times daily (before meal) for blood sugars (BS) above 150 when on Decadron. Hospital physician ordered insulin lispro sliding scale (2 units for BS 151-200, 4 units for BS 201-250, 6 units for BS 251-300, etc.), start date 3/13/18 at 2000 hours. The nursing Patient History, performed 3/12/18 at 1729 hours indicated the following: Home diet: Diabetic. The Diabetic History was blank. BS results (in insulin range) between admission and the physician order/medication reconciliation for insulin were as follows: 3/12/18 at 1650 hours - 245, at 2002 hours - 243 and 3/13/18 at 1706 hours - 245. The MR indicated the first (and only) insulin administration was 3/13/18 at 2112 hours with 4 units given.
ii. The MR indicated dexamethasone (Decadron) was on the ACF medication list and was ordered by the hospital physician, start 3/12/18 at 2000 hours.
E. P6 was admitted 3/14/18 at 1743 hours. The MR lacked documentation of effective medication reconciliation. The following discrepancies between the ACF Discharge/Transfer medication list and hospital physician orders were as follows: The following medication from the ACF was listed as "Prescription/Reported Meds": Teriparatide (Forteo), daily. The hospital MR lacked documentation of a physician order to continue or discontinue the above medication and lacked documentation of pharmacy comparison with newly ordered medications.
F. P8 was admitted 2/13/18 at 1335 hours. The MR lacked documentation of effective medication reconciliation. The following discrepancies between the ACF Discharge/Transfer medication list and hospital physician orders were as follows: The ACF transfer documents indicated the patient was to start taking or continue taking: Insulin lispro 0-5 units at bedtime for 200 doses, meclizine 2 times daily as needed; nitroglycerin as needed. The hospital MR lacked documentation of a physician order to continue or discontinue the above medications and lacked documentation of pharmacy comparison with newly ordered medications.
i. The H&P performed 2/15/18 at 2132 hours indicated the patient had a Past Medical History of coronary artery disease, diabetes and myocardial infarction.
ii. The MAR (medication administration record) lacked documentation of insulin administration.

3. Interviews:
A. On 4/19/18 between approximately 1:00pm and 4:00pm during MR review, A4, Charge Nurse, indicated medication reconciliation begins with the admission department uploading the discharging facility's (ACF) pre-screening information and MAR. A4 verified lack of documentation of medication reconciliation for patients P1 and P4.
On 4/20/18 at approximately 12:00pm, A4 verified lack of documentation of medication reconciliation, documentation of elevated BSs and lack of documentation of insulin administration for patient P5. Between approximately 1:00pm and 3:30pm, A4 verified lack of documentation of medication reconciliation for patients P5, P6 and P8.
B. On 4/19/18 at approximately 1:45pm, A3 indicated insulin would only be given per physician order.
C. On 4/19/18 at approximately 4:00pm, A5, pharmacist, indicated that the pharmacist often begin the medication reconciliation process by entering a medication list, based off the ACF list, into the MR for the physician to review and from which to create their orders. A5 verified lack of documentation of medication reconciliation for patient P1.
D. On 4/20/18 between approximately 12:15pm and 1:00pm, A6, Director of Pharmacy, verified patient P5 did not have an order for insulin on the day of admission. A6 verified that the MRs did not have documentation of physician evaluation of each historical medication with which medications to continue or discontinue. A6 also verified that documentation of discrepancies or irregularities and communication to the physician were not noted in the MR.