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Based on document review and interview, the hospital failed to ensure evaluation of nursing care for proper medication reconciliation in accordance with their policy and procedure for 8 of 10 medical records (MR) reviewed (P3, P4, P5, P6, P7, P8, P9 and P10).

Findings include:

1. Review of the policy titled Medication Reconciliation and Drug Regimen Review, revised 10/2017, indicated the following: Upon initial nursing assessment, the nurse reviews medications verbally with patient and/or caregiver. The Nurse then compares the list of medications, allergies and sensitivities taken verbally from the patient with both the list of medication received from transferring facility and the initial physician's orders. The Nurse will notify the physician of any medications, allergies or sensitivities not appearing on the initial physician's orders or any discrepancies.

2. Review of MRs lacked documentation of the nurse having reviewed medications verbally with patients and/or caregivers upon initial nursing assessment for patients P3, P4, P5, P6, P7, P8, P9 and P10.

3. On 3/14/19 between approximately 4:45 p.m. and 5:45 p.m., A1, Chief Nursing Officer, and A7, House Supervisor, verified that the MRs of patients P3, P4, P5, P6, P7, P8, P9 and P10 lacked documentation of nursing having reviewed medications with the patients and/or caregivers for medication reconciliation.

Based on document review and interview, the hospital failed to minimize drug errors by failing to ensure patient medications were adequately reconciled by pharmacy for 1 of the 10 patients (P4) in accordance with policy and procedure (P&P).

Findings include:

1. Review of the policy titled Medication Reconciliation and Drug Regimen Review, revised 10/2017, indicated the following:
Upon initial nursing assessment, the nurse reviews medications verbally with patient and/or caregiver. The Nurse then compares the list of medications, allergies and sensitivities taken verbally from the patient with both the list of medication received from transferring facility and the initial physician's orders. The Nurse will notify the physician of any medications, allergies or sensitivities not appearing on the initial physician's orders or any discrepancies.
The nurse will send a copy of one of the following...to the pharmacy, along with admission orders:
a. Medication Reconciliation Form
b. Discharge Summary
c. Continuation of Care (Transfer) Form
d. Current day's MAR (Medication Administration Record)
The pharmacist will review the admission orders and reconcile the medications with one of the four types of documents listed above.

2. Review of the MR for patient P4 lacked documentation of initial medication reconciliation to include an order to continue or discontinue a medication, diltiazem, as recommended by the transferring hospital. Details were as follows: The "Medication List" from the transferring hospital (H1) indicate the patient was discharged from the hospital on 2/8/19 and was to continue taking "Cartia XT" 2 times daily. Generic drug: diltiazem. Medication reconciliation admission orders, dated 2/8/19, lacked documentation of Cartia/diltiazem having been listed on the form by the nurse and lacked documentation of it having been ordered by the physician. Pharmacy medication reconciliation documentation, dated 2/8/19, indicated "Performed - No Significant Med Issues" and lacked documentation of the pharmacist having reconciled the admission medication orders for the diltiazem. Physician orders, dated 2/11/19 at 1725 hours, indicated the following: Diltiazem 240 mg ER (Extended Release)...Per H1 transfer sheet and family states home med (medication). The medication administration record lacked documentation of the patient having received diltiazem between 2/8/19 and 2/11/19.