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Based on record review and interview, the facility failed to inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing patient care, in that, 10 of 11 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) medical record did not document receipt of the patient rights notice at admission.

Findings included

Patient #1's, #2's, #3's, #4's, #5's, #6's, #7's, #8's, #9's, and #10's medical record did not document receipt of the patient rights notice at admission.

During an interview and electronic records review on 3/20/18 ending at 4:30 PM, Personnel #1 was asked for the patient's signature for the receipt of patient's rights notice to include the process for complaint submission. Personnel #1 reviewed the record and confirmed the finding.

The Patient Rights and Responsibilities policy does not reflect the right to receive information on Patient's Rights in advance of furnishing patient care.

Based on record review and interview, the facility failed to ensure the effectiveness and safety of services and quality of care for 1 of 11 patients (Patient #1) during the 3/17/17 admission, in that, Patient #1 received Patient #11's medications after a transcription error, which required a return to acute/transfer.

Findings included

The 3/18/17 incident report reflected the above incident and showed it was reviewed on 4/03/17 by the hospital for the acute transfer 4/03/17. There was no review for the medication errors that occured.

The 3/17/17 (Hospital the patient came from) medical record for Patient #1 reflected, "Discharge Patient Medication Report...Amiodarone 200 mg (milligrams) daily...Beta-Carotene...Diphenhydramine 25 mg q8hr PRN (every eight hours as needed)...Levothyroxine 75 mcg daily...Lisinopril 20 mg twice daily...Memantine 10 mg at bedtime...Metoprolol 25 mg twice daily...Potassium Chloride 10 mEq (Milliequivalent) daily..."

The 3/17/17 (current Hospital) for Patient #1 reflected, "Medication Administration Record (MAR)...Potassium Chloride 20 mEq and Warfarin 5 mg on 3/17/17 at 21:17 PM...History and Physical...12:00 AM...blood pressure 127/57...Patient throughout the day today started declining in function and she had been unresponsive. Blood pressure was low at 70/40. Since the patient had a traumatic fall and scalp laceration and she has been on Coumadin, intracranial hemorrhagic is suspected and will go to acute care for further assessment...MAR...Potassium Chloride 20 mEq (2nd dose) on 3/18/17 at 5:42 AM...Furosemide 80 mg, Spironolactone 25mg, Magnesium Oxide 400 mg, and Carvedilol 25 mg on 3/18/17 at 10:16 AM...Acute Care Transfer...13:50 PM...patient exhibiting paradoxical breathing, hypotension of 70/40, bradycardia of 46, and decreased responsiveness. PA notified - order rec'd (received) to transfer pt (patient) via 911...Post Admission Physician Evaluation...3/18/17...Documented Medications (after each of the following listed medications, "(Patient#11's Hospital)" was listed as the place the medication list was from...Carvedilol 25 mg...Cyclobenzaprine 10 mg...Furosemide 80 mg...Levothyroxine 125 mcg...Magnesium Oxide 400 mg ..Potassium Chloride 20 mEq every 8 hours ..Simvastatin 40 mg...Spironolactone 25 mg...Warfarin 5 mg..."

The 3/18/17 Physician Discharge Summary listed the same wrong medications as discharge medications.

Medical Record review ended on 3/20/18 at 4:30 PM, all findings were verified by Personnel #1.

There was no Peer review for the 3/18/17 incident report and or medication errors.

During a telephone interview on 3/23/18 ending at 9:28 AM, Personnel #1, Personnel #2, and Personnel #8 were present. They were asked about the incident report review signed 4/03/17. Personnel #8 stated, "It was reviewed for the ACT (Acute Transfer) but, it was not known about the medication errors until you came." Personnel #1 stated, "We had 7 admissions that day. The medications were entered by pharmacy after the packets were scanned to them. Pharmacy transposed the forms/patients. The patient's name from that hospital was similar to her name. He got his medications but, she got his as well." Ms. Lawhead stated, "We will take this through the (Quality/Medication Error) process now."

The March 2017 "Medication Reconciliation" policy required, "a good faith effort...after admission...compare the list of medications prior to admission...to identify any inconsistencies so the physician or his /her qualified designee can then modify orders if appropriate."

The November 2017 "Provision of Care Plan" required, "We look to provide out patients with the finest clinicians, technology, facilities and programs available. We do this in a safe environment, responding to the needs of our diverse patient population, always working to achieve superior outcomes for each patient..."

Based on record review and interview, the pharmacy failed to ensure safe use of medications for 1 of 11 patients (Patient #1) during the 3/17/17 admission, in that, Patient #1 received Patient #11's medications after a transcription error, which required a return to acute/transfer.

Findings included

The 3/17/17 (Hospital the patient came from) medical record for Patient #1 reflected, "Discharge Patient Medication Report...Amiodarone 200 mg (milligrams) daily...Beta-Carotene...Diphenhydramine 25 mg q8hr PRN (every eight hours as needed)...Levothyroxine 75 mcg daily...Lisinopril 20 mg twice daily...Memantine 10 mg at bedtime...Metoprolol 25 mg twice daily...Potassium Chloride 10 mEq (Milliequivalent) daily..."

The 3/17/17 (current Hospital) for Patient #1 reflected, "Medication Administration Record (MAR)...Potassium Chloride 20 mEq and Warfarin 5 mg on 3/17/17 at 21:17 PM...History and Physical...12:00 AM...blood pressure 127/57...Patient throughout the day today started declining in function and she had been unresponsive. Blood pressure was low at 70/40. Since the patient had a traumatic fall and scalp laceration and she has been on Coumadin, intracranial hemorrhagic is suspected and will go to acute care for further assessment...MAR...Potassium Chloride 20 mEq (2nd dose) on 3/18/17 at 5:42 AM...Furosemide 80 mg, Spironolactone 25mg, Magnesium Oxide 400 mg, and Carvedilol 25 mg on 3/18/17 at 10:16 AM...Acute Care Transfer...13:50 PM...patient exhibiting paradoxical breathing, hypotension of 70/40, bradycardia of 46, and decreased responsiveness. PA notified - order rec'd (received) to transfer pt (patient) via 911...Post Admission Physician Evaluation...3/18/17...Documented Medications (after each of the following listed medications, "(Patient #11's Hospital)" was listed as the place the medication list was from...Carvedilol 25 mg...Cyclobenzaprine 10 mg...Furosemide 80 mg...Levothyroxine 125 mcg...Magnesium Oxide 400 mg ..Potassium Chloride 20 mEq every 8 hours ..Simvastatin 40 mg...Spironolactone 25 mg...Warfarin 5 mg..."

The 3/18/17 Physician Discharge Summary listed the same wrong medications as discharge medications.

Medical Record review ended on 3/20/18 at 4:30 PM, all findings were verified by Personnel #1.

The 3/18/17 incident report reflected the above incident and showed it was reviewed on 4/03/17 by the hospital for the acute transfer 4/03/17.

There was no Peer review for the 3/18/17 incident report.

During a telephone interview on 3/23/18 ending at 9:28 AM, Personnel #1, Personnel #2, and Personnel #8 were present. They were asked about the incident report review signed 4/03/17. Personnel #8 stated, "It was reviewed for the ACT (Acute Transfer) but, it was not known about the medication errors until you came." Personnel #1 stated, "We had 7 admissions that day. The medications were entered by pharmacy after the packets were scanned to them. Pharmacy transposed the forms/patients. The patient's name from that hospital was similar to her name. He got his medications but, she got his as well." Ms. Lawhead stated, "We will take this through the (Quality/Medication Error) process now."

The March 2017 "Medication Reconciliation" policy required, "a good faith effort...after admission...compare the list of medications prior to admission...to identify any inconsistencies so the physician or his /her qualified designee can then modify orders if appropriate."