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Based on document review and interview, the facility failed to provide documentation of patient/family involvement in medication reconciliation in 10 of 10 (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) medical records reviewed.

Findings include:

1. Review of policy titled: Medication Reconciliation - Verification (MM 23.1), last reviewed 02/24/22 indicated that the facility implements and maintains a process to obtain a complete list of a patient's current medications upon admission. The process is multidisciplinary between the nurse, pharmacist, the physician with patient/family involvement.

2. Review of Patient 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10's medical records lacked documentation of nursing reviewing the patient's current medications before admission. Unable to verify the conversation was completed.

3. Interview on 12/06/22 at 12:45 pm, with P52 (Registered Nurse) confirmed that the medical records lacked documentation of conversation between patient/family and nursing.

Based on document review and interview, the facility failed to ensure that the medical record contained sufficient information to justify treatment provided to 1 of 10 patients (Patient 3).

Findings include:

1. Review of patient 3's medical record indicated an admission diagnosis of peritonitis and abscess near peritoneal dialysis catheter with history of Addison's disease. Physician's (Physiatry) History and Physical dated 01/22/22 indicated "Addison's disease: continue Hydrocortisone" and listed hydrocortisone in previous medications prior to admission. Physician (Internal Medicine) note dated 01/22/22 indicated "Addisons: Recent stress dose Hydrocortisone". Physician (Nephrologist) note dated 01/22/22 indicated history of Addison's disease. Physician note dated 01/24/22 indicated "Addisons: Recent stress dose Hydrocortisone". Physician's Discharge Summary indicated "Addison's disease: continue Hydrocortisone". Medical record lacked documentation of an order for Hydrocortisone and/or why it was not ordered.

2. Interview on 12/06/22 at 12:45 pm, with P52 (Clinical Education and Infection Prevention) confirmed that physician notes indicated patient had Addison's disease and that medical records lacked documentation of an order for Hydrocortisone.