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Based on document review and interviews, the Hospital failed to communicate to the medical staff a new allergy policy outlining new provider responsibilities regarding the allergy review process for discharging physicians.

The document titled Pharmacy and Therapeutics Committee Meeting Minutes, dated 12/20/2018, indicated that a new policy for allergy documentation was approved, (with final responsibility of allergy documentation in the patient medical record to be placed on the discharging physician).

The policy titled Identification and Documentation of Allergic Reactions, with an effective implementation date of 12/2018, indicated that final responsibility for ensuring the allergy section for the patient will be reviewed by the discharging clinician as part of the discharge medication reconciliation process.

At the time survey commenced, the above policy was not rolled out by the Medical Executive Committee to all applicable medical staff (despite approval and effective date of 12/2018) who have a responsibility to maintain an updated allergy list of any given patient upon discharge.

The Surveyor interviewed Hospitalist #1 on 02/11/2019 at 10:45 A.M. Although Hospitalist #1 acknowledged that her standard of practice was to always conduct an allergy review during the discharge process, Hospitalist #1 was unaware of the new allergy policy that was implemented approximately two months prior.