HospitalInspections.org

Based on a review of documentation and an interview with staff, the director of nursing failed to be responsible for the operation of the service.

Findings were:

Documentation sent with the patient from [prior facility] included a list of medications titled "Patient Profile" and a printed copy of the patient's MAR [medication administration record] for 3-26-18 (the date of transfer). Under a column marked "order status", the following 3 medications listed, as their status, "hold".
1. Pramipexole
2. Bupropion XL
3. Venlafaxine
No discharge orders were found and there was no indication given as to why the prior hospital had held the 3 listed medications. The clinical record contained no documentation of any attempts made to contact Brownwood Regional to find out why the 3 medications had been held. All 3 of the medications (held by the previous facility) were restarted at RRH.

Facility policy 4.02 titled "Medication Reconciliation" states, in part:
"Purpose:
The purpose of this policy is to establish a process known as medication reconciliation to insure(sic):
Medications ordered during and prescribed at discharge from a HealthSouth hospital stay are medically appropriate in light of the patient's previous home and hospital medication history ...

Policy:
Upon admission, a good faith effort will be made to obtain information about the medications the patient was taking prior to admission ...

Procedure:
1) A designated person will obtain information about the historical medications.
a. Minimum required information includes dose, route and frequency
b. Information will be documented in a list or other format determined to be useful to the physician for the reconciliation and should include all of following, if available:
1. Home medication list

2. Medication Administration Record (MAR) from previous care setting
a) Initially, this information should be made available on ORBIT upon completion of the HealthSouth Preadmission Screening form.
b) The previous care setting should be contacted if up-to-date information is not present on ORBIT or upon admission to HealthSouth.

3. Discharge orders from the previous care setting that typically arrive with the patient."

In an interview with staff #3 on 5-1-18, staff #3 confirmed that the clinical record did not contain either discharge orders from the prior facility or documentation of any attempts at obtaining updated medication information from the prior facility.

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 5-1-18.