Observations:
Based on review of facility policy, medical records (MR) and staff interview (EMP), it was determined the facility failed to document physician signature on the medication reconciliation form for six of 21 medical records reviewed ( MR1, MR6, MR7, MR8, MR11 and MR21)
Findings include:
Requested a policy for the Medication Reconciliation Form and none was provided.
Review of facility form "Medication Reconciliation Form" revealed ... Current Medications which includes Medication, Dose, Frequency and Last Dose ... Discharge Instructions for Medications: includes Resume your current medication (as listed above), no medications at this time ... Below are the medications prescribed by your physician today: Medication, Dose, Frequency Rx Given to Patient ... Physician Signature, Date/Time, Patient/Responsible Party, Date/Time, Nurse's Signature, Date/Time ..."
Review of MR 1 on September 5, revealed the Medication Reconciliation Form did not have a physician signature, date, or time completed.
Review of MR6 on September 5, revealed the Medication Reconciliation Form did not have a physician signature, date, or time completed.
Review of MR7 on September 5, revealed the Medication Reconciliation Form did not have a physician signature, date, or time completed.
Review of MR8 on September 5, revealed the Medication Reconciliation Form did not have a physician signature, date, or time completed.
Review of MR11 on September 5, revealed the Medication Reconciliation Form did not have a physician signature, date, or time completed.
Review of MR21 on September 5, revealed the Medication Reconciliation Form did not have a physician signature, date, or time completed.
Interview with EMP2 on September 5, 2024, at approximately 11:30 AM confirmed there was no physician signature on the Medication reconciliation form.
| | Plan of Correction - To be completed: 11/08/2024
1. Redundant medication reconciliation forms will be eliminated from the patient charts, and only one form will be used for the med rec form. This will be the form generated from the One Medical Passport system, which will be printed and placed into the patient chart. This form will also be placed in a standardized area of the chart, next to the physician's order sheet, such that staff and physicians will always know where to locate it to obtain necessary signatures prior to patient discharge. Additionally, our discharge policy will be updated to include language such that a physician must sign the med rec form prior to patient discharge.
2. Patients will be protected by ensuring that our staff and physicians are educated on the medication reconciliation process, the new med rec form, and the updated policy citing the need for a physician signature to be on that form before patient discharge from the facility.
3. The facility will ensure that the problem does not recur by ensuring that staff and physicians are following our updated patient discharge policy, which will include the need for a physician to sign the med rec form prior to patient discharge. Staff will be in-serviced on this policy update, and our annual physician education packet will be updated to include this information.
4. The facility will monitor the performance of this plan of correction by conducting a quality assurance study on randomly selected charts. A RN from our patient safety committee will audit ten charts per month for a period of three months. Following this, five charts per month will be audited for another three months. This audit will include an inspection of the record to ensure that there is a physician signature on the med rec form. Results will be documented and reviewed at quarterly Patient Safety Committee meetings and forwarded to our Quality Assurance Committee. If the issue persists, additional training will be conducted and the audit will be repeated.
5. This corrective action will be fully implemented by 11/8/2024
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