Every finding on record at Excelsior Springs City Hospital

Based on policy review, agency and facility record review, home visit observation, and interview, the agency failed to maintain an accurate/updated medication profile/plan of care (POC) in two (Records/Patients #1 and #2) of three home visit observations conducted. This deficient practice has the potential to adversely affect the agencys ability to ensure safe and effective use of medication for all patients served by the agency. --- Findings included: Review of the agencys policy, titled, ";Drug Regimen Review," dated 02/27/2019, showed, in part: - Patients admitted to Home Health and Hospice will receive a medication regimen review by an RN (registered nurse) within 5 (five) days of admission; - This review will include an assessment of potential adverse effects, drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and non-compliance with drug therapy; - On admission the RN/PT (registered nurse or physical therapist) will obtain a list of all medications the patient is currently taking; - An RN will review the medication profile within 5 days of start of care or resumption of care or whenever a drug is prescribed and assess for: * Potential adverse effects; * Drug reactions; * Ineffective drug therapy; * Non-compliance with drug therapy; * Significant drug interactions; * Duplicate drug therapy; and - Documentation will be placed in the medical record of each review as well as the notification of the physician and physician response. RECORD/PATIENT #2: Observation on 02/07/2023 at 10:00 AM, during the patient's home visit at the long-term care facility (LTCF) where he/she resided, showed multiple discrepancies: - Acetaminophen Extra Strength (chronic pain) tablet 500 milligrams (mg), give 1000 mg by mouth two times a day. The agencys medication list showed Acetaminophen Extra Strength 1000 mg three times a day; - Amlodipine (high blood pressure) 10 mg, give one tablet by mouth one time a day. The agency's medication list showed amlodipine 2.5 mg nightly; - Buspirone (anxiety) tablet 5 mg, give one tablet by mouth in the morning for anxiety. The agencys medication list showed buspirone 5 mg twice a day; - Docusate sodium (stool softener) capsule 100 mg, give one capsule by mouth one time a day. The agencys medication list showed docusate sodium one twice a day; - Melatonin (sleep aide) tablet 3 mg, give one tablet by mouth at bedtime. The agencys medication profile failed to list melatonin; - Mirtazapine (insomnia) 7.5 mg, give two tablets by mouth at bedtime. The agencys medication list showed mirtazapine one tablet at bedtime; and - Robitussin (cough) syrup, give 10 cc by mouth as needed for cough as needed three times a day. The agencys medication profile failed to list Robitussin. RECORD/PATIENT #1: Observation on 02/07/2023 at 11:45 AM, during the patient's home visit at the assisted living facility (ALF) where he/she resided, showed multiple discrepancies: - Albuterol AER HFA (shortness of breath), inhale two puffs by mouth every six hours as needed. C - Diabetic Tussin (cough medicine) liquid 100 mg/5 ml, give 5-10 ml (100-200 mg) by mouth every six hours as needed. The agencys medication profile failed to list diabetic tussin; - Miconazole cream (skin infections) 2%, apply to affected area(s) topically twice a day as needed. The agencys medication profile failed to list Miconazole cream; - Mucus Relief (expectorant) tab 600 mg ER (extended relief), take one tablet by mouth twice daily. The agencys medication profile failed to list Mucus relief; - Nystatin powder (redness), apply to affected area(s) topically three times a day as needed. The agencys medication profile failed to list Nystatin powder; and - Oyster shell (low calcium levels) tab 500 mg, take two tablets (1000 mg) by mouth once daily. The agencys medication profile failed to list Oyster shell. The evidence showed the agency failed to reconcile the patient's medications accurately. During an interview on 02/08/2023 at 2:48 PM and 2:50 PM, Registered Nurse A stated that he/she should reconcile the agency medication list to the medication list in the facility. The Amlodipine should be 10 mg, which he/she put the medication in the computer, so he/she swore he/she did. During an interview on 02/08/2023 at 2:59 PM, the administrator stated that the medications should match with the facility medication profile