Every finding on record at Hh Health System - Lincoln Inc.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were accurately documented for 3 of 3 (Patient #1, 2, and 3) patients observed during home visits. The findings included: 1. Review of the facility policy, "Medication Reconciliation," revealed, "...Policy: The Agency will reconcile patient's medications at time of admission and on an ongoing basis...Procedure...Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. Medications are assessed with each visit. All non-reconciled medications will be sent to the PCP [primary care physician] on a supplemental order for review and clarification..." 2. Medical record review for Patient #1 revealed an admission date of 3/23/2021 with a primary terminal diagnosis of Persistent Atrial Fibrillation. Patient #1 was a resident at Skilled Nursing Facility (SNF) #1. The "Medication Summary" printed on 1/11/2022 revealed the following medication: Maalox (200 milligrams [mg] aluminum hydroxide, 200 mg magnesium hydroxide, and 20 mg simethicone; medication is indicated to relieve the symptoms of indigestion, heartburn, sour stomach, and the discomfort caused by gas) to be given by mouth every 4 hours as needed (medication ordered on 7/1/2021). Review of the "Order Summary Report" printed on 1/11/2022 from SNF #1 revealed Maalox was not listed on SNF #1's medication list. In an interview on 1/11/2022 at 9:37 AM, Nurse #1 stated she was supposed to reconcile the medications listed on the facility's "Medication Summary" with the medications listed on SNF #1's "Order Summary Report" on each visit. 3. Medical record review for Patient #2 revealed an admission date of 8/11/2021 with a primary terminal diagnosis of Malignant Neoplasm of the Lung. Observations made during a home visit on 1/11/2022 at 10:26 AM revealed the following medications: morphine 20 mg/milliliter (ml), bisacodyl 10 mg suppositories, and Aquaphor Healing Ointment. These medications were not listed on the facility's "Medication Summary" printed on 1/11/2022. In an interview on 1/11/2022 at 10:45 AM, Family Member #1 confirmed the morphine and bisacodyl suppositories had been ordered on admission to the facility on 8/11/2021. Family Member #1 stated the family had been using the Aquaphor Healing Ointment on Patient #2 since his radiation treatment in July 2021. 4. Medical record review for Patient #3 revealed an admission date of 11/19/2021 with a primary terminal diagnosis of Parkinson's Disease. The "Medication Summary" printed on 1/11/2022 revealed the following medication: ropinirole 0.25 mg per gastric tube three times daily (medication ordered on 11/29/2021). Observations in Patient #3's home on 1/11/2022 at 11:25 AM revealed no ropinirole with Patient #3's medications. In an interview on 1/11/2022 at 11:45 AM, Family Member #2 stated she could not find the ropinirole. Family Member #2 reviewed the receipts of the medications delivered to the home and stated she could not find any receipt that the medication (ropinirole) had ever been delivered to the home.