Vitalcaring Group

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview and record review the agency failed to ensure a review of all medications was conducted each visit in order to identify any potential adverse effects and drug reactions, and noncompliance with drug therapy. The agency failed to ensure an accurate Drug Regimen was reviewed for medication changes for 2 (#5 and #6) of 5 sampled patients with home visits. Review of the agency policy titled: “Medication List and Monitoring” revealed in part…The agency will maintain a current, accurate list of all prescription and over the counter medications taken by the patient/client. Professional clinical staff will update the medication list with any changes in the medication regimen. #5 Review of patient #5’s Home Health Certification and Plan of Care dated 01/05/2024 to 03/04/2024 revealed the following diagnoses: Chronic Obstructive Pulmonary Disease, Systemic Lupus Erythematosus, Type II Diabetes Mellitus, Essential Hypertension and Malignant Neoplasm of Ascending Colon. Review of the patients’ home medication list during a home visit on 01/23/2024 accompanied by S3 LPN revealed Patient #5 was talking all the medications listed in her POC except for: Amlodipine 5mg 1 tablet daily for hypertension Buspirone 15mg 1 tablet two times daily for anxiety CO Q-10mg capsule 1 capsule daily Gabapentin 100mg 1 capsule two times daily Loratadine 10mg 1 capsule daily for allergies Ondansetron HCL 4mg tablet 1 tablet every 8 hours for nausea Prolia 60mg/ml subcutaneous syringe 1ml subq every 6 months, last given 03/2022 Protonix 40mg tablet 1 tablet daily Tizanidine 4mg tablet 1 tablet every 8 hours prn pain Interview on 01/23/2024 at 11:30 a.m. with Patient #5 and her daughter revealed Patient #5’s Amlodipine had been changed to Clonidine, and the patient had not taken Buspirone in over a month, had not taken Loratadine, CO Q-10, Ondansetron HCL and Gabapentin in over 6 months. Interview also revealed Patient #5’s Protonix had been discontinued and Pepcid started over a month ago. Patient #5 stated she had taken a Prolia injection last month and it had been discontinued, and she had not taken Tizanidine in a year. Observation on 01/23/2024 at 11:35 a.m. revealed Patient #5 had a bottle of Levocetirizine 5mg , with instructions to take 1 tablet nightly. The original prescription date was noted as 08/09/2023. Interview with Patient #5 at the time of observation revealed her Loratadine had been discontinued and replaced with Levocetirizine in August. Interview on 01/24/2024 at 11:37 a.m. with S3 LPN revealed Patient #5’s medication list should have been reviewed and updated to reflect the discontinuation and addition of medications and had not been. LPN confirmed she had performed a skilled nurse visit for Patient #5 last week. #6 Review of patient #6’s Home Health Certification and Plan of Care dated 01/07/2024 to 03/06/2024 revealed the following diagnoses: Hypertensive Heart Disease with Heart Failure, Chest Pain, Atrioventricular Block, Anxiety, Osteoarthritis and Obstructive Sleep Apnea. Review of the patients’ home medication list during a home visit on 01/23/2024 accompanied by S2 RN revealed Patient #6 was talking all the medications listed in his POC except for : Meclizine 25mg 1 tablet three times daily prn dizziness Midodrine 2.5mg 1 tablet two times daily for low blood pressure Ranolazine ER 500mg 1 tablet two times daily for chest pain Interview on 01/23/2024 at 9:07 a.m. with Patient #6 revealed he had not taken Meclizine in “awhile” and had no Meclizine in the home. Patient #6 also stated he had not taken Midodrine in 3 months and had stopped taking Ranolazine two months ago. Interview revealed Patient #6 had a skilled nurse visit performed by S3 LPN last week. Interview on 01/23/2024 at 9:10 a.m. with S2 RN revealed Patient #6’s medication list should have been updated to reflect medication changes and discontinuations and had not been. Interview on 01/23/2024 at 1:30 p.m. with S1 Administrator, revealed medications should be reconciled and list updated at each skilled nurse visit. S1 Administrator confirmed Patient #5 and Patient #6’s medications should have been reconciled at each visit and updated prior to today.”