Encompass Health Rehabilitation Hospital of Erie,

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 39272 Based on review of medical records (MR), review of facility documents and interview with staff (EMP), it was determined that the facility failed to have a process in place to ensure that medication reconciliation occurred whenever a patient returned from a medical or surgical appointment back to the facility. This failure resulted in a patient not receiving the ordered medications Eliquis 2.5 mg twice per day and 81mg of aspirin daily. Three days later the patient suffered a cardiac arrest. Findings include: 1. An Immediate Jeopardy was called at 3:13 PM on May 16, 2023, when it was identified that the facility did not have a process in place to ensure a medication reconciliation was completed for patients who returned from being outside of the facility, presenting safety concerns for patients who returned with changes to current medication/treatment orders. 2. The Immediate Jeopardy was resolved at 5:27 PM on May 16, 2023, when the facility submitted an immediate action plan which included a plan to ensure a medication reconciliation was complete for every patient who left and subsequently returned to the facility. Staff education on immediate action plan was being provided prior to all staff’s next scheduled shift. 3. A review of the facility’s analysis of the incident indicated that on April 7, 2023, the facility identified multiple contributing factors to the incident. Factors that contributed to the event included that there were not any processes in place for medication reconciliation upon returning from an outside appointment, that there were not any processes in place for who to notify when concerns were identified, that there were not any processes in place for staff expectations, which resulted in staff not understanding roles and responsibilities of each position, and that the PA, Attending Physician, and Consulting Physician notes were inconsistent and contradicted each other. Cross Reference: 482.23(a) Organization of Nursing Services”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 39272 Based on review of facility documentation and employee interview (EMP) it was determined that the facility failed failed to follow processes for medication reconciliation and implementing telephone/verbal orders. Findings include: 1. Review of a report submitted to the Department on April 1, 2023, revealed that a medication error/dose omission occurred on March 27, 2023, when Aspirin and Eliquis was not administered upon return from a leave of absence. 2. Review of an email communication from EMP1 revealed that the facility had developed an action plan to include development of an organization chart to include staff roles and responsibilities, education for staff expectations, and medical record audits for leave of absence and medication reconciliation. Target completion date for the action plan was identified as May 12, 2023. EMP1 confirmed that action plan was not completed upon arrival to the facility on May 16, 2023. 3. Review on May 16, 2023, of a facility document completed on March 28, 2023, related to the Aspirin and Eliquis medication errors, further revealed that nursing staff notified the physician of a patient potassium level of 5.1 on March 23, 2023. Telephone order that was obtained to discontinue current potassium supplement was not discontinued on the Electronic Medication Record. As a result, the patient received an additional seven doses of the potassium supplement. Further review of the document revealed that additional medication errors occurred on March 24, 2023, when Aspirin and Eliquis were not restarted as ordered upon return from an outpatient appointment. 4. Review on May 16, 2023, of a facility document completed on March 28, 2023, related to the Aspirin and Eliquis medication errors revealed potential contributing factors related to this event included a communication issue, an education/instruction deficit, and a training issue. 5. Review on May 19, 2023, of a facility document completed on April 7, 2023, related to the identified medication revealed the identifying factors that contributed to the event included that there were not any processes in place for medication reconciliation upon returning from an outside appointment, that there were not any processes in place for who to notify when concerns were identified, that there were not any processes in place for staff expectations, which resulted in staff not understanding roles and responsibilities of each position, and that the PA, Attending Physician, and Consulting Physician notes were inconsistent and contradicted each other.”