Medication Reconciliation at SNF Admission: Where Mismatches Hide

A new admission usually arrives with a stack of paperwork and a long medication list. Somewhere between the hospital's discharge summary, the transfer form and the orders entered in your system, things can drift apart. A medicine gets left off, a dose changes, or a drug that was paused in the hospital quietly restarts.

Medication reconciliation is the process of catching those mismatches before they reach the resident. It is not glamorous work, but it is some of the most important work done on admission day.

How Often Mismatches Happen

The research is sobering. In a 2009 study in the Journal of General Internal Medicine, Tjia and colleagues reviewed 199 hospital-to-SNF admissions. At least one medication discrepancy was found in 142 of them, or 71.4%. Of 2,319 medications reviewed, 21.3% had a discrepancy. The hospital discharge summary and the transfer referral form disagreed with each other in more than half of admissions.

The study found cardiovascular drugs, opioid pain medicines, neuropsychiatric drugs, diabetes medicines, antibiotics and anticoagulants made up more than half of the discrepant medications.

A more recent prospective study by Patterson and colleagues, published in 2022 in Research in Social and Administrative Pharmacy, looked at four long-term care facilities over nine months. Nearly 41% of newly admitted or readmitted residents had at least one medication discrepancy at intake. Residents taking 14 or more medications, and those with heart failure, anemia or high blood pressure, were at higher risk.

Where Mismatches Hide

Discrepancies tend to cluster in a few predictable places:

• Two hospital documents that do not agree. The discharge summary, the after-visit list and the transfer form may have been completed at different times by different people.
• Held medications. A medicine stopped or paused in the hospital may still appear on an older home list, or may be missing when it was meant to restart.
• Duplicate therapy. A brand name and a generic, or two drugs from the same class, can end up on the same order set.
• High-risk classes. Anticoagulants, insulin and other diabetes medicines, and opioids deserve a second look every time, because small errors can cause serious harm.
• As-needed and over-the-counter items. Eye drops, inhalers, vitamins and supplements are easy to overlook.

Who Does What

Roles vary by facility, so follow your own policy. In general:

• The admitting nurse gathers every available medication source and compares them line by line against the admission orders.
• The provider (physician or nurse practitioner) reviews and resolves any discrepancy. Decisions about continuing, stopping or changing a medicine belong to the provider.
• The consultant pharmacist reviews the medication regimen according to your facility's process and may catch issues the first pass missed.
• The resident and family can confirm what the resident was actually taking at home and what changed in the hospital.

The Agency for Healthcare Research and Quality (AHRQ) MATCH toolkit describes reconciliation in plain terms: obtain and verify the current list, compare it with what is ordered, discuss unintended differences with the prescriber for resolution and share an updated list at the next transition.

What the Standards Say

For years, The Joint Commission's National Patient Safety Goal NPSG.03.06.01 asked accredited organizations to "maintain and communicate accurate patient medication information." Its elements included collecting the current list, comparing it with new orders to find omissions, duplications, contraindications, unclear information and changes, and giving the patient or family an updated written list.

Effective January 1, 2026, The Joint Commission replaced its National Patient Safety Goals with National Performance Goals. Medication information now falls under the goal "Effectively managing medications," which also covers anticoagulant safety. The core expectation has not changed: an accurate list, compared and resolved, at every handoff.

Quick Checklist for Admission Day

• Gather every source: the hospital discharge summary, the transfer form, the medication administration record from the hospital if available and the resident's or family's home list.
• Compare each source against the admission orders, line by line, including as-needed and over-the-counter items.
• Flag every held or stopped medication and confirm with the provider whether and when it should resume.
• Give anticoagulants, insulin and other diabetes medicines, and opioids a dedicated second check.
• Document each discrepancy, who was notified and how it was resolved.

A daily admission screen can help by flagging residents with long or high-risk medication lists, so nurses know where a second look matters most.

This article is general education for skilled nursing teams. Follow your facility's policies and the direction of your medical director and providers.