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Based on review of hospital policies/procedures, Medical Staff Rules and Regulations, medical records, and staff interviews, it was determined the medical staff failed to require physicians documented complete orders, as demonstrated by:

1. failure to write the strength, route, and frequency of medications ordered for 3 of 3 Intensive Care Unit (ICU) patients (#27, 29, and 35); and

2. failure to write new post procedure orders for 3 of 3 ICU patients (#28, 29, and 35).

Findings include:

1. The hospital policy titled Medication Administration #8721.710 (last revised 03/08) requires: "...A complete order will include name of medication, strength, route and frequency...."

Physicians' orders were incomplete, as follows:

Patient #27: 05/23/11 (0220) "...OK to use propofol - start at 20 - 30 mcg...titrate to effect if no success with fentanyl gtt (drip) or versed...." (date incorrect - should be 05/20/11). The order did not identify titration parameters or desired effect. Nursing documented Propofol was initiated 05/20/11 (0230) at 20 mcg...(0300) increased to 30 mcg...discontinued 05/21/11 (1445).

Patient #29: 05/23/11 (1040) "...Fentanyl drip resume to control pain...." The order did not identify dosing, start rate, or titration parameters. Nursing documented Fentanyl was initiated 05/23/11 (1000) at 75 mcg, then decreased on 05/24/11 (0330) to 50 mcg.

05/23/11 (1040) "...Propofol drip PRN (as needed) for comfort...." The order did not identify start rate, titration parameters, or desired effect. Nursing documented Diprivan (Propofol) initiated on 05/23/11(2220) at 20 mcg.

05/23/11 (1040) "...resume TF (tube feeding) water at the same rate as yesterday via FT (feeding tube)...." The order did not identify the rate.

05/23/11 (0840) "...resume pre-op orders...." The physician did not re-write the orders, as required by policy.

05/23/11 (0840) "...normalize pCO2 (partial pressure carbon dioxide)...." The physician was unclear as to how the order was to be accomplished.

05/23/11 (0840) "...Cardene drip titrate to keep sys (systolic blood pressure) less than 160...." The order did not identify the start rate, and titration parameters. Nursing documented the following: 05/23/11 (0910) Cardene 5 mg...(1045) increased to 7.5 mg...(2330) decreased to 6 mg...05/24/11 (2400) decreased to 5 mg...(0430) decreased to 2 mg.

Order with no date/no time "...12.5 gr (grain) of Mannitol now...." The order did not identify the concentration, route, or rate. Nursing documented "Mannitol 12.5 g (gram)" at 05/24/11 (0505).

According to Taber's Cyclopedic Medical Dictionary, "gr" is the abbreviation for "grain", and "g" is the abbreviation for "gram." One (1) gram is equal to 15.432 grains. Mannitol is available in concentrations of 5%, 10%, 15%, 20%, and 25%, and calculated in grams (for dosing), according to Nursing 2010 Drug Handbook.

05/24/11 (no time) "...Resume Propofol for comfort...." The order did not identify the start dose, titration parameters, and desired effect.

Patient #35: 05/24/11 (1200) "...vasopressin gtt...." The order did not identify dosing.

05/23/11 (1130) "...resume pre-op meds, orders, diet, vent (ventilator)...." The physician did not identify, or re-write the orders, as required by policy.

05/23/11 (0550) "...Levophed gtt titrate for MAP (mean arterial pressure) (greater than) 65...." The order did not identify the starting rate, and titration parameters. Levophed is administered to titrate to systolic blood pressure, instead of MAP, according to Nursing 2010 Drug Handbook.

05/21/11 (0030) "...put pt.(patient) back on APRV (Airway Pressure Release Ventilation Protocol) at ordered settings previously...." The order did not identify which/what previous settings.

The managers of Clinical Pharmacy and Quality/Risk, confirmed the incomplete physicians' orders during interviews conducted on 05/25/11.

2. The hospital policy titled Medication Administration #8721.710 (last revised 03/08) requires: "...Following general anesthesia, 'ALL' medications will be discontinued and require a physician's order for treatment...Upon transfer of a patient to a different level of care, all 'PRN (as needed)', IV (intravenous), medication orders and daily labs will be discontinued by receiving unit. If any of these orders are to be continued, they must be re-written...."

The Medical Staff Rules and Regulations 2010, requires: "...All previous orders are automatically discontinued when the patient goes to surgery or is transferred...Orders for patient care will be canceled at the time of surgery. It will be the responsibility of the physician to write new orders for continuation of the patient's care after surgery...."

Physicians documented the following "resume" orders:

Patient #28: 05/21/11 (1635) "...resume pre-op orders/meds/diet...05/22/11 (1108)...resume pre op orders/meds/diet...05/23/11 (1436)...Resume pre-op orders/meds/diet...."

Patient #29: 05/23/11 (1040) "...resume TF (tube feeding) water at the same rate as yesterday via FT (feeding tube)...05/23/11 (0840) resume pre-op orders...05/24/11 (no time)...Resume Propofol for comfort...."

Patient #35: 05/23/11 (1130) "...resume pre-op meds, orders, diet, vent (ventilator)...05/21/11 (0030)...put pt.(patient) back on APRV (Airway Pressure Release Ventilation Protocol) at ordered settings previously...." The order did not identify which/what previous settings.

The managers of Clinical Pharmacy and Quality/Risk, confirmed the incomplete physician orders during interviews conducted on 05/25/11. The managers verified that the hospital adopted protocols for APRV and Diprivan, however, the protocols were intended as informational and not considered orders.

Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined the nursing staff failed to require patients were medicated and provided treatments according to physicians' orders, and that medications administered were documented according to policy, as demonstrated by:

1. failure to clarify incomplete physicians' orders for patients' medications, and treatment orders, for 3 of 3, Intensive Care Unit (ICU) patients (#27, 29, and 35);

2. failure to document administered medications, according to policy, for 2 of 2 patients (#27 and 35); and,

Findings include:

1. There was no documentation to conclude that nursing clarified physicians' incomplete medication orders for patient #'s 27, 29, and 35.

The managers of Clinical Pharmacy and Quality/Risk, confirmed that there was no documentation to conclude the nursing staff clarified incomplete physicians' orders, during interviews conducted on 05/25/11.

Cross reference A353, Item # 1.

2. The hospital policy titled Medication Administration #8721.710 (last revised 03/08) requires: "...Guidelines For The Use of the Medication Administration Record...To discontinue a medication, write the letters 'DC'd' and the date and time, yellow (highlighter) out medication...."

Medication documentation was unclear, and contrary to policy, as follows:

Patient #27: Physician ordered: "...morphine 4 - 8 mg IV (intravenous) Q (every) 2 (hours) PRN pain..." 05/23/11 (0035), and "...morphine 2 - 8 mg Q 1 - 2 hours PRN pain..." 05/23/11 (1840).

The 05/24/11 MAR (Medication Administration Record) revealed: Pharmacy printed "morphine sulfate 10 mg/1 mg vial...4 - 8 mg...interv (intravenously) every 2 hours." Nursing scratched out "4 - 6 mg" and hand wrote "2 - 8 mg," and scratched out "every 2 hours" and hand wrote "1 - 2 hours."

Patient #35: The MAR revealed, 05/24/11 Pharmacy printed, "...Insulin regular human 100 units/ml...Dose: mod (moderate) sub-Q (subcutaneous) every 6 hours...." Nursing scratched out "mod" and hand wrote "mild," and scratched out "every 6 hours" and wrote "Q 1 (hour)."

05/24/11: Pharmacy printed, "...Keppra 500 mg/5 ml oral soln (solution)...feeding tube twice daily...." Nursing scratched out "oral soln" and hand wrote "IV" (intravenous), and scratched out "feeding tube twice daily" and hand wrote "IV BID" (twice daily). The medication was administered (1015) and (2100), however it was unclear if it was delivered oral or IV. It was also unclear when the MAR was amended.

05/24/11: Pharmacy printed, "...Zosyn 4.5 GM...Intraven (intravenously) Q 8 (hours)...." Nursing scratched out "4.5 GM" and hand wrote "2.25 gm." The medication was administered (0200), (1000), and (1800), however it was unclear what dose was administered, and when the MAR was amended.

05/24/11: Pharmacy printed, "Levaquin 750 mg...Intraven...daily...." Nursing scratched out "750 mg" and hand wrote "250 mg." The medication was administered (1400), however it was unclear what dose was administered, and when the MAR was amended.

Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined that the registered nurse (RN) failed to require a physician's order to administer calcium carbonate to Patient #46.

Findings include:

The hospital policy titled Medication Administration #8721.710 (last revised 03/08) requires: "...A complete order will include name of medication, strength, route and frequency...."

Patient #46: The Physician's Order sheet 12/18/10 (2205) revealed the following hand written order signed by the RN, "...Nursing Order: Calcium carbonate for heartburn...." The pharmacy dispensed the medication, and the nurse administered the medication, without a physician's order.

The manager of Clinical Pharmacy and Quality/Risk, confirmed during interviews conducted on 05/27/11, that the hospital does not not recognize/approve "nursing orders."

Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined that the pharmacist failed in the responsibility for reviewing physicians' orders for completeness, clarified orders for accuracy, and dispensed medication according to complete orders, as demonstrated by:

1. failure to clarify incomplete physicians' orders for 3 of 3 ICU patients (#27, 29, and 35);

2. failure to require a physician's order for calcium carbonate for 1 of 1 patient (#46).

Findings include:

1. The pharmacy dispensed medications according to incomplete physicians' orders for patient #'s 27, 29, and 35.

The managers of Clinical Pharmacy and Quality/Risk, confirmed that medications were dispensed without clarifying physicians' orders, during interviews conducted on 05/25/11.

Cross reference A 353, Item #1.

2. Patient #46: Physician's Order sheet on 12/18/10 (2205) revealed nursing wrote, "...Nursing Order: Calcium carbonate for heartburn...." The pharmacy dispensed the medication without a physician's order.

The managers of Clinical Pharmacy and Quality/Risk, confirmed during interviews conducted on 05/27/11, that the hospital does not not recognize/approve "nursing orders," that the order was not clarified, and the pharmacy dispensed the medication without a physician's order.