HospitalInspections.org

Based on review of hospital policies/procedures, medical records, interviews, review of documents provided by the hospital and personnel files, it was determined that the hospital failed to provide an organized nursing service 24-hours per day with an adequate number of registered nurses and competent nursing staff to assess patients' care needs and deliver, assign and supervise the care required by each patient as evidenced by:

(A395) failure to require that a registered nurse supervise and evaluate the nursing care of each patient;

(A398) failure to require that contracted/registry RN's be oriented to the hospital's policies and procedures and be supervised and evaluated ; and

(A405) failure to require that registered nurses administer medications according to physicians' complete orders

The cumulative effect of these systemic problems resulted in the hospital's failure to provide an adequate, organized nursing service.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to require that restraints be used in accordance with an order of a Licensed Independent Practitioner (LIP) for 3 of 4 patients (Pts # 5, 9 and 24).

Findings include:

Review of hospital policy titled Restraints-LTAC revealed: "...A restraint may only be used in accordance with the order of a physician or other licensed independent practitioner (LIP) authorized by the hospital to order the restraint...Medical Management: Ensure physical safety of nonviolent patient...Physician/LIP order is required prior to initiation, except in an emergent situation. Must be timed and dated...Renewal of the order...every calendar day...Patients (sic) immediate situation...Patients (sic) response to the interventions...Patients (sic) medical & behavioral condition...need to continue or terminate use...A new order is required in the event restraints are reapplied after discontinuation...."

Review of Patient # 5's medical record revealed:

The Daily Nursing Record dated 12/11/13, contained documentation that Pt # 5 was in soft wrist restraints with 3 or 4 side rails elevated from 0800 on 12/11/13, through 0600 on 12/12/13.

A form titled Restraint Order contained a mark in the box for "...RENEWAL of restraint clinically indicated per...." The line designated for a signature was blank and the date recorded next to the blank line was 12/11/13. MD # 3's signature was written on the line designated for "...PHYSICIAN Authentication of Telephone Order...." with the date recorded as 12/16/13. The order included "bilateral" "Soft wrist restraints" and "Side Rails up X 4".

The Daily Nursing Record dated 12/12/13, contained documentation that Pt # 5 was in soft wrist restraints from 0800 on 12/12/13, through 0600 on 12/13/13. Pt # 5's medical record did not contain an LIP's order for restraints written on 12/12/13.

The Daily Nursing Record dated 12/17/13, contained documentation that Pt # 5 was in soft wrist restraints from 0800 on 12/17/13, through 0600 on 12/18/13.

A Restraint Order form with the date 12/17/13 written along the bottom contained MD # 5's signature in the space designated for: "...PHYSICIAN Authentication of Telephone Order...." with no date or time. NP # 6's signature was written on the line designated for: "...RENEWAL of restraint clinically indicated....." with the date 12/25/13. Spaces for patient condition/behavior requiring restraint, restraint placement, and criteria for release were all blank.

The Daily Nursing Record dated 12/21/13, contained documentation that Pt # 5 was in soft wrist restraints with 3 or 4 Side Rails elevated, from 0800 on 12/21/13 through 0600, on 12/22/13.

A Restraint Order form with date 2/21/13 written along the bottom contained NP #6's signature on the line designated for "...RENEWAL of restraint clinically indicated....." The order was not dated or timed.

The Daily Nursing Record dated 12/23/13, contained documentation that Pt # 5 was in soft wrist restraints from 0800 on 12/23/13, through 0600 on 12/24/13. Pt # 5's medical record did not contain an LIP's order for restraints written on 12/23/13.

The Daily Nursing Record dated 12/24/13, contained documentation that Pt # 5 was in soft wrist restraints from 0800 on 12/24/13, through 0600 on 12/25/13.

A Restraint Order form contained NP #6's signature on the line designated for "...RENEWAL of restraint clinically indicated....." The signature was dated. 12/24/13. Spaces for patient condition/behavior requiring restraint, restraint placement, and criteria for release were all blank.

The Daily Nursing Record dated 12/25/13, contained documentation that Pt # 5 was in soft wrist restraints with 3 or 4 siderails elevated from 0800 on 12/25/13, through 1800 on 12/25/13.

A Restraint Order form with date 12/25/13 written along the bottom contained NP #6's signature on the line designated for "...RENEWAL of restraint clinically indicated....." The order was not dated or timed.

The Daily Nursing Record dated 12/26/13, contained documentation that Pt # 5 was in soft wrist restraints with 3 or 4 siderails elevated from 0800 on 12/26/13, through 0600 on 12/27/13.

A Restraint Order form with date 2/26/13 written along the bottom contained NP #6's signature on the line designated for "...RENEWAL of restraint clinically indicated....." The order was not dated or timed. MD #5 also signed the order form on the line designated for "...PHYSICIAN Authentication of Telephone Order...." This signature was not dated or timed.

Review of Pt # 9's medical record revealed:

The Daily Nursing Record dated 12/7/13, contained documentation that Pt # 9 was in soft wrist restraints on 12/7/13, from 0800 through 1600 and from 2000 through 2200. He was also in soft wrist restraints on 12/8/13 from 2400 through 0600.

A Restraint Order Form contained an X next to the line designated for: "...RENEWAL of restraint clinically indicated per...." dated 12/7/13. Marks were placed in boxes for soft wrist restraints; right and left. The form did not contain a practitioner's signature.

A Restraint Order Form with marks placed in boxes for soft wrist restraints; right and left, dated 12/8/13 next to the line designated: "...RENEWAL of restraint clinically indicated per...." The form did not contain a practitioner's signature.

Review of Pt # 24's medical record revealed:

On 6/1/13, at 1900, an RN documented: "...side rails up X4, no soft wrist restraints...." At 0000, an RN documented: "...Soft wrist restraints were initiated...."

The Daily Nursing Record dated 6/1/13 contained documentation that Pt # 24 was in soft restraints from 0800 through 1800. Nursing documented that Pt # 24 had 3 or 4 side rails up without soft restraints from 2000 through 2200. Nursing documented soft restraints with 3 or 4 side rails from 2400 (0000) through 0200.

Pt # 24's medical record contained a physician's renewal order for bilateral soft wrist restraints and 3 siderails dated 5/31/13 and timed 11:00 PM. Nursing did not obtain a new order for soft restraints after discontinuing them at 1900 and re-initiating them at 2400 (0000). Pt # 24's medical record did not contain an order for restraints dated 6/1/13.

The Director of Quality Management confirmed during interviews conducted on 1/7/14, 1/8/14 and 1/9/14 that the records did not contain restraint orders as required by hospital policy/procedure.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital did not require the removal of restraints at the earliest possible time for 1 of 4 patients (Pt # 5).

Findings include:

Review of hospital policy titled Restraints-LTAC revealed: "...Restraint may not be used unless the use of restraint is necessary to ensure the immediate physical safety of the patient, a staff member, or others...Any use of restraint must be ended at the earliest possible time, regardless of the length of time stated in the order...Restraint may only be used while the unsafe situation continues...."

Review of Pt # 5's medical record revealed:

On 12/11/13 at 0400, an RN documented "...Patient asleep easily rousable but falls back to sleep...." The Daily Nursing Record flow sheet contained documentation that the patient was restrained at 0400 with soft wrist restraint and 3 or 4 elevated side rails. The flow sheet also contained documentation that the patient was pulling at invasive tubes/lines and remained in restraint due to risk of injury at 0400.

On 12/15/13, at 0800, an RN documented: "...Sleeping. Resisted having eyelids opened for pupil inspection. Does not open eyes during eval. Does not follow commands. Assisting on vent...." The Daily Nursing Record flow sheet contained documentation that the patient was restrained at 0800 with soft wrist restraints and 4 elevated side rails.

On 12/16/13, at 1400, an RN documented: "...He gets agitated (with) repositioning & bath but settled down & slept again after 10-15 min...."
On 12/16/13, at 1825, an RN documented: "...Wakes up only briefly looks around, squirms for maybe 10-15 min...then is asleep again. Klonopin @ 1700 held R/T (Related to) to sedation...."

The Daily Nursing Record flow sheet contained documentation that Pt # 5 was restrained at 1400 through 1800 with soft wrist restraints and 3 or 4 elevated side rails due to pulling at invasive tube/lines and attempting to crawl out of bed.

On 12/18/13 at 0800, an RN documented: "...Pt difficult to wake resting in bed on vent...."
On 12/19/13, at 0600, an RN documented; "...patient remains restrained. Restless at times. Sleeping at present...."

The Daily Nursing Record flow sheet contained documentation that Pt # 5 was restrained on 12/18/13 from 0800 through 0600 on 12/19/13 with soft wrist restraints and 3 or 4 elevated side rails due to pulling at invasive tube/lines.

On 12/20/13 at 0000 (12/21/13), an RN documented: " Pt resting in bed. No S/S (Signs/Symptoms) of distress...."
On 12/20/13 at 0330, an RN documented: "...pt resting in bed (with) eyes closed. No S/S of distress...."

The Daily Nursing Record flow sheet contained documentation that Pt # 5 was restrained on 12/19/13 from 0800 through 0600 on 12/20/13, with soft wrist restraints and 3 or 4 elevated side rails due to pulling at invasive tube/lines and risk of imminent injury.

On 12/22/23 at 2340, an RN documented: "...Pt appears to be resting (with) eyes closed...."
On 12/23/13 at 0200, an RN documented: "...Pt appears to be resting (with) eyes closed...."

The Daily Nursing Record flow sheet contained documentation that Pt # 5 was restrained on 12/22/13 from 2300 through 0200 on 12/23/13, with soft wrist restraints and 3 or 4 elevated side rails due to pulling at invasive tube/lines and risk of imminent injury.

The Director of Quality Management confirmed during interview conducted on 1/8/14, that the nursing narrative notes did not provide justification for the patient to remain in restraints and that there were discrepancies between the Daily Nursing Record flow sheets and the nursing the narrative notes.

Based on review of the hospital's Medical Staff Bylaws, hospital policy/procedure, medical record, credential file and interview, it was determined that the hospital failed to require that a Nurse Practitioner (NP) authorized to order restraints have documentation of a working knowledge of hospital policy regarding the use of restraint for 1 of 1 NP who signed restraint orders for Pt # 5.

Findings include:

Review of hospital Medical Staff Bylaws revealed: "...As a condition of appointment with Clinical privileges...each Practitioner who exercises Clinical Privileges...must continuously fulfill all of the following responsibilities and obligations to:...Abide by the Bylaws and Rules...and policies of the Medical Staff and the Hospital...."

Review of hospital policy/procedure titled Restraints-LTAC revealed: "...Physicians and other LIPs authorized to order restraints must have a working knowledge of hospital policy regarding the use of restraint...."

Review of Pt # 5's medical record revealed Restraint Order Forms signed by NP # 6 on 12/17/13, 12/21/13, 12/24/13, 12/26/13.

Cross Reference Tag A0168 for further information regarding restraint orders for Pt # 5.
Order was not always dated and timed and /or spaces for patient condition/behavior requiring restraint placement, and criteria for release were all blank.

Review of NP # 6's credential file revealed that it did not contain documentation that NP #6 completed
orientation or training regarding the hospital's restraint policy.

The Director of Medical Records and Medical Staff Credentialing confirmed, during interview conducted
on 1/8/14, that the hospital was unable to provide documentation of NP # 6's orientation and/or training regarding the hospital's restraint policy.

Based on review of the Medical Staff Bylaws and Rules and Regulations, hospital policy/procedure, hospital document, medical records and interviews, it was determined that the medical staff failed to enforce the bylaws to carry out its responsibilities as evidenced by:

1. failing to require that physicians write and/or verbally give complete orders for 2 of 2 patients who received titrated vasoactive medication Pts # 2 and 9);

2. failing to require that physicians authenticate verbal orders as required by Medical Staff Rules and Regulations for 2 of 2 patients who received titrated vasoactive medications;

3. failing to require that the Mortality Review of a deceased patient be complete and contain documentation of the patient's death following unexpected medical complications for 1 of 1 patient (Pt # 10);

4. failing to require compliance with Code Blue Emergency Management policy/procedure and required documentation of pronouncement of death by practitioner for 1 of 1 patient who received resuscitation intervention from an outside agency (Pt # 10); and

5. failing to require the preparation and timely completion of an accurate medical record by practitioners providing services to 1 of 1 patient who died following medical complications (Pt # 10).

Findings include:

Review of the hospital's Medical Staff Bylaws revealed: "...Responsibilities of the Medical Staff...As a condition of appointment...reappointment...and continued Medical Staff membership, each Medical Staff member and each Practitioner who exercises Clinical Privileges...must continuously fulfill all of the following responsibilities and obligations to:...Abide by the Bylaws and Rules, and all other lawful standards and policies of the Medical Staff and the Hospital, including without limitation the governing documents for the Hospital that may be amended from time to time...."

1. Review of the hospital's Medical Staff Rules and Regulations revealed: "...All orders for treatment shall be in writing, written clearly, legible and completely...."

Review of the hospital policy/procedure titled Medication Administration- ACU revealed: "...All Orders will be reviewed for completeness of the following elements:...a. Date and Time of the order...b. Drug Name...c. Exact Strength or concentration (when applicable)...d. Dose...e. Frequency...f. Route...g. Quantity and/or duration ( when applicable)...h. Specific instructions for use (when applicable)...i. Physician/LIP signature...."

Review of Pt # 2's medical record revealed physician orders: "...1-2-14 at 1645, Levophed gtt (drip) to keep SBP (systolic blood pressure) > 90...TORB Dr. #8/employee #3...."
The order did not contain initial dosage, drip rate or titration instructions.

Review of the physician orders for patient #9 revealed on 12/1/13 the Levophed Infusion Physician Order with boxes checked for initial rate of 5 mcg/min and titration rate 2 mcg/min. The orders did not contain the required concentration of Levophed.

Interview with the Director of Quality Management on 1-3-14, confirmed that there was no Vasoactive Medication Order protocol in pt # 2's medical record and the order written on 1-2-14 for Levophed was incomplete. She confirmed that the Levophed Infusion Physician Order in Pt # 9's medical record was incomplete, since it did not contain the concentration of Levophed

2. Review of the hospital's Medical Staff Rules and Regulations revealed: "...All orders for treatment shall be in writing, written clearly, legible and completely and shall be dated, timed and signed by a practitioner....A verbal order shall be considered to be in writing if dictated to a duly authorized person (including ...registered nurse...)...verbal orders must be authenticated within forty-eight (48) hours...All standing orders and/or protocols must be signed, dated and timed by the responsible practitioner when utilized...."

Review of hospital policy titled Physician Orders revealed: "...Medications, treatments and diagnostic testing shall not be be given without a written order signed by a physician...All orders, including telephone orders must be dated, timed and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and authorized to write orders...order sets/physician protocols may be used...these order sets will be signed, dated and timed...order authentication: the following expectation is utilized to define "promptly", verbal/telephone orders: within 48 hours...."

Review of the medical record for patient # 2 revealed between the dates 11-8-13 through 1-2-14, there were 13 verbal orders not signed as authenticated by a physician as of 1-10-14.

Review of the medical record for patient # 9 revealed on 12/13/13 there was one verbal order not signed as authenticated by a physician.

Interview with The Director of Quality Management on 1-10-14 confirmed the above orders were not signed as authenticated by a physician.

3. Review of the hospital's Medical Staff Rules and Regulations revealed: "...Mortality review will be conducted as part of the Clinical Risk Management Program. Cases failing approved criteria will be subject to peer review for all aspects of care...."

Review of the form titled Mortality Review for Pt # 10 revealed: "...Was poor prognosis documented on admission or as conditioned (sic) worsened/during hospital stay? (blank)...Was medical record documentation reflective of events leading to death? (blank)...Was this an unexpected/unanticipated death? If 'yes,' referral must be made to Peer Review Committee-Initial that referral made...No...."

Review of Pt # 10's medical record revealed:

Pt # 10 had "T4" paraplegia secondary to a motor vehicle accident, with chronic pain syndrome, traumatic brain injury, a colostomy, anxiety, depression and multiple decubitus ulcers on his buttocks and bilateral heel and foot. He was transferred to the hospital from a "nursing home" due to fevers on 11/20/13. He had previously undergone surgical debridement with a flap. Prior to admission, his right leg wound was worsening and his decubitus ulcers were deep and he had eschar. He was transferred to the hospital for further care and evaluation. He was started on intravenous antibiotics. He had a Peripherally Inserted Central Catheter (PICC). The attending physician was making arrangements to transfer the patient to a medical center for joint incision and drainage and "probably cleaning with debridement." On 11/28/13, a physician noted that the patient was afebrile, with right hip, pelvic, and right ankle/heel myositis and osteomyelitis, requiring surgical intervention for wound care.

On 11/29/13, at 0430, nursing documented: "... received report of H/H (Hemoglobin/Hematocrit) @ 4.7/15.5...." The patient was to be transported to a medical center for a transfusion. At 0600, nursing noted: "...shallow breathing/pale looking...0645...code blue called...."

On 11/29/13, at 1130, MD # 1 documented: "...His Hgb (Hemoglobin) 4.7 which is drop from 10 on 11/22/13. (no) visible source of bleeding...Pt is pronounced 816...."

MD # 1 confirmed, during interview conducted on 1/8/14 that the patient was very ill, however; he was surprised at his drop in H & H and surprised that he died as he did. He confirmed that Pt # 10's death followed unexpected medical complications.

MD # 7 confirmed, during interview conducted on 1/9/14, that the patient's death followed unexpected medical complications.

The Director of Quality Management confirmed during interview conducted on 1/8/14, that she had documented the Mortality Review in early December for deaths occurring in November. She reviewed Pt # 10's medical record and received verbal information that the patient was very ill. She confirmed that she was not aware that the patient's H&H had dropped. She confirmed that she would have done more research had she known.

4. Review of hospital policy/procedure titled Code Blue: Emergency Management revealed: "...Code Blue Record...CPR times stated (sic) and stopped. Results of compressions...."

Review of hospital's Medical Staff Bylaws revealed: "...Responsibilities of the Medical Staff...Prepare and complete timely, legible, and accurate medical and other required records for all patients for whom the Practitioner in any way provides services in the Hospital...."

Review of the hospital's Medical Staff Rules and Regulations revealed: "...In the event of a Hospital patient death, the deceased shall be pronounced dead by a practitioner or his/her lawful designee within a reasonable time...The body shall not be released until an entry has been made in the medical record by the Medical Staff member/designee pronouncing the patient dead...."

Review of Pt # 10's medical record revealed a Cardiopulmonary Resuscitation and Rapid Response Documentation form dated 11/29/13 with Code Blue: time 0745. The last time recorded on the form was 0804. The patient's breathing and pulse were marked as "assisted" and rhythm was recorded as "PEA" (Pulseless Electrical Activity). The comments section contained documentation: "...(name of ambulance company) arrived took over care...." "...Reason Resuscitation Ended: Expired...Efforts Terminated...." The space designated for "Time Resuscitation Event Ended" was blank.

The Death Summary completed by MD # 1 contained documentation that "...the patient has been pronounced dead by (MD # 7)...the patient's body had been transferred to mortuary as per (MD #7) who was the physician present at the time that occurred...."

MD # 7 confirmed during interview conducted on 1/9/14, that he arrived to the Code Blue after the "fire dept and police" were present. The ambulance crew was in charge of running the "Code" and deferred to his direction when he arrived. MD # 7 confirmed that he "called the code" meaning that he determined when to discontinue attempts to resuscitate the patient.

The medical record did not contain documentation of the time that resuscitation efforts stopped. MD # 7 did not document pronouncement of the patient's death as required by Medical Staff Bylaws.

MD # 7 confirmed during interview conducted on 1/9/14 that the documentation in the medical record was incomplete.

5. Review of the hospital's Medical Staff Bylaws revealed: "...Responsibilities of the Medical Staff...As a condition of appointment...reappointment...and continued Medical Staff membership, each Medical Staff member and each Practitioner who exercises Clinical Privileges...must continuously fulfill all of the following responsibilities and obligations to:...Prepare and complete timely, legible, and accurate medical and other required records for all patients for whom the Practitioner in any way provides services in the Hospital...."

Review of the hospital's Medical Staff Rules and Regulations revealed: "...The medical record is deemed delinquent if it is not completed by day thirty (30)...complete his/her medical records...attending privileges will be suspended...Delinquent records shall include the following deficiencies:...Discharge summary not dictated or written, except in the event where it is not possible to complete the record because the final laboratory or other essential reports are not yet available...."

Review of Pt # 10's medical record on 1/8/14 revealed that the patient expired on 11/29/13 at 0816. The medical record did not contain documentation of MD #7's pronouncement of death. It did not contain a Death Summary. The Death Summary was dictated by MD # 1 on 1/9/14. There were no outstanding reports which accompanied the dictation. The Death Summary contained documentation by MD # 1 that MD # 7 pronounced the patient dead.

The Director of Quality Management placed the Death Summary in the medical record on 1/9/14, more than 30 days after the patient's death and confirmed the date of death and the date of completion of the Death Summary. The dates were more than 30 days apart.

Based on review of hospital policy/procedure, nursing assignment sheets, medical records and interviews, it was determined that the hospital failed to require that a registered nurse supervise and evaluate the care of each patient as evidenced by:

1. failing to assign an RN to supervise, monitor and evaluate the patient care for 7 of 7 shifts when LPN's were assigned to provide patient care (Day Shift and Night Shift on 12/25/13, Day Shift and Night Shift on 12/26/13, Night Shift on 12/27/13, Night Shift on 12/31/13 and Night Shift on 1/2/14;

2. failing to require that an RN document, in the patient's medical record, supervision, monitoring and evaluation of the care of patients assigned to LPN's for 8 of 8 patients (Pts # 12, 8, 13, 15, 16, 19, 17 and 6).

3. failing to clarify physicians' orders for pain medication appropriate to 2 of 2 patient's level of pain (Patients #11 and 26) and;

4. failing to document pain assessments, including post intervention for 8 of 14 patients(Patients # 8, 11, 13, 15, 19, 20, 21 and 26).

5. failing to ensure that a verbal order for a "stat" x-ray which was required for confirmation of placement of an artificial airway be timed when written for 1 of 1 patient ( # 1).



Findings include:

Review of hospital policy titled Scope of Practice revealed: "...The Registered Nurse assesses plans, directs and evaluates nursing services provided to the patient...Delegation...A RN assigns and delegates nursing activities. The RN shall:...Supervise, monitor, and evaluate the care assigned to a LPN...."

Review of hospital policy titled Documentation-Nursing revealed: "...A standardized assessment for each system will be performed and documented on the 24 hour Nursing Assessment Flow Sheet. Each system is assessed individually and any exception to the standards identified is so noted by either a selection of exceptions provided, or a brief, concise narrative note in the nursing notes...All patient assessments are to be signed or co-signed by and (sic) RN at least once per shift and with significant change in condition...."

1. Review of the nursing assignment sheet for Day Shift on 12/25/13 revealed that an RN was not assigned to provide care or supervise the care of Pts assigned to LPN # 30 (Pts # 33, 6, 12 and 34).

Review of the nursing assignment sheet for Night Shift on 12/25/13 revealed that an RN was not assigned to provide care or supervise the care of Pts assigned to LPN #31 (Pts # 16, 35, 19, 37 and 38).

Review of the nursing assignment sheet for Day Shift on 12/26/13 revealed that an RN was not assigned to provide care or supervise the care of Pts assigned to LPN # 30 (Pts 33, 6, 12 and 34).

Review of the nursing assignment sheet for Night Shift on 12/26/13 revealed that an RN was not assigned to provide care or supervise the care of Pts assigned to LPN # 32 (Pts # 32, 6, 12, 14 and 17).

Review of nursing assignment sheet for Night Shift on 12/27/13 revealed that an RN was not assigned to provide care or supervise the care of Pts assigned to LPN # 15 (Pts # 13, 14, 17, 32, 6 and 12).

Review of nursing assignment sheet for Night Shift on 12/31/13 revealed that an RN was not assigned to provide care or supervise the care of Pts assigned to LPN # 28 (Pts # 16, 13, 15, 14, 8 and 19).

The Director of Quality Management confirmed during interview conducted on 1/9/14, that an RN was not assigned to the patients listed above. RN's were assigned to other patients on the same unit as the LPN's.

2. Review of the nursing assignment sheet for 12/27/13 revealed that LPN # 15 was assigned to Pt #12 during the night shift.

Review of Pt # 12's medical record revealed an 8 page Daily Nursing Record dated 12/27/13. The documentation of nursing assessments and the flow sheets were completed and signed by LPN # 15. An RN initialed the assessments and co-signed the flowsheets. On 12/28/13 at 0430, LPN # 15 documented: "...K+ (Potassium) 3.0 protocol started, faxed to (MD #1)...." The entry was signed by LPN # 15 with no RN co-signature or note. Pt # 15's medical record did not contain documentation that an RN was supervising, monitoring and directing the LPN's care of the patient when the LPN reviewed the patient's lab results which indicated a change in patient condition and the LPN implemented the protocol.

Review of the nursing assignment sheet for 12/31/13 revealed that LPN # 28 was assigned to Pts # 8, 13, 15, 16 and 19 on 12/31/13 during the night shift.

Review of Pt # 8's medical record revealed an 8 page Daily Nursing Record dated 12/31/13. The documentation of nursing assessments and all other documentation of care provided to Pt # 8 during the night shift on 12/31/13 was signed by LPN #28. An RN did not initial the assessments. An RN did not make an entry in the medical record during the shift

Review of Pt # 8's Daily Nursing Record dated 1/1/14 day shift revealed that the documentation of nursing assessments and all other documentation of care provided to Pt # 8 during the day shift on 1/1/14, was signed by LPN # 29. An RN did not initial the assessments. An RN did not make an entry in the medical record during the shift.

An RN did not document an assessment of Pt # 8 or document supervision and direction of Pt # 8's care from 1900 on 12/31/13 until 2000 on 1/1/14.

Review of Pt # 13's medical record revealed the 8 page Daily Nursing Record dated 12/31/13. The documentation of nursing assessments and all other documentation of care provided to Pt # 13 during the night shift on 12/31/13 was signed by LPN #28. An RN did not initial the assessments. An RN did not make an entry in the medical record during the shift.

Review of Pt # 15's medical record revealed the 8 page Daily Nursing Record dated 12/31/13. The documentation of nursing assessments and all other documentation of care provided to Pt # 15 during the night shift on 12/31/13 was signed by LPN #28. An RN did not initial the assessments.

Pt # 15's medical record contained a physician's order, dated 12/17/13, for Vital Signs to be recorded every 4 hours. The order was not discontinued. The LPN recorded Pt # 15's vital signs once during the night shift on 12/31/13. An RN did not make an entry in the medical record during the shift.

Review of Pt # 16's medical record revealed the 8 page Daily Nursing Record dated 12/31/13. The documentation of nursing assessments and all other documentation of care provided to Pt # 16 during the night shift on 12/31/13 was signed by LPN #28. An RN did not initial the assessments. An RN did not make an entry in the medical record during the shift.

Review of Pt # 19's medical record revealed the 8 page Daily Nursing Record dated 12/31/13. The documentation of nursing assessments and all other documentation of care provided to Pt # 19 during the night shift on 12/31/13 was signed by LPN #28. An RN did not initial the assessments. An RN did not make an entry in the medical record during the shift.

Review of the nursing assignment sheet for 1/2/14 revealed that LPN # 15 was assigned to Pts # 17 and 6 on 1/2/14 during the night shift.

Review of Pt # 17's medical record revealed the 8 page Daily Nursing Record dated 1/2/14.
The documentation of nursing assessments and all other documentation of patient care provided during the night shift on 1/2/14, was signed by LPN #15. An RN co-signed the assessments and flowsheet. The LPN documented additional observations and patient care on 1/2/14 in narrative notes. An RN did not co-sign or record an entry in the narrative notes to indicate supervision and direction of the LPN's care of the patient or concurrence with the LPN's observations.

Review of Pt # 6's medical record revealed the 8 page Daily Nursing Record dated 1/2/14. The flow sheet containing documentation related to turning the patient, patient activity, hygiene and safety was signed by the LPN and co-signed by an RN. At 2000, LPN # 15 documented: "...BP (Blood Pressure) meds held R/T (Related to) HR (Heart Rate) (reduced) 46, BP parameters, pt asymptomatic...Dr...aware of meds held...." The entry was signed by LPN # 15 with no RN co-signature. Pt # 6's medical record did not contain documentation of an RN's assessment of Pt #6 at the time of his drop in pulse and did not contain documentation that an RN supervised and directed the care of the patient when his heart rate dropped and his medications were held.

On 1/8/14, the Chief Clinical Officer confirmed that the RNs employed by the hospital had not worked with LPN's for approximately 18 months and probably would not know how to provide documentation that they were supervising, monitoring and evaluating the care assigned to an LPN as required by hospital policy.

On 1/9/14, the Chief Clinical Officer, Director of Quality and Director of Health Information Services confirmed that the patients' medical records listed above did not contain entries completed by an RN which served to document that an RN supervised, directed and evaluated the care of each of the patients.

3. The hospital policy titled Pain Management Policy #CSM 102 (last revised 08/12), requires: "...The patient will undergo reassessment of pain at least per shift, following treatments/therapies, and after control intervention...hospital uses the Wong-Baker Pain Rating...with corresponding number 0 to 10...0 Pain free...no medication needed...10 Unable to speak. Crying out or moaning...."

Patient #11 was admitted on 11/16/13 for shortness of breath (SOB) pneumonia, plural effusion and esophageal perforation, according to the medical record. The physician ordered: "Percocet 1 tablet PO (oral) every 4 hr PRN (as needed) for pain scale of 3-5."

12/04/13: Pain 9/10; 6/10 and 7/10. The nurse administered Percocet 1 tablet PO according to the physician's order for pain 3-5. There was no documentation that the nurse contacted the physician to clarify/confirm orders to address a higher level of pain.

Patient #26 was admitted on 12/27/13 for abdominal wound S/P (status post) exploration ileostomy take down, infection and anastomosis leak, according to the medical record. The physician ordered: "Percocet 1 tablet PO (oral) every 4 hr PRN (as needed) for pain scale of 3-5."

Patient #26's Daily Nursing Record, dated 01/09/14 revealed the following:
at 0915 hours the patient's pain was rated 6 of 10 on the pain scale; at 1850 hours the patient's pain was rated 6 of 10 on the pain scale; at 0320 hours the patient's pain was rated 6 of 10 on the pain scale pain.

The Chief Clinical Officer confirmed during an interview conducted on 01/09/14, there was no documentation that the nurses' notified the physicians of the patient's reported pain level of 6/10 and clarified medication orders for such.

4. The hospital policy titled Pain Management Policy #CSM 102 (last revised 08/12), requires: "...Periodically reassess the patient for pain and relief from pain, including the intensity and quality (i.e. character, frequency, location, and duration) of pain, and responses to treatment...The patient will undergo reassessment of pain at least per shift, following treatments/therapies, and after control intervention...caregiver will assess the effectiveness of the medication (Within 30 minutes for IV (intravenous) medications, 60 minutes for...PO...medications...."

Patient # 8's medical record revealed the following:

On 1/1/14, a pain assessment was not documented on the day shift. On 1/1/14 at 2000, an RN documented Pain Location as "General" with a pain rating of 5/10 and administration of "Percocet 2 tabs". The location of pain was not documented.

Patient #11's medical record revealed the following:

12/04/13: pain 9/10 and 6/10. No interventions documented; the patient was not reassessed for pain.

Patient # 13's medical record revealed the following:

On 12/31/13 at 2100, an LPN documented: "...Requested pain med...pt given scheduled pain med as ordered...." The medical record did not contain documentation of a pain assessment prior to or after administration of medication.

Patient # 15's medical record revealed the following:

A pain assessment was not recorded during the day shift on 12/31/13.

Patient # 19's medical record revealed the following:

A pain assessment was not recorded on 12/31/13.

Patient # 20's medical record revealed the following:

A pain assessment was not recorded during the night shift 1/17/14

Patient # 21's medical record revealed the following:

An RN documented on 1/8/14 at 0425, that the patient had abdominal pain with a rating of 7/10 and was given Dilaudid .5 mg IVP (Intravenous Push). The RN did not record Pt # 21's response to the intervention.

An RN documented on 1/8/14 at 1200 that Pt # 21 had abdominal pain with a rating of 7/10 and was given Morphine. The RN did not record Pt # 21's response to the intervention.

Patient #26's Daily Nursing Record, dated 01/09/14 revealed the following:
at 0915 hours the patient's pain was rated 6 of 10 on the pain scale. The nurse administered medication. At 1850 hours, the patient's pain was rated 6 of 10 on the pain scale. The nurse administered medication. At 0320 hours, the patient's pain was rated 6 of 10 on the pain scale. The nurse repositioned the patient and administered medication.There was no documentation of reassessment of pain post interventions.

The Chief Clinical Officer confirmed during an interview conducted on 01/09/14, that pain assessments were incomplete and there was no documentation that the nurses' returned to reassess the patients' level of pain after receiving pain medication per facility policy.

5. Review of the hospital policy titled Physician Orders revealed: "...All orders, including telephone orders must be dated, timed...."

Review of the medical record for Pt # 1, revealed hospital admission on 12-11-13 with the diagnosis of acute respiratory failure requiring a tracheostomy and oxygen. On 12-11-13 at approximately 1600, the patient pulled out the trach tube and required emergent replacement of the trach tube. At 2330, the nurse documented: "...crepitus in neck has been present since the start of night (NOC) shift and remains unchanged...." On 12-11-13, RN # 27 recorded a physician's verbal order for Morphine 2 mg intravenous push (IVP) every (Q) 4 hours for pain and a stat (immediate) x-ray of the neck to determine trach placement. RN # 27 did not record the time for either of these orders.

The Director of Quality Management confirmed in an interview on 1-7-13 that the stat order for neck x-ray was not timed, and the order for Morphine 2mg was not timed.

Based on review of nursing assignment sheets, personnel files and interview, it was determined that the hospital failed to require that contracted/registry RN's be oriented to the hospital's policies and procedures and be supervised and evaluated, for 5 of 5 contracted registry RNs providing patient care on 1/2/14 (registry RNs # 33, 34, 35, 36 and 37).

Findings include:

Review of nursing assignment sheets for Night Shift on 1/2/14 revealed that registry RN # 33 was assigned to provide care for 4 patients. Registry RN # 34 was assigned to provide care for 3 patients. Registry RN # 35 was assigned to provide care for 4 patients. Registry RN # 36 was assigned to provide care for 5 patients. Registry RN # 37 was assigned to provide care for 4 patients.

The Staffing and Human Resources Coordinator confirmed, during interview conducted on 1/7/14, that all of the registry RNs listed above provided care for patients on 1/2/14.

Review of registry RN #33's personnel file revealed an unsigned Agency Orientation Acknowledgement form dated 1/2/14 and a self-assessment completed 12/9/13.

Review of the personnel files for registry RNs # 34, 35, 36 and 37 revealed that they contained self- assessments. They did not contain documentation of orientation to the policies/procedures of the hospital or documentation of supervision or evaluation of the registry RNs.

The Staffing and Human Resources Coordinator confirmed, during interview conducted on 1/7/14, that the hospital did not have documentation of the orientation, supervision or evaluation of the registry RNs.

Based on review of hospital policies and procedures, hospital documents, Medical Executive Committee Meeting minutes, medical records, and staff interviews, it was determined that nursing leadership failed to require registered nurses administer medications according to physicians complete orders, as evidenced by:

1. failing to utilize the approved hospital High Observation Drip Physician Order protocol for vasoactive medication orders for 2 of 2 patients (Pt's # 2 and 9);

2. failing to follow physician's orders for initial dose and titration of Levophed for 2 of 2 patients (Pt's # 2 and 9);

3. failing to clarify incomplete physician orders for 2 of 2 patients (Pt's # 2 and 9) to who received tritrated Levophed;

4. failing to document administration of Levophed on the Medication Administration Record (MAR) for one of one patient (Pt # 9);

5. failing to note incorrect entry of Levophed on the MAR by pharmacy for one of one patient (Pt # 9);

6. failing to administer Propofol in accordance with the desired sedation score specified in physician orders for one of one patient who received Propofol (Pt # 9);

7. failing to document Levophed dosages on the frequent vital sign sheet for one of one patient (Pt # 2); and

8. failing to administer medication for the medical condition specified in the order by the physician for one of one patient (Pt # 20).

Findings include:

1. The hospital policy titled IV - High Observation Drips, required: "...RN will initiate a High Observation Drip once a Physician order has been obtained...The High Observation Drip Physician Order Protocol should be placed in the order section of the patient's medical record...RN will verify dosing and mixing with Pharmacy and a second RN...."

Review of Medical Executive Committee Meeting minutes dated August 28, 2013 revealed: "...Vasoactive Orders revised 8/13, this is Mesa only

Medical record review identified patient # 2 was admitted 11/6/13 for tracheal bleeding with a past medical history of atrial fibrillation, coronary artery disease, heart failure, diabetes, chronic hypotension, and renal failure requiring hemodialysis. On 11/14/13, the patient was moved to the High Observation Unit. An RN recorded a verbal order from Physician # 1: "...Levophed, to follow protocol...." The Critical Medication Frequent Monitoring Flowsheet revealed at 2200 the patient's blood pressure was 88/35, MAP 50, and Levophed was initiated. The Levophed was turned off at 0500. Levophed was used intermittently, from 11-15-13 to 1-2-14, without a new physician order. There was no High Observation Drip Physician Order protocol for Vasoactive Medication Order in the medical record.

The Chief Clinical Officer and Director of Quality Management confirmed during an interview conducted on 1-7-14, there was no new physician order for vasoactive medication administration from 11-15-13 to 1-2-14, for patient # 2.

Medical record review identified patient # 9 was admitted 10-17-13 with aspiration pneumonia, past medical history of COPD (chronic obstructive pulmonary disease), stage III B lung nonsmall cell carcinoma with chemotherapy and radiation, diabetes, cardiomyopathy, hypertension and peripheral neuropathy. On 12-1-13 at 2200, the blood pressure is recorded as 72/40, the physician was notified and orders were received to start Levophed. The RN used a form titled, " Levophed Infusion Physician Orders" to initiate the Levophed order. This order form was not approved for this hospital, had a different hospital logo and was dated rev. 5/11. There was no High Observation Drip Physician Order protocol for Vasoactive Medication Order approved for use at this hospital in Pt # 9's medical record.

Employees # 4 and 7, the House Supervisor and the Director of Quality Management confirmed during interviews conducted on 1-7-14, that there were no approved protocols for Vasoactive Medication Orders in the medical records of Pts # 2 and 9 as required. They also confirmed that nursing administered the Levophed to both patients.

The Director of Quality Management and employee # 19 confirmed during interviews conducted on 1/8/14, that the "Levophed Infusion Physician Order" form in Pt # 9's medical record should not have been used at this hospital; and should not have been processed as an order by pharmacy.

2. Review of the hospital form titled, Vasoactive Medication Orders revealed: "...Norepinephrine 8 mg Dextrose 5% water sol 250 IV final concentration = 32mcg/ml....initiate infusion at 10 micrograms per min (mcg/min) and titrate every 15 min by increments of 5 mcg/min...maintain mean arterial pressure (MAP) greater than 65 millimeters of mercury (mmHg)...once blood pressure is stable, decrease drip by 5 mcg/min until titrated off...."

The medical record for patient # 2 revealed that on 11-14-13 at 2200, the MAP was 50 and the initial starting dose of Levophed was 2mcg/min. At 2315, the MAP was 72, and the Levophed was titrated up to 5mcg/min. At 0200, the MAP was 66, and the Levophed was titrated down to 2 mcg/min. At 0500, the MAP was 63 and the Levophed was turned off.

Review of the form titled, Levophed Physician Order revealed: "...norepinephrine injectable 4mg (milligrams)/250ml (milliliters) D5W(dextrose 5% and water) for a concentration of (16mcg/ml). The Levophed is to start at 5 mcg/min and titrate at 2 mcg/min every 5 minutes to achieve the desired SBP (systolic blood pressure) 90-100...." The form has a different hospital logo.

The medical record for patient # 9 revealed: "... on 12-1-13 at 2200, employee # 11 signed and dated the order form titled, Levophed Infusion Physician Order. The order had check marks in the boxes for initial rate 5 mcg/min and titration rate 2 mcg/min only. The order did not contain the required concentration of the Levophed.

On 12-1-13 at 2200, the Critical Medication Frequent Monitoring Flowsheet revealed that Pt # 9's blood pressure was 72/40 and nursing started the Levophed with an initial dose of 15 mcg/min. Nursing titrated the Levophed through the remainder of the shift with the following readings: "... blood pressure at 2230 is 124/56 and the Levophed is titrated down to 10 mcg/min; at 0030 the blood pressure is 149/59 and the Levophed is titrated down to 9mcg/min; and at 0500 the blood pressure is 126/59 and the Levophed is titrated down to 7 mcg/min...." The documentation did not include the concentration of Levophed administered to the patient.

The Director of Quality Management confirmed during an inteview conducted on 1-8-14, that the orders for initiating and titrating Levophed for patient #'s 2 and 9 were not followed; and there was no documented concentration of Levophed for patient # 9.

3. The hospital policy titled Medication Administration - ACU required: "...all Orders will be reviewed for completeness...exact strength or concentration, dose, frequency, specific instructions...."

Review of Pt # 2's medical record revealed physician orders: "...1-2-14 at 1645, Levophed gtt (drip) to keep SBP (systolic blood pressure) > 90...TORB Dr. # 8/employee # 3...."
The order did not contain initial dosage, drip rate or titration instructions.

Review of the physician orders for patient # 9 revealed on 12/1/13 the Levophed Infusion Physician Order with boxes checked for initial rate of 5 mcg/min and titration rate 2 mcg/min. The orders did not contain the required concentration of Levophed.

The Director of Quality Management confirmed during an interview conducted on 1-3-14, that there was no Vasoactive Medication Order protocol in pt # 2's medical record and the order written on 1-2-14 for Levophed was incomplete. She confirmed that the Levophed Infusion Physician Order in Pt # 9's medical record was incomplete, since it did not contain the concentration of Levophed. She also confirmed that nursing did not clarify the incomplete orders before administering the medication.

4. The hospital policy titled Medication Administration - ACU required:"...all medications administered will be recorded in the patient's medication administration record (MAR) along with the date given, time given, and the initials of the person administering the medication...."

Review of the hospital policy titled Medication Administration - ACU revealed: "...All written orders for medications will be reported to the pharmacy to be entered in to the MAR system and transcribed onto the current MAR by nursing...."

Review of the nursing narrative and documentation for patient # 9 indicated the patient received Levophed on 12-1-13. The order was faxed to the pharmacy. The Levophed was not transcribed on the MAR for 12-1-13. Documentation on the MAR from 12-1-13 to 12-4-13 for Levophed did not contain the date, time or initials of the person administering this medication.

5. The hospital policy titled Medication Administration - ACU required:"...MARs will be reviewed/reprinted every 24 hours and verified against the chart by nursing...."

Review of medical record for patient # 9 revealed the Levophed Infusion Physician Order form on 12-1-13 at 2200 was used to order Levophed, signed and dated by employee # 11 and authenticated by Physician # 7. The order set is written as: "... norepinephrine injectable 4mg(milligrams)/250ml (milliliters) D5W(dextrose 5% and water) for a concentration of (16mcg/ml). The Levophed is to start at 5 mcg/min and titrate at 2 mcg/min every 5 minutes to achieve the desired SBP (systolic blood pressure) 90-100...." Employee # 11 checked off the boxes designated for initial rate and titration rate only.

The Levophed dose entered on the MAR by pharmacy for dates 12-3-13 and 12-4-13 was: "... norepinephrine 8 mg Dextrose 5% water sol 250 IV final concentration = 32mcg/ml...initiate infusion @ 10 mcg/min...titrate every 15 minutes by increments of 5 mcg/min to maintain MAP>65 mmhg...." The Levophed entry on the MAR was discrepant from the order and was not reconciled. Nursing administered Levophed. The medical record did not contain documentation of the concentration of Levophed that was administered.

The Director of Quality Management and employee # 19 confirmed during interviews conducted on 1-8-14, that the written order for Levophed on 12-1-13, was not the same order entered on the MAR by pharmacy, and was not clarified by nursing or pharmacy.

Employee # 19 confirmed during an interview conducted on 1-8-14, the Levophed Infusion Physician Order form was not used at this hospital.

6. The Physician's Orders titled IV Pain/Sedation Medication Orders required: "...Propofol (Diprovan) start infusion at 5 mcg/kg/min, increase by 5mcg/kg/min until desired sedation indicated...maintain a RASS (Richmond Agitation Sedation Scale) between -2 & -3...."

Review of medical record for patient # 9 revealed on 12-1-13, the patient required intubation and was started on IV propofol at 1400. The initial dose of propofol is documented on the Critical Medication Frequent Monitoring Flowsheet as "5" without a corresponding unit of measurement (mcg/kg or ml/hr). The dose of propofol was increased in increments of "10" between 0230 to 0330 hours. At 0600, one reference to the RASS score of -2 was documented in the nurses narrative. The patient remained on propofol 12-2-13 and the RASS score was not documented in the nurses' narratives.

7. The hospital policy titled IV-High Observation Drips requires:"...patient will be monitored ...with frequent vital signs...RN will use a frequent vital signs flow sheet...."

Review of Daily Nursing Record for patient # 9, revealed on 1/6/14, the Levophed is documented as continuous from 0700 through 0600. The vital signs and MAP are not documented on the Critical Medication/Frequent Monitoring Flowsheet from 0730 to 2243. At 2243, the vital signs are documented every 30 minutes until 0612. No dosages of Levophed are documented coinciding with the frequent vital signs from 2243 to 0612.

The Chief Clinical Officer confirmed during an interview conducted on 1/10/14, the Daily Nursing Record documented the patient received Levophed continuously on 1-6-14, from 0700 through 0600, did not contain frequent vital signs until 2243, and Levophed doses were not documented with coinciding vital signs on the frequent vital sign sheet from 2243 to 0612.

8. The hospital policy titled Medication Administration - ACU requires:"...all medications administered will require a written order...to treat a specific medical condition/diagnosis...."

Medical record reviewed identified patient # 20 admitted 1-7-14 with respiratory failure, ventilator dependent. Past medical history included COPD (chronic obstructive pulmonary disease), electrolyte imbalance, anxiety and depression, and hypertension. The LTAC-Admission Physician Orders include Lorazepam (Ativan) 0.25mg PO (by mouth) TID (three times a day) PRN (as needed) anxiety. Nursing documentation on 1-8-13 at 0520, included: "...Pt BP 202/107 HR 139. Pt. not responding to simple commands. Ativan administered per prn orders without change..." Lorazepam is documented by employee # 12 as being administered at 0530.

The Chief Clinical Officer confirmed during an interview conducted on 1-10-14, the patient received Lorazepam at 0530, and that the vital signs and nursing assessment of: "...patient not responding to simple commands...", did not correspond with the specific medical condition for which the Lorazepam was ordered.

Based on review of policies and procedures, hospital documents, Medical Executive Committee minutes, medical records, and staff interviews, it was determined the hospital pharmacy failed to ensure utilization of approved protocol for infusion of vasoactive medication, as evidenced by:

1. failing to require complete physician orders for titrated medication for 2 of 2 patients (#'s 2 and 9); and

2. failing to require use of hospital approved vasoactive medication orders for 2 of 2 patients (#'s 2 and 9).

Findings include:

1.Review of hospital policy titled Medication Administration - ACU required: "...all Orders will be reviewed for completeness...exact strength or concentration, dose, frequency, specific instructions...."

Review of hospital policy titled IV- High Observation Drips revealed: "...RN will initiate a High Obsrvation Drip once a Physician order has been obtained. The High Observation Drip Physician Order Protocol should be placed in the order section of the patient's medical record...."

Review of Medical Executive Committee Meeting minutes dated August 28, 2013 revealed: "...Vasoactive Orders revised 8/13, this is Mesa only...."

Review of physician orders for patient # 2 revealed: "...1-2-14 at 1550 discontinue (D/C) norepinephrine. Keep systolic blood pressure (SBP) > 90...signature unreadable...." Physician orders on 1-2-14 at 1645 revealed: "... Levophed gtt (drip) to keep SBP (systolic blood pressure) > 90...telephone order read back (TORB) Dr. #8/employee #3...." There was no High Observation Drip Physician Order Protocol for Vasoactive Medication Orders in the record.

Review of physician orders for patient # 9 on 12-1-13 revealed the form titled, Levophed Physician Orders, another hospital logo and dated rev. 5/11. revealed: "...norepinephrine injectable 4mg (milligrams)/250ml (milliliters) D5W(dextrose 5% and water) for a concentration of (16mcg/ml). The Levophed is to start at 5 mcg/min and titrate at 2 mcg/min every 5 minutes to achieve the desired SBP (systolic blood pressure) 90-100. Employee # 11 checked off the order boxes for initial rate and titration rate only and not a concentration. The form was signed as TORB by employee #11 and authenticated by Physician #7. There was no High Observation Drip Physician Order Protocol for Vasoactive Medication Orders in the record.

The Director of Quality Management confirmed during an interview conducted on 1-3-14, the order written for Levophed on 1/2/14 at 1645 for patient # 2 Levophed was incomplete.

Employee # 26 confirmed during an interview conducted on 1-3-14, the order written for Levophed on 1-2-14 at 1645 for patient # 2 should have been submitted to pharmacy using the Vasoactive Medication Order protocol and was incomplete.

The Director of Quality Management and employee # 19 confirmed during an interview conducted on 1/8/14, the "Levophed Infusion Physician Order" form was not used at this hospital, should not have been processed by pharmacy, and did not have an order for concentration.

2. Review of hospital policy titled IV- High Observation Drips revealed: "...RN will initiate a High Observation Drip once a Physician order has been obtained. The High Observation Drip Physician Order Protocol should be placed in the order section of the patient's medical record...."

Review of approved hospital document, Vasoactive Medication Orders for Levophed revealed: "...Norepinephrine 8 mg Dextrose 5% water sol 250 IV final concentration = 32mcg/ml....initiate infusion at 10 micrograms per min (mcg/min) and titrate every 15 min by increments of 5 mcg/min...maintain mean arterial pressure (MAP) greater than 65 millimeters of mercury (mmHg)...once blood pressure is stable, decrease drip by 5 mcg/min until titrated off...."

Review of medical record for patient # 9, revealed: "... on 12-1-13, employee # 11 signed and dated the form titled, Levophed Physician Orders, with another hospital logo and dated rev. 5/11 revealed: "...norepinephrine injectable 4mg (milligrams)/250ml (milliliters) D5W(dextrose 5% and water) for a concentration of (16mcg/ml). The Levophed is to start at 5 mcg/min and titrate at 2 mcg/min every 5 minutes to achieve the desired SBP (systolic blood pressure) 90-100...." The order has checked off the order boxes for initial rate and titration rate only and not a concentration. The order was faxed to the pharmacy. The Levophed is not documented on the MAR 12-1-13.

The Levophed dose is documented on the MAR by pharmacy for dates 12/3/13 and 12/4/13 reads: "... norepinephrine 8 mg Dextrose 5% water sol 250 IV final concentration = 32mcg/ml...initiate infusion @ 10 mcg/min...titrate every 15 minutes by increments of 5 mcg/min to maintain MAP>65 mmhg...."

The Director of Quality Management and employee # 19 confirmed during an interview conducted on 1-8-14, the written order for Levophed on 12-1-13, was not the same order entered by pharmacy on the MAR, and was not clarified by nursing or pharmacy.