HospitalInspections.org

Liwanag, Lillian
Based on record review and interview, the facility failed to ensure that the medication administration is given by the nursing staff on a timely manner, accurately, and as ordered by the physician as evidenced on 3 (SP#12, SP#35, SP#40) of 40 Sampled Patients (SP).

The findings include:

(1.) Clinical record review conducted on 04-12-12 of SP#12 revealed that the patient was admitted on 04-05-12 .Review of the physician order dated 04-07-12 at 15:00 pm showed "D/C (Discontinue) Vancomycin". Review of the MAR (Medication Administration Record) dated 04-07-12 revealed that SP#12 received Vancomycin 1000mg (milligram)/20ml (milliliter) in Dextrose 5% in Water 250 ml. at 17:38 pm.
Interview with the Director of Pharmacy conducted on 04-12-12 at 12:20 pm confirmed above finding that the Vancomycin was ordered to D/C on 04-07-12 at 15:00 pm and was scanned to pharmacy on 04-08-12 at 04:44am and the medication was discontinued in the system at 4:52am..

Further review of the clinical record conducted on 04-12-12 of SP#12 showed a physician order dated 04-08-12 at 13:30pm to decrease Carvedilol to 3.125 mg po (by mouth) every 12 hours. Review of the MAR showed that SP#12 received Carvedilol 6.25 mg one tablet orally on 04-08-12 at 10:36pm and on 04-09-12 at 10:13am.
Interview with the Director of Pharmacy conducted on 04-12-12 at 12:20 pm confirmed above finding that the order for the decreased dose for Carvedilol was scanned to Pharmacy on 04-09-12 at 14:07pm and was discontinued in the system at 14:38pm.

(2.) Clinical record review conducted on 04-12-12 of SP#35 revealed that the patient was admitted on 04-09-12 with a diagnoses of Elevated Troponin and DVT (Deep Vein Thrombosis). Review of the physician order dated 04-11-12 at 15:45pm showed "Coumadin 5 mg po daily". Review of the MAR showed that the medication was scheduled by the pharmacy to be given at 18:00pm. but was given at 20:15pm..( 2 hours later)

Interview with the Director of Pharmacy conducted on 04-12-12 at 12:25 pm confirmed above finding that Coumadin was supposed to be given at 18:00pm per facility pharmacy policy and procedure.

(3.) Clinical record review conducted on 04-12-12 of SP#40 revealed that the patient was admitted on 04-03-12 with a diagnosis of Malfunction Peg Tube. Review of the physician order dated 04-05-12 at 1:00pm showed "Labetalol 10 mg. IV (Intravenous) every 6 hours ATC (around the clock). Hold for SBP (systolic blood pressure less than 100 and HR (heart rate)) less than 60." Review of the patient's blood pressure and heart rate on 04-05-12 showed SBP range of 133 to 184, HR range of 65 to 126.
Review of the MAR showed that the medication was first administered on 04-06-12 at 5:26pm. (28 hours after the medication was ordered).
The patient's SBP range on 04-06-12 between 4:00am to 07:49am was 172-181 and HR range of 70-79 but there was no medication administered at this time.
The second dose was given at 11:40pm and the third dose was given on 04-07-12 at 10:03am.

Interview with the Director of Pharmacy conducted on 04-12-12 at 12:30pm confirmed above findings that the medication was not given as ordered by the physician.

Further review of SP#40 physician order on 04-04-12 at 2:15pm showed "KCl (Potassium Chloride) 20 meq. (milliequivalent) oral times one". Review of the MAR showed that the medication was not given. This order was scanned to Pharmacy at 18:51pm( 4 hours later) and the nurse noted it at 18:56pm. The Pharmacy entered the schedule time for the medication to be administered at 19:58pm.( 7 hours later). At 22:30 pm , the Nephrologist was called because the patient was on NPO (nothing per orem).
This finding was confirmed with the Director of Pharmacy on 04-12-12 at 12:30pm that there was a delay in treatment.

Records showed no evidence of any justification for the medication discrepancies for SP#12, SP#35, and SP#40.

Interview during the tour of 4th floor Overflow Unit with the Director of Medical-Surgical Department conducted on 04-12-12 from 10:00am to 11:30am confirmed above findings that nurses failed to administer medications as ordered by the physician.

Pharmacy Director also confirmed incidents when the unit staff was delayed in scanning physician orders to Pharmacy. The Pharmacy Director stated that with the new system that will be in place by mid May 2012, Nursing and Pharmacy will have a better collaborative oversight and monitoring process to ensure that physician's orders are carried out on a timely manner, and that medications are administered as ordered.

Interview with the Director of Continuous Quality Improvement (DCQI) on 4/12/2012 around 2 PM revealed that QI (Quality Improvement) regularly reviews patient records on a quarterly basis. Discrepancies in medication administration is monitored, tracked and appropriate actions are recommended by Quality Improvement. The DCQI confirmed the findings and stated that the hospital is committed in taking these incidents as opportunities for improvement.

Review of the Facility Policy Number 300.06.00, Policy Name: General Guidelines for Medication Administration showed: All discrepancies between MAR and physician order must be reported to the pharmacy for further investigation."; Procedure #16. to "Follow the standard medication administration time schedule in as much as possible. For question on how and when to incorporate newly started medication orders safely into the standardized schedule contact the pharmacy department."; Procedure #20. "Confirm the five "rights" prior to administering a medication (right patient, right drug, right dose, form, right route, right time.)".

Based on record review and interview, the facility failed to ensure that Pharmaceutical Services is administered in accordance with the orders of the physician responsible for the patient care as evidenced in 3(SP#12, SP#35, SP#40) of 40 Sampled Patients (SP)



The findings include:

(1.) Clinical record review conducted on 04-12-12 of SP#12 revealed that the patient was admitted on 04-05-12 .Review of the physician order dated 04-07-12 at 15:00 pm showed "D/C (Discontinue) Vancomycin". Review of the MAR (Medication Administration Record) dated 04-07-12 revealed that SP#12 received Vancomycin 1000mg (milligram)/20ml (milliliter) in Dextrose 5% in Water 250 ml. at 17:38 pm.
Interview with the Director of Pharmacy conducted on 04-12-12 at 12:20 pm confirmed above finding that the Vancomycin was ordered to D/C on 04-07-12 at 15:00 pm and was scanned to pharmacy on 04-08-12 at 04:44am and the medication was discontinued in the system at 4:52am..

Further review of the clinical record conducted on 04-12-12 of SP#12 showed a physician order dated 04-08-12 at 13:30pm to decrease Carvedilol to 3.125 mg po (by mouth) every 12 hours. Review of the MAR showed that SP#12 received Carvedilol 6.25 mg one tablet orally on 04-08-12 at 10:36pm and on 04-09-12 at 10:13am.
Interview with the Director of Pharmacy conducted on 04-12-12 at 12:20 pm confirmed above finding that the order for the decreased dose for Carvedilol was scanned to Pharmacy on 04-09-12 at 14:07pm and was discontinued in the system at 14:38pm.

(2.) Clinical record review conducted on 04-12-12 of SP#35 revealed that the patient was admitted on 04-09-12 with a diagnoses of Elevated Troponin and DVT (Deep Vein Thrombosis). Review of the physician order dated 04-11-12 at 15:45pm showed "Coumadin 5 mg po daily". Review of the MAR showed that the medication was scheduled by the pharmacy to be given at 18:00pm. but was given at 20:15pm..( 2 hours later)

Interview with the Director of Pharmacy conducted on 04-12-12 at 12:25 pm confirmed above finding that Coumadin was supposed to be given at 18:00pm per facility pharmacy policy and procedure.

(3.) Clinical record review conducted on 04-12-12 of SP#40 revealed that the patient was admitted on 04-03-12 with a diagnosis of Malfunction Peg Tube. Review of the physician order dated 04-05-12 at 1:00pm showed "Labetalol 10 mg. IV (Intravenous) every 6 hours ATC (around the clock). Hold for SBP (systolic blood pressure less than 100 and HR (heart rate)) less than 60." Review of the patient's blood pressure and heart rate on 04-05-12 showed SBP range of 133 to 184, HR range of 65 to 126.
Review of the MAR showed that the medication was first administered on 04-06-12 at 5:26pm. (28 hours after the medication was ordered).
The patient's SBP range on 04-06-12 between 4:00am to 07:49am was 172-181 and HR range of 70-79 but there was no medication administered at this time.
The second dose was given at 11:40pm and the third dose was given on 04-07-12 at 10:03am.

Interview with the Director of Pharmacy conducted on 04-12-12 at 12:30pm confirmed above findings that the medication was not given as ordered by the physician.

Further review of SP#40 physician order on 04-04-12 at 2:15pm showed "KCl (Potassium Chloride) 20 meq. (milliequivalent) oral times one". Review of the MAR showed that the medication was not given. This order was scanned to Pharmacy at 18:51pm( 4 hours later) and the nurse noted it at 18:56pm. The Pharmacy entered the schedule time for the medication to be administered at 19:58pm.( 7 hours later). At 22:30 pm , the Nephrologist was called because the patient was on NPO (nothing by mouth).
This finding was confirmed with the Director of Pharmacy on 04-12-12 at 12:30pm that there was a delay in treatment.

Records showed no evidence of any justification for the medication discrepancies for SP#12, SP#35, and SP#40.

Interview during the tour of 4th floor Overflow Unit with the Director of Medical-Surgical Department conducted on 04-12-12 from 10:00am to 11:30am confirmed above findings that nurses failed to administer medications as ordered by the physician.

Pharmacy Director also confirmed incidents when the unit staff was delayed in scanning physician orders to Pharmacy. The Pharmacy Director stated that with the new system that will be in place by mid May 2012, Nursing and Pharmacy will have a better collaborative oversight and monitoring process to ensure that physician's orders are carried out on a timely manner, and that medications are administered as ordered.

Interview with the Director of Continuous Quality Improvement (DCQI) on 4/12/2012 around 2 PM revealed that QI (Quality Improvement) regularly reviews patient records on a quarterly basis. Discrepancies in medication administration is monitored, tracked and appropriate actions are recommended by Quality Improvement. The DCQI confirmed the findings and stated that the hospital is committed in taking these incidents as opportunities for improvement.

Review of the Facility Policy Number 300.06.00, Policy Name: General Guidelines for Medication Administration showed: All discrepancies between MAR and physician order must be reported to the pharmacy for further investigation."; Procedure #16. to "Follow the standard medication administration time schedule in as much as possible. For question on how and when to incorporate newly started medication orders safely into the standardized schedule contact the pharmacy department."; Procedure #20. "Confirm the five "rights" prior to administering a medication (right patient, right drug, right dose, form, right route, right time.)".

Based on interview and record review the facility failed to provide adequate documentation of discharge planning evaluation including an assessment of the availability of appropriate services for 1 of 10 sampled patient (SP)# 1 who needed post-hospital services.

Findings include:

Clinical record review of Sample Patient (SP)#1, Focus of Investigation conducted from 4-10-12 to 4-11-12 revealed that he was a resident of a local Assisted Living Facility (ALF) prior to admission to the hospital. Nursing documentation showed that discharge planning was initiated upon admission.
Review of the assessment on the " Present On Admission Intake Assessment " revealed that SP#1 had a skin assessment documenting that the patient presented with unstageable pressure ulcers ( full thickness tissue loss where the wound bed of the ulcer is covered by slough or eschar) to both right and left feet.

Review of Social Worker ' s documentation conducted on 4-11-12 revealed a Discharge Planner ' s Activity Log written by herself stating: " [SP#1 ' s Physician named] was contacted and ALF Owner - both refused transfer to SNF [Skilled Nursing Facility]. On 2/16/2012 at 09:58 am the patient SP#1 was transferred and admitted to a new ALF under Hospice care . "
58A-5.0181(1) FAC -Admission Procedures, Appropriateness of Placement and Continued Residency Criteria. States that a resident may (j) Not have any stage 3 or 4 pressure sores.
The internal medical discharge summary in SP#1 medical record dated 2/16/2012 also has noted necrotic wounds to both of the patient's feet.
Interview with the Case Manager conducted on 4-9-12 at 11:35am revealed a discussion of the discharge planning process for ALF discharges. She explained that the hospital Interdisciplinary Team [IDT composed of the Case Manager, Nurse, Pharmacist, Physical Therapist, Respiratory Therapist and Physician Advisor] hold daily meetings discussing the condition of the patients and pending discharges. She discussed the criteria patients have to meet to be discharged to ALF's such as:
· " Patients ability to do ADL's [Activities of Daily Living] independently or with assist;
· No ulcers above Stage II;
· No nursing care needed because not all ALF's have nurses to provide the patient ' s needs. "
She explained that the patient and/or family ' s request is always considered as long as the patient meets criteria for ALF admission.

Interview with the Director of Case Management conducted on 4-10-12 at 1120am revealed that the Case Managers, Discharge Planners and Social Workers consider the patient ' s ADL's, bed mobility, cognition and skin conditions when referring patients to ALF's. He explained that they discuss the case with the Physician and check out other options considering the patient ' s needs. He stated that SP#1 was appropriately discharged to the ALF considering his skin conditions and bed mobility, " because patient care will be provided by Hospice. " He added that SP#1 ' s designated Caregiver " was extremely upset about Nursing Home placement " and " wanted patient back in the ALF. "






Based on interview and record review the facility failed to provide adequate documentation of discharge planning evaluation including an assessment of the availability of appropriate services for 1 of 10 sampled patient (SP)# 1 who needed post-hospital services.

Findings include:

Clinical record review of Sample Patient (SP)#1, Focus of Investigation conducted from 4-10-12 to 4-11-12 revealed that he was a resident of a local Assisted Living Facility (ALF) prior to admission to the hospital. Nursing documentation showed that discharge planning was initiated upon admission.
Review of the assessment on the " Present On Admission Intake Assessment " revealed that SP#1 had a skin assessment documenting that the patient presented with unstageable pressure ulcers ( full thickness tissue loss where the wound bed of the ulcer is covered by slough or eschar) to both right and left feet.

Review of Social Worker ' s documentation conducted on 4-11-12 revealed a Discharge Planner ' s Activity Log written by herself stating: " [SP#1 ' s Physician named] was contacted and ALF Owner - both refused transfer to SNF [Skilled Nursing Facility]. On 2/16/2012 at 09:58 am the patient SP#1 was transferred and admitted to a new ALF under Hospice care . "
58A-5.0181(1) FAC -Admission Procedures, Appropriateness of Placement and Continued Residency Criteria. States that a resident may (j) Not have any stage 3 or 4 pressure sores.
The internal medical discharge summary in SP#1 medical record dated 2/16/2012 also has noted necrotic wounds to both of the patient's feet.
Interview with the Case Manager conducted on 4-9-12 at 11:35am revealed a discussion of the discharge planning process for ALF discharges. She explained that the hospital Interdisciplinary Team [IDT composed of the Case Manager, Nurse, Pharmacist, Physical Therapist, Respiratory Therapist and Physician Advisor] hold daily meetings discussing the condition of the patients and pending discharges. She discussed the criteria patients have to meet to be discharged to ALF's such as:
· " Patients ability to do ADL's [Activities of Daily Living] independently or with assist;
· No ulcers above Stage II;
· No nursing care needed because not all ALF's have nurses to provide the patient ' s needs. "
She explained that the patient and/or family ' s request is always considered as long as the patient meets criteria for ALF admission.

Interview with the Director of Case Management conducted on 4-10-12 at 1120am revealed that the Case Managers, Discharge Planners and Social Workers consider the patient ' s ADL's, bed mobility, cognition and skin conditions when referring patients to ALF's. He explained that they discuss the case with the Physician and check out other options considering the patient ' s needs. He stated that SP#1 was appropriately discharged to the ALF considering his skin conditions and bed mobility, " because patient care will be provided by Hospice. " He added that SP#1 ' s designated Caregiver " was extremely upset about Nursing Home placement " and " wanted patient back in the ALF. "



Based on interview and record review the facility failed to provide adequate documentation of discharge planning evaluation including an assessment of the availability of appropriate services for 1 of 10 sampled patient (SP)# 1 who needed post-hospital services.

Findings include:

Clinical record review of Sample Patient (SP)#1, Focus of Investigation conducted from 4-10-12 to 4-11-12 revealed that he was a resident of a local Assisted Living Facility (ALF) prior to admission to the hospital. Nursing documentation showed that discharge planning was initiated upon admission.
Review of the assessment on the " Present On Admission Intake Assessment " revealed that SP#1 had a skin assessment documenting that the patient presented with unstageable pressure ulcers ( full thickness tissue loss where the wound bed of the ulcer is covered by slough or eschar) to both right and left feet.

Review of Social Worker ' s documentation conducted on 4-11-12 revealed a Discharge Planner ' s Activity Log written by herself stating: " [SP#1 ' s Physician named] was contacted and ALF Owner - both refused transfer to SNF [Skilled Nursing Facility]. On 2/16/2012 at 09:58 am the patient SP#1 was transferred and admitted to a new ALF under Hospice care . "
58A-5.0181(1) FAC -Admission Procedures, Appropriateness of Placement and Continued Residency Criteria. States that a resident may (j) Not have any stage 3 or 4 pressure sores.
The internal medical discharge summary in SP#1 medical record dated 2/16/2012 also has noted necrotic wounds to both of the patient's feet.
Interview with the Case Manager conducted on 4-9-12 at 11:35am revealed a discussion of the discharge planning process for ALF discharges. She explained that the hospital Interdisciplinary Team [IDT composed of the Case Manager, Nurse, Pharmacist, Physical Therapist, Respiratory Therapist and Physician Advisor] hold daily meetings discussing the condition of the patients and pending discharges. She discussed the criteria patients have to meet to be discharged to ALF's such as:
· " Patients ability to do ADL's [Activities of Daily Living] independently or with assist;
· No ulcers above Stage II;
· No nursing care needed because not all ALF's have nurses to provide the patient ' s needs. "
She explained that the patient and/or family ' s request is always considered as long as the patient meets criteria for ALF admission.

Interview with the Director of Case Management conducted on 4-10-12 at 1120am revealed that the Case Managers, Discharge Planners and Social Workers consider the patient ' s ADL's, bed mobility, cognition and skin conditions when referring patients to ALF's. He explained that they discuss the case with the Physician and check out other options considering the patient ' s needs. He stated that SP#1 was appropriately discharged to the ALF considering his skin conditions and bed mobility, " because patient care will be provided by Hospice. " He added that SP#1 ' s designated Caregiver " was extremely upset about Nursing Home placement " and " wanted patient back in the ALF. "

Liwanag, Lillian
Based on record review and interview, the facility failed to ensure that the medication administration is given by the nursing staff on a timely manner, accurately, and as ordered by the physician as evidenced on 3 (SP#12, SP#35, SP#40) of 40 Sampled Patients (SP).

The findings include:

(1.) Clinical record review conducted on 04-12-12 of SP#12 revealed that the patient was admitted on 04-05-12 .Review of the physician order dated 04-07-12 at 15:00 pm showed "D/C (Discontinue) Vancomycin". Review of the MAR (Medication Administration Record) dated 04-07-12 revealed that SP#12 received Vancomycin 1000mg (milligram)/20ml (milliliter) in Dextrose 5% in Water 250 ml. at 17:38 pm.
Interview with the Director of Pharmacy conducted on 04-12-12 at 12:20 pm confirmed above finding that the Vancomycin was ordered to D/C on 04-07-12 at 15:00 pm and was scanned to pharmacy on 04-08-12 at 04:44am and the medication was discontinued in the system at 4:52am..

Further review of the clinical record conducted on 04-12-12 of SP#12 showed a physician order dated 04-08-12 at 13:30pm to decrease Carvedilol to 3.125 mg po (by mouth) every 12 hours. Review of the MAR showed that SP#12 received Carvedilol 6.25 mg one tablet orally on 04-08-12 at 10:36pm and on 04-09-12 at 10:13am.
Interview with the Director of Pharmacy conducted on 04-12-12 at 12:20 pm confirmed above finding that the order for the decreased dose for Carvedilol was scanned to Pharmacy on 04-09-12 at 14:07pm and was discontinued in the system at 14:38pm.

(2.) Clinical record review conducted on 04-12-12 of SP#35 revealed that the patient was admitted on 04-09-12 with a diagnoses of Elevated Troponin and DVT (Deep Vein Thrombosis). Review of the physician order dated 04-11-12 at 15:45pm showed "Coumadin 5 mg po daily". Review of the MAR showed that the medication was scheduled by the pharmacy to be given at 18:00pm. but was given at 20:15pm..( 2 hours later)

Interview with the Director of Pharmacy conducted on 04-12-12 at 12:25 pm confirmed above finding that Coumadin was supposed to be given at 18:00pm per facility pharmacy policy and procedure.

(3.) Clinical record review conducted on 04-12-12 of SP#40 revealed that the patient was admitted on 04-03-12 with a diagnosis of Malfunction Peg Tube. Review of the physician order dated 04-05-12 at 1:00pm showed "Labetalol 10 mg. IV (Intravenous) every 6 hours ATC (around the clock). Hold for SBP (systolic blood pressure less than 100 and HR (heart rate)) less than 60." Review of the patient's blood pressure and heart rate on 04-05-12 showed SBP range of 133 to 184, HR range of 65 to 126.
Review of the MAR showed that the medication was first administered on 04-06-12 at 5:26pm. (28 hours after the medication was ordered).
The patient's SBP range on 04-06-12 between 4:00am to 07:49am was 172-181 and HR range of 70-79 but there was no medication administered at this time.
The second dose was given at 11:40pm and the third dose was given on 04-07-12 at 10:03am.

Interview with the Director of Pharmacy conducted on 04-12-12 at 12:30pm confirmed above findings that the medication was not given as ordered by the physician.

Further review of SP#40 physician order on 04-04-12 at 2:15pm showed "KCl (Potassium Chloride) 20 meq. (milliequivalent) oral times one". Review of the MAR showed that the medication was not given. This order was scanned to Pharmacy at 18:51pm( 4 hours later) and the nurse noted it at 18:56pm. The Pharmacy entered the schedule time for the medication to be administered at 19:58pm.( 7 hours later). At 22:30 pm , the Nephrologist was called because the patient was on NPO (nothing per orem).
This finding was confirmed with the Director of Pharmacy on 04-12-12 at 12:30pm that there was a delay in treatment.

Records showed no evidence of any justification for the medication discrepancies for SP#12, SP#35, and SP#40.

Interview during the tour of 4th floor Overflow Unit with the Director of Medical-Surgical Department conducted on 04-12-12 from 10:00am to 11:30am confirmed above findings that nurses failed to administer medications as ordered by the physician.

Pharmacy Director also confirmed incidents when the unit staff was delayed in scanning physician orders to Pharmacy. The Pharmacy Director stated that with the new system that will be in place by mid May 2012, Nursing and Pharmacy will have a better collaborative oversight and monitoring process to ensure that physician's orders are carried out on a timely manner, and that medications are administered as ordered.

Interview with the Director of Continuous Quality Improvement (DCQI) on 4/12/2012 around 2 PM revealed that QI (Quality Improvement) regularly reviews patient records on a quarterly basis. Discrepancies in medication administration is monitored, tracked and appropriate actions are recommended by Quality Improvement. The DCQI confirmed the findings and stated that the hospital is committed in taking these incidents as opportunities for improvement.

Review of the Facility Policy Number 300.06.00, Policy Name: General Guidelines for Medication Administration showed: All discrepancies between MAR and physician order must be reported to the pharmacy for further investigation."; Procedure #16. to "Follow the standard medication administration time schedule in as much as possible. For question on how and when to incorporate newly started medication orders safely into the standardized schedule contact the pharmacy department."; Procedure #20. "Confirm the five "rights" prior to administering a medication (right patient, right drug, right dose, form, right route, right time.)".

Based on record review and interview, the facility failed to ensure that Pharmaceutical Services is administered in accordance with the orders of the physician responsible for the patient care as evidenced in 3(SP#12, SP#35, SP#40) of 40 Sampled Patients (SP)



The findings include:

(1.) Clinical record review conducted on 04-12-12 of SP#12 revealed that the patient was admitted on 04-05-12 .Review of the physician order dated 04-07-12 at 15:00 pm showed "D/C (Discontinue) Vancomycin". Review of the MAR (Medication Administration Record) dated 04-07-12 revealed that SP#12 received Vancomycin 1000mg (milligram)/20ml (milliliter) in Dextrose 5% in Water 250 ml. at 17:38 pm.
Interview with the Director of Pharmacy conducted on 04-12-12 at 12:20 pm confirmed above finding that the Vancomycin was ordered to D/C on 04-07-12 at 15:00 pm and was scanned to pharmacy on 04-08-12 at 04:44am and the medication was discontinued in the system at 4:52am..

Further review of the clinical record conducted on 04-12-12 of SP#12 showed a physician order dated 04-08-12 at 13:30pm to decrease Carvedilol to 3.125 mg po (by mouth) every 12 hours. Review of the MAR showed that SP#12 received Carvedilol 6.25 mg one tablet orally on 04-08-12 at 10:36pm and on 04-09-12 at 10:13am.
Interview with the Director of Pharmacy conducted on 04-12-12 at 12:20 pm confirmed above finding that the order for the decreased dose for Carvedilol was scanned to Pharmacy on 04-09-12 at 14:07pm and was discontinued in the system at 14:38pm.

(2.) Clinical record review conducted on 04-12-12 of SP#35 revealed that the patient was admitted on 04-09-12 with a diagnoses of Elevated Troponin and DVT (Deep Vein Thrombosis). Review of the physician order dated 04-11-12 at 15:45pm showed "Coumadin 5 mg po daily". Review of the MAR showed that the medication was scheduled by the pharmacy to be given at 18:00pm. but was given at 20:15pm..( 2 hours later)

Interview with the Director of Pharmacy conducted on 04-12-12 at 12:25 pm confirmed above finding that Coumadin was supposed to be given at 18:00pm per facility pharmacy policy and procedure.

(3.) Clinical record review conducted on 04-12-12 of SP#40 revealed that the patient was admitted on 04-03-12 with a diagnosis of Malfunction Peg Tube. Review of the physician order dated 04-05-12 at 1:00pm showed "Labetalol 10 mg. IV (Intravenous) every 6 hours ATC (around the clock). Hold for SBP (systolic blood pressure less than 100 and HR (heart rate)) less than 60." Review of the patient's blood pressure and heart rate on 04-05-12 showed SBP range of 133 to 184, HR range of 65 to 126.
Review of the MAR showed that the medication was first administered on 04-06-12 at 5:26pm. (28 hours after the medication was ordered).
The patient's SBP range on 04-06-12 between 4:00am to 07:49am was 172-181 and HR range of 70-79 but there was no medication administered at this time.
The second dose was given at 11:40pm and the third dose was given on 04-07-12 at 10:03am.

Interview with the Director of Pharmacy conducted on 04-12-12 at 12:30pm confirmed above findings that the medication was not given as ordered by the physician.

Further review of SP#40 physician order on 04-04-12 at 2:15pm showed "KCl (Potassium Chloride) 20 meq. (milliequivalent) oral times one". Review of the MAR showed that the medication was not given. This order was scanned to Pharmacy at 18:51pm( 4 hours later) and the nurse noted it at 18:56pm. The Pharmacy entered the schedule time for the medication to be administered at 19:58pm.( 7 hours later). At 22:30 pm , the Nephrologist was called because the patient was on NPO (nothing by mouth).
This finding was confirmed with the Director of Pharmacy on 04-12-12 at 12:30pm that there was a delay in treatment.

Records showed no evidence of any justification for the medication discrepancies for SP#12, SP#35, and SP#40.

Interview during the tour of 4th floor Overflow Unit with the Director of Medical-Surgical Department conducted on 04-12-12 from 10:00am to 11:30am confirmed above findings that nurses failed to administer medications as ordered by the physician.

Pharmacy Director also confirmed incidents when the unit staff was delayed in scanning physician orders to Pharmacy. The Pharmacy Director stated that with the new system that will be in place by mid May 2012, Nursing and Pharmacy will have a better collaborative oversight and monitoring process to ensure that physician's orders are carried out on a timely manner, and that medications are administered as ordered.

Interview with the Director of Continuous Quality Improvement (DCQI) on 4/12/2012 around 2 PM revealed that QI (Quality Improvement) regularly reviews patient records on a quarterly basis. Discrepancies in medication administration is monitored, tracked and appropriate actions are recommended by Quality Improvement. The DCQI confirmed the findings and stated that the hospital is committed in taking these incidents as opportunities for improvement.

Review of the Facility Policy Number 300.06.00, Policy Name: General Guidelines for Medication Administration showed: All discrepancies between MAR and physician order must be reported to the pharmacy for further investigation."; Procedure #16. to "Follow the standard medication administration time schedule in as much as possible. For question on how and when to incorporate newly started medication orders safely into the standardized schedule contact the pharmacy department."; Procedure #20. "Confirm the five "rights" prior to administering a medication (right patient, right drug, right dose, form, right route, right time.)".

Based on interview and record review the facility failed to provide adequate documentation of discharge planning evaluation including an assessment of the availability of appropriate services for 1 of 10 sampled patient (SP)# 1 who needed post-hospital services.

Findings include:

Clinical record review of Sample Patient (SP)#1, Focus of Investigation conducted from 4-10-12 to 4-11-12 revealed that he was a resident of a local Assisted Living Facility (ALF) prior to admission to the hospital. Nursing documentation showed that discharge planning was initiated upon admission.
Review of the assessment on the " Present On Admission Intake Assessment " revealed that SP#1 had a skin assessment documenting that the patient presented with unstageable pressure ulcers ( full thickness tissue loss where the wound bed of the ulcer is covered by slough or eschar) to both right and left feet.

Review of Social Worker ' s documentation conducted on 4-11-12 revealed a Discharge Planner ' s Activity Log written by herself stating: " [SP#1 ' s Physician named] was contacted and ALF Owner - both refused transfer to SNF [Skilled Nursing Facility]. On 2/16/2012 at 09:58 am the patient SP#1 was transferred and admitted to a new ALF under Hospice care . "
58A-5.0181(1) FAC -Admission Procedures, Appropriateness of Placement and Continued Residency Criteria. States that a resident may (j) Not have any stage 3 or 4 pressure sores.
The internal medical discharge summary in SP#1 medical record dated 2/16/2012 also has noted necrotic wounds to both of the patient's feet.
Interview with the Case Manager conducted on 4-9-12 at 11:35am revealed a discussion of the discharge planning process for ALF discharges. She explained that the hospital Interdisciplinary Team [IDT composed of the Case Manager, Nurse, Pharmacist, Physical Therapist, Respiratory Therapist and Physician Advisor] hold daily meetings discussing the condition of the patients and pending discharges. She discussed the criteria patients have to meet to be discharged to ALF's such as:
· " Patients ability to do ADL's [Activities of Daily Living] independently or with assist;
· No ulcers above Stage II;
· No nursing care needed because not all ALF's have nurses to provide the patient ' s needs. "
She explained that the patient and/or family ' s request is always considered as long as the patient meets criteria for ALF admission.

Interview with the Director of Case Management conducted on 4-10-12 at 1120am revealed that the Case Managers, Discharge Planners and Social Workers consider the patient ' s ADL's, bed mobility, cognition and skin conditions when referring patients to ALF's. He explained that they discuss the case with the Physician and check out other options considering the patient ' s needs. He stated that SP#1 was appropriately discharged to the ALF considering his skin conditions and bed mobility, " because patient care will be provided by Hospice. " He added that SP#1 ' s designated Caregiver " was extremely upset about Nursing Home placement " and " wanted patient back in the ALF. "






Based on interview and record review the facility failed to provide adequate documentation of discharge planning evaluation including an assessment of the availability of appropriate services for 1 of 10 sampled patient (SP)# 1 who needed post-hospital services.

Findings include:

Clinical record review of Sample Patient (SP)#1, Focus of Investigation conducted from 4-10-12 to 4-11-12 revealed that he was a resident of a local Assisted Living Facility (ALF) prior to admission to the hospital. Nursing documentation showed that discharge planning was initiated upon admission.
Review of the assessment on the " Present On Admission Intake Assessment " revealed that SP#1 had a skin assessment documenting that the patient presented with unstageable pressure ulcers ( full thickness tissue loss where the wound bed of the ulcer is covered by slough or eschar) to both right and left feet.

Review of Social Worker ' s documentation conducted on 4-11-12 revealed a Discharge Planner ' s Activity Log written by herself stating: " [SP#1 ' s Physician named] was contacted and ALF Owner - both refused transfer to SNF [Skilled Nursing Facility]. On 2/16/2012 at 09:58 am the patient SP#1 was transferred and admitted to a new ALF under Hospice care . "
58A-5.0181(1) FAC -Admission Procedures, Appropriateness of Placement and Continued Residency Criteria. States that a resident may (j) Not have any stage 3 or 4 pressure sores.
The internal medical discharge summary in SP#1 medical record dated 2/16/2012 also has noted necrotic wounds to both of the patient's feet.
Interview with the Case Manager conducted on 4-9-12 at 11:35am revealed a discussion of the discharge planning process for ALF discharges. She explained that the hospital Interdisciplinary Team [IDT composed of the Case Manager, Nurse, Pharmacist, Physical Therapist, Respiratory Therapist and Physician Advisor] hold daily meetings discussing the condition of the patients and pending discharges. She discussed the criteria patients have to meet to be discharged to ALF's such as:
· " Patients ability to do ADL's [Activities of Daily Living] independently or with assist;
· No ulcers above Stage II;
· No nursing care needed because not all ALF's have nurses to provide the patient ' s needs. "
She explained that the patient and/or family ' s request is always considered as long as the patient meets criteria for ALF admission.

Interview with the Director of Case Management conducted on 4-10-12 at 1120am revealed that the Case Managers, Discharge Planners and Social Workers consider the patient ' s ADL's, bed mobility, cognition and skin conditions when referring patients to ALF's. He explained that they discuss the case with the Physician and check out other options considering the patient ' s needs. He stated that SP#1 was appropriately discharged to the ALF considering his skin conditions and bed mobility, " because patient care will be provided by Hospice. " He added that SP#1 ' s designated Caregiver " was extremely upset about Nursing Home placement " and " wanted patient back in the ALF. "



Based on interview and record review the facility failed to provide adequate documentation of discharge planning evaluation including an assessment of the availability of appropriate services for 1 of 10 sampled patient (SP)# 1 who needed post-hospital services.

Findings include:

Clinical record review of Sample Patient (SP)#1, Focus of Investigation conducted from 4-10-12 to 4-11-12 revealed that he was a resident of a local Assisted Living Facility (ALF) prior to admission to the hospital. Nursing documentation showed that discharge planning was initiated upon admission.
Review of the assessment on the " Present On Admission Intake Assessment " revealed that SP#1 had a skin assessment documenting that the patient presented with unstageable pressure ulcers ( full thickness tissue loss where the wound bed of the ulcer is covered by slough or eschar) to both right and left feet.

Review of Social Worker ' s documentation conducted on 4-11-12 revealed a Discharge Planner ' s Activity Log written by herself stating: " [SP#1 ' s Physician named] was contacted and ALF Owner - both refused transfer to SNF [Skilled Nursing Facility]. On 2/16/2012 at 09:58 am the patient SP#1 was transferred and admitted to a new ALF under Hospice care . "
58A-5.0181(1) FAC -Admission Procedures, Appropriateness of Placement and Continued Residency Criteria. States that a resident may (j) Not have any stage 3 or 4 pressure sores.
The internal medical discharge summary in SP#1 medical record dated 2/16/2012 also has noted necrotic wounds to both of the patient's feet.
Interview with the Case Manager conducted on 4-9-12 at 11:35am revealed a discussion of the discharge planning process for ALF discharges. She explained that the hospital Interdisciplinary Team [IDT composed of the Case Manager, Nurse, Pharmacist, Physical Therapist, Respiratory Therapist and Physician Advisor] hold daily meetings discussing the condition of the patients and pending discharges. She discussed the criteria patients have to meet to be discharged to ALF's such as:
· " Patients ability to do ADL's [Activities of Daily Living] independently or with assist;
· No ulcers above Stage II;
· No nursing care needed because not all ALF's have nurses to provide the patient ' s needs. "
She explained that the patient and/or family ' s request is always considered as long as the patient meets criteria for ALF admission.

Interview with the Director of Case Management conducted on 4-10-12 at 1120am revealed that the Case Managers, Discharge Planners and Social Workers consider the patient ' s ADL's, bed mobility, cognition and skin conditions when referring patients to ALF's. He explained that they discuss the case with the Physician and check out other options considering the patient ' s needs. He stated that SP#1 was appropriately discharged to the ALF considering his skin conditions and bed mobility, " because patient care will be provided by Hospice. " He added that SP#1 ' s designated Caregiver " was extremely upset about Nursing Home placement " and " wanted patient back in the ALF. "