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Based on review of policy and procedures, clinical records and interview, it was determined the facility failed to assure 3 ( #11, #13 and #19) of 30 (#1-#30) patients received medication as ordered by the physician. The failure to administer medications or notify the patient placed three patients at risk for harm and had the potential to affect 128 inpatients on census on 03/22/11. The findings are:

A. On 03/24/11 at 1510, Registered Nurse (RN) #2 provided the facility policy and procedure "Nursing Service 7.15: Medication Administration Guidelines" for review by Surveyor. The policy stated "If for some reason a medication is not given, the nurse will note the omission on the eMAR (electronic Medication Administration Record), document reason and electronically sign the entry. Physicians will be notified of the omission as appropriate."
B. Review of the clinical record for Patient #11 on 03/24/11 revealed a physician's order dated 03/17/11 for Metoprolol (Lopressor) 25 milligrams, by mouth three times per day. Review of the eMAR Summary with RN #1 on 03/24/11 revealed an entry for the Lopressor on 03/17/11 at 0800 that stated "Not Done Not Appropriate at this time @0800." The clinical record did not include documentation of a physician order to hold the Lopressor or that the physician was notified the medication was not administered. The findings were confirmed by RN #1 on 03/24/11 at 1430.
C. Review of the clinical record for Patient #13 on 03/24/11 at 1550 revealed a physician's order dated 03/21/11 for Isosorbide dinitrate (Isordil) 40 milligrams, two tablets P.O. (by mouth) TID (three times per day). Review of the eMAR Summary with RN #1 on 03/24/11 revealed the Isordil was not administered as ordered from 03/22/11 to 03/24/11 eight of nine times. The clinical record did not include documentation of a physician order to hold the Isordil or that the physician was notified the medication was not administered. The findings were confirmed by RN #1 on 03/24/11 at 1550 and she stated "They are supposed to notify the physician when a medication is held."
D. Review of the clinical record for Patient #19 on 03/25/11 at 0900 revealed a physician's order dated 03/20/11 for bumetanide two milligrams, two tabs P.O. daily. Review of the eMAR Summary with RN #1 on 03/25/11 revealed the bumetanide was not administered at 0900, and the entry had the statement "Not Done patient hypotensive, will monitor @0900." A physician order was noted on the eMAR Summary 03/21/11 for lisinopril 10 milligrams, one tablet P.O. daily and was noted 03/23/11 at 0900 as "Not Done; patient hypotensive, will monitor @0900." An order for Lopressor 100 milligrams, two tablets P.O. twice per day as noted on 03/21/11. The medication was documented as "Not done, patient hypotensive, will monitor." The clinical record did not include documentation of a physician order to hold the bumetanide, isordil, lisinopril or that the physician was notified of the patient's hypotension. The patient was discharged 03/24/11.