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Based on interview and record review it was determined that the hospital failed to ensure a qualified Registered Nurse was provided to meet patient care needs for 1 of 7 current patients. (#4)


Findings include:


1) On 3/17/2011 a complaint investigation was conducted and patient #4 was interviewed at approximately 12:30 PM. He stated he was moved from the Intensive Care Unit (ICU) on 3/16/2011 around mid-day and that the nursing staff had failed to provide him with medications. He stated that he and his full time caregiver had requested pain medications and antianxiety medications several times, but it was not until "close to midnight" before he received something for pain. Patient #4's caregiver was also interviewed at this time and she stated the nurse assigned to him on the evening shift on 3/16/2011 appeared "overwhelmed," and was unable to provide the patient with his medications.

2) A review of the medication orders and Medication Administration Records (MARs) revealed the patient did not receive any medications by the Registered Nurse (RN) initially assigned to the patient on the 7 P- 7 A shift. A review of the nursing notes revealed no nursing assessment or notes entered by the evening RN.

3) On 3/17/2011 at approximately 2:30 PM and interview was conducted with the 3rd Floor Unit Manager. She stated it is a standard for each shift to perform a nursing assessment.

3) On 3/18/2011 at approximately 7:50 AM, an interview was conducted with the RN assigned to patient #4 on 3/16/2011 evening shift. She stated she had never worked the 3rd floor unit and had a total 6 patients to care for. She stated she was busy with other patients and did not provide patient #4 with his medications and did not conduct a nursing assessment. The RN also stated she did not receive any orientation or training specific to the 3rd floor which contained medical type patients and that her primary work location was the post partum area. She stated when she reported for work on 3/16/2011, her supervisor told her to she was being assigned to the 3rd floor.

Based on on interview and record review was determined that the hospital failed to ensure medications were administered in a safe and efficient manner for 2 of 7 current patients. (#1 and #4)

Findings include:


1) On 03/17/2011 during a medical record review for patient #1, who was admitted on the evening of 03/15/2011, the eMar (Electronic Medication Administration Record) listed the patient's physician ordered intravenous and "as needed" medications and their administration times, but did not show the oral medications that were to be continued as listed on the Home Medication Continuation Form. The Home Medication Continuation Form was stamped that it was faxed to the pharmacy on 03/16/2011 at 6:20 PM. However, the Pharmacy Department failed to receive the faxed order. A 24 hour chart check was completed by the RN on the 7 P to 7 A shift on 03/17/2011, but failed to identify that the oral medications were not on the eMAR. Therefore, patient #1 failed to receive her oral medications during this time.

On 03/17/2011 at approximately 2:00 PM an interview was conducted with Patient #1. She stated she has only received IV (intravenous) medication (points to IV bag) since she has been here. She states she has not received any oral medications.

On 03/18/2011 at 07:55 am an interview was conducted with the RN assigned to patient #1 during the evening shift 7 P-7 A on 03/16-17/2011. She confirmed that she did do the 24 hour Chart Check for the patient, but did not remember seeing the Home Medication Continuation Form. She verified that the 24 hour chart check is done to ensure that the physician orders previously written have been carried out.

A review of the hospital's policy for "Medication Reconciliation" (effective 6/2/2010) revealed nursing staff are to ensure the home medications are reviewed and compare to the medications ordered.

2) On 3/17/2011 at approximately 12:30 PM and interview was conducted with patient #4. He stated he was moved from the Intensive Care Unit (ICU) on 3/16/2011 around mid-day and that the nursing staff had failed to provide him with medications. He stated that he and his full time caregiver had requested pain medications and antianxiety medications several times, but it was not until "close to midnight" before he received something for pain. Patient #4's caregiver was also interviewed at this time and she stated the nurse assigned to him on the evening shift on 3/16/2011 appeared "overwhelmed," and was unable to provide the patient with his medications. The caregiver stated "something was wrong with all of the computers and nursing staff told us they could not give medications while they were down."

A review of the medication orders and Medication Administration Records (MARs) revealed the patient did not receive any medications by the Registered Nurse (RN) initially assigned to the patient on the 7 P- 7 A shift. The MAR revealed a second RN did finally provide the patient with Dilaudid for pain control at approximately 11:45 PM on 3/16/2011.

On 3/18/2011 at approximately 7:50 AM, an interview was conducted with the RN assigned to patient #4 on 3/16/2011 evening shift. She stated she had never worked the 3rd floor unit and had a total 6 patients to care for. She stated she was busy with other patients and did not provide patient #4 with his medications and did not conduct a nursing assessment.

On 3/18/2011 at approximately 9:30 AM, an interview was conducted with the Director of Information Technology and Services. He stated a planned "downtime" for the RIS (nursing documentation system) was performed on 3/16/2011 at 2230 EDT for approximately 30 minutes, however the email notification to the staff contained a "typo" and indicated the downtime would be at 2330. Therefore nursing staff were "caught off guard" by the early system interruption