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Based on record review and staff interviews it was determined the facility failed to ensure the registered nurse properly evaluated and supervised the care for one patient (#1) out of a sample of four. The nurse failed to ensure physician orders and supplies were promptly obtained in order to provide uninterrupted administration of the patient's routine medications. Findings include:

The medical record for Patient #1 revealed this patient presented to the emergency department from an extended care facility on 07/01/10 at approximately 9:55 AM. The chief complaint was listed as decreased responsiveness. The extended care facility had provided copies of the patient's routine orders, including orders for medications and the facility's administration times. A review of these documents also revealed Patient #1 had a history of a traumatic brain injury and seizures. The patient's daily medications included the anticonvulsants carbamazepine (administered at 6:00 AM, 12:00 PM and 6:00 PM) and valproic acid (administered at 6:00 AM, 12:00 PM, 6:00 PM and 12:00 AM). The extended care facility records also revealed the resident was unable to receive any medications by mouth and that all oral medications were administered by way of a gastric tube. Hospital records documented the patient was admitted to the medical floor as an inpatient at approximately 4:45 PM on 07/01/10. Review of the admission physician orders revealed the carbamazepine and valproic acid were recopied and continued by the physician. However, these orders were not signed by the physician until 07/02/10 at 6:00 AM. A review of the medication administration records revealed the first doses of carbamazepine and valproic acid were not administered until 07/02/10 at 11:00 AM.

An interview was conducted on 10/28/10 at 2:03 PM with the nurse who provided care for Patient #1 on 07/01/10 from 7:00 PM until 7:00 AM on 7/02/10. The nurse stated he/she did not contact the physician to obtain admission orders, including orders for medications. He/she also stated the feeding tube inserted in Patient #1 was unfamiliar to him/her and did not have a standard connector that was normally used for medication administration. The nurse stated he/she did not think to contact the nursing supervisor for further guidance.

An interview was conducted on 10/29/10 at 10:40 AM with the nurse who provided care for Patient #1 on the morning of 07/02/10. The nurse stated that he/she was unable to administer the feeding tube medications on the morning of 07/02/10 because a special connector was required that was unavailable that morning. The connector was not obtained until a member of the extended care facility staff visited the patient that morning and realized Patient #1 had not received any routine medications.

A telephone interview was conducted with Patient #1's attending physician on 10/29/10 at 10:25 AM. The physician stated, although Patient #1 suffered no permanent problems, the patient could have suffered seizures as the result of the delayed administration of the anticonvulsant medication. The physician stated the nursing staff should have contacted him/her for admission orders so the patient could have received the medication within a few hours of admission.