HospitalInspections.org

The Hospital was out of compliance for the Condition of Participation for Patient Rights.

Findings included:

The Hospital failed to ensure for 2 (Patient #2 and Patient #10) of 11 sampled patients that the Hospital provided care in a safe setting when both Patient #2 and Patient #10 were able to attempt suicide and required higher level of care while being treated for suicidal ideation.

Refer to TAG: A-0144.

Based on interviews and records reviewed, the Hospital failed to provide care in a safe setting when 2 (Patient #2 and Patient #10) of 11 patient records reviewed were able to attempt suicide while being treated for suicidal ideation.

Findings include:

1. Patient #2 arrived in the Emergency Department in 5/2021 with suicidal ideation after overdosing on his own Wellbutrin (antidepressant).

Review of the Hospital's Management of the Patient Requiring Suicide Precautions in Non-Psychiatric Settings indicated that a suicide risk assessment is performed on all patients, whether they have a behavioral health issue. Depending on the patient's response to the: Columbia Suicide Risk Assessment, a level of suicide risk is determined.

A patient who is determined to be a high risk for suicidal ideation would have the following interventions:

- 1:1 sitter
- Ligature reduction room
- Security search
- Undressed into Hospital Behavioral Health hospital attire

A patient who is identified as a moderate risk for suicidal ideation would have the following interventions:

- 4:1 patient to sitter observation (constant observation)
- Ligature reduction room
- Safety food tray
- Security Search
- Undressed into Hospital Behavioral Health hospital attire

Nurses will contact security via Operator requesting to respond for "Search". Document the reason for the search and security notification in the medical record.

Any patient placed on suicide precautions will have all belongings removed, secured, and sent home or stored out of reach.

Document the reason for the search and security notification in the medical record.

Review of the Patient Care Timeline indicated that Patient #2 arrived in the Emergency Department at 6:44 P.M.

The ED triage note indicated that at 6:54 P.M., Patient #2 told Nurse #1 that he/she was suicidal with a plan to overdose on drugs or alcohol. Patient #2 admitted to taking Wellbutrin (antidepressant) 5-8 tablets prior to arrival. Patient noted they are 300 mg XR (extended release).

Review of the Suicide Risk/Self Harm- (Columbia Suicide Severity Rating Scale) assessment performed by Registered Nurse (RN) #1 on 5/6/22 at 6:58 P.M. indicated that Patient #2 wished to be dead in the last month, had non-specific active suicidal thoughts in the past month and had active suicidal ideation with any methods (not plan) without intent to act in the last month. RN #1 documented that Patient #1 did not have active suicidal ideation with some intent to act, without a specific plan in the past month, did not have active suicidal ideation with a specific plan and intent in the last month and did not have suicidal behavior in the last month. Given the answers to the Suicide Risk/Self Harm Assessment, the Patient #2 was identified as a moderate risk for suicide.

Review of the Recent Emergency Department Visit Summary indicated that on April 6, 2021, Patient #2 was at the Hospital's Emergency Department for Psychiatric Evaluation, Suicidal Ideation, being Suicidal, alcohol dependence and major depressive disorder. One month prior to this Emergency Department visit.

Review of the Hospital's Security Incident Report dated 5/6/2021 at 9:42 P.M. indicated that the triage nurse told the Security Officer that Patient #2 has suicidal ideation and for the Security Officer to keep an eye on Patient #2. The Security Officer notes indicated that the Security Officer escorted Patient #2 to a hallway bed in the Emergency Department. Once in the Emergency Department hallway, Patient #2 asked to use the bathroom, the Security Officer showed Patient #2 the bathroom and left the door open to continue to observe patient. The Security Officer's report indicated that Patient #2 had his/her bags in the bathroom and was able to ingest pills that were in his/her bag. The Security Officer then took the pills away and left Patient #2 to get the RN #2 who was assigned to the Patient once he/she was brought to the hallway bed. When the Security Officer left to get the nurse, Patient #2 was able to ingest more of his/her own medication from his/her belongings while under the observation of Hospital staff for suicidal ideation.

Review of the Patient Care Timeline indicated that the order for the Patient's belongings search was not placed until 7:30 P.M., 45 minutes after the Patient presented to the Emergency Department for suicidal intent and 32 minutes after Patient #2 was found to be moderate risk for suicide.

During an interview with the Police and Security Operations Manager on 2/2/22 at 8:50 A.M., he said that although the Security Officer was told to keep an eye on the Patient due to suicidal intent, the order for Patient Search wasn't placed at the time of ingestion.

During an interview with the Director of Emergency Services on 2/2/22 at 10:00 A.M., he said that the order for a search isn't in place at the initial moment of patients being identified in triage as suicidal. The Director of Emergency Services said that the incident happened in rapid sequence. He said that the Search Policy isn't consistent with the procedure used.

During an interview with RN #1 on 2/2/22 at 11:35 A.M., she said that she does not specifically recall this event. She said that she typically would screen the patient in the triage room, she would leave the suicidal patient in the triage room, with his/her belongings and notify the Charge Nurse that there is a suicidal patient who needs a bed. She does not call security to come and search belongings, that is done when the Patient is brought back to the Emergency Department.

During an interview with Charge Nurse #1 on 2/2/22 at 12:30 P.M., she said that if they tell security a patient is suicidal, the security would know to do a search. She said she is supposed to call the security office, tell them she has a suicidal patient and where a patient is being bedded. She said that is when she tells them to do a search and change of clothing for a suicidal patient.

During an interview with RN #2 on 2/3/22 at 8:35 A.M., she said that she was Patient #2's primary nurse when he/she was brought back to the hallway. RN #2 said that she recalls she had been starting her shift at the time of the event. She said that Patient #2 was accompanied by security and Patient #2 had a lot of belongings. She said that there hadn't been a Section 12 (involuntary hold order) placed yet so no search order had been placed.

2. Patient #10 is a 16-year-old who was admitted to the Inpatient Children's Psychiatric Unit in 4/2021 for depression, borderline personality traits, anxiety and impulsivity with risky behaviors. Patient #10 has a history of suicide attempts, intentionally overdosing on medications and alcohol.

Review of the Hospital's Levels of Patient Observation for Safety - Inpatient Psychiatric Units indicated that:

The level of observation for each patient is determined by a provider order.

Constant Observation (1:1)
- A patient is placed on 1:1 observation when the patient's psychosis, impulsivity, and/or suicidality/homicidality puts them, or others at acute risk of harm.
- A sitter safety sheet must be completed on each patient ordered for constant observation by the Charge or RN assigned to the patient. The sitter safety sheet should reflect the reason for observation, the level of observation, and any special instructions.
- Constant observation requires the sitter to remain focused and attentive to the patient at all times.
- depending on the patients clinical presentation and need, the constant observations will be ordered as a Level 1 within 2 - 4 feet of the patient and visualizing them at all times; or Level 2- maintain an unimpeded view of the patient at all times, either directly or via mirror.

Appendix B "Just in Time Orientation":

Patient is never to be left alone. You must be relieved by a nurse, another staff person appointed by the nurse before leaving the patient. Also, when the patient uses the bathroom or shower, the staff member must be able to visualize the patient at all times. Therefore, the bathroom or shower door must remain open to the extent necessary to visualize the patient, unless otherwise indicated by MD order.

Behavior to watch for and to report to the nurse: agitation, attempts to get out of bed, signs and symptoms of escalation, unusual behaviors, attempts to hurt self (be specific if possible), medical status changes, etc..

Review of the Physician's Orders dated 12/1/21 indicated that Patient #10 was on 1:1 observation (Level 2 with 15 minute checks).

Review of the Registered Nurse's (RN #5) Progress Notes dated 12/9/21 at 11:20 A.M, indicated that Patient #10 was very agitated because he/she was unable to attain the phone number of his/her case manager. Patient #10 left the nurses station in a very angry state and several staff members overheard him/her say that he/she was going to kill him/herself. Patient #10 went into his/her room after leaving the desk. Patient #10 was found in his/her bathroom with a pair of leggings wrapped tightly around his/her neck. Patient #10 was pulling on the legs in an attempt to strangle him/herself. This writer, with the assistance of two mental health specialists removed the clothing from around his/her neck. Patient #10 struggled during the process. Security was alerted for assistance if needed. Patient #10 left the bathroom and walked to the center of his/her room. Patient #10 dais that he/she would remain safe. Security remained in the area for several minutes.

Review of the Case Management Progress Note date 12/9/21 at 12:15 P.M. indicated that Patient #10 was an inpatient on the unit for 224 days. Patient #10 had suicidal thoughts/behaviors, as evidenced by expression of self-destructive thoughts/plans/gestures, non-compliance with therapeutic regimen, poor frustration tolerance, substance use in the context of suicidal ideation, hopelessness, and poor impulse control.

The Case Management Progress note indicated that Patient #10 wrote a letter to the case manager and to another staff member requesting to no longer work with them. Patient #10 refused to check in with the staff members in the morning.

Review of the Significant Event Note dated 12/9/21 at 12:21 P.M. indicated that Patient #10 self-reported to RN #6 that he/she drank a minimum of 2 fluid ounces of the Hospital supplied odor eliminator. The Patient was observed to be vomiting and was crying stating "I'm in so much pain and it burns". Patient was reporting feeling difficulty with breathing and with swallowing.

Review of the Rapid Response documentation dated 12/9/21 at 11:51 P.M. indicated that Patient 10 ingested room air freshener, approximately 2-4 fluid ounces. Patient was also tachycardic (increased heart rate) with nausea and vomiting.

Review of the Sitter/Safety Observer Sheet dated 12/9/21 indicated that at 11:30 A.M., Patient #10 was in the bathroom trying to strangle him/herself. Then at 11:45 A.M. Patient #10 was in the bathroom vomiting.

During an interview with the Nurse Director of the Inpatient Child Psychiatric Unit on 2/2/22 at 1:00 P.M., he said that Patient #10 had been there a long time and that the 1:1 staff got lax with their observation of Patient #10. The Nurse Director said that the 1:1 staff should have been more on top of the patient. He said that the policies are there, but weren't followed.

During an interview with RN# 5 on 2/3/22 at 10:00 A.M., she said that she doesn't remember if she was the 1:1 at the time that Patient #10 drank the deodorizer. She said that she was the nurse who went into the bathroom to remove the leggings when Patient #10 tried to strangle him/herself. RN #5 said that she doesn't know how Patient #10 was in the bathroom alone two times if she was on a 1:1. RN#5 said that she doesn't know where the patient got the room deodorizer or if the Hospital still has them available on the unit.

During an interview with RN #6 on 2/3/22 at 10:30 A.M., she said that some 1:1 find purging to be too difficult to tolerate so she went to check on Patient #10 who was purging in the bathroom. She said that when she went in the bathroom to check on Patient #10, she handed her a bottle and said she just drank it. RN #6 said she is unsure where Patient #10 got the bottle of deodorizer. She could not remember who the 1:1 was at the time of the ingestion.

The Hospital failed to do a timely search of Patient #2's belongings , while actively suicidal, allowing him/her the opportunity to ingest an unknown amount of medication in an act of self-harm while on a 1:1 safety observation; and the Hospital failed to provide adequate 1:1 supervision for Patient #10 while admitted on the Inpatient Child Psychiatric Unit, with suicidal ideation, allowing him/her to strangle him/herself with leggings in a closed bathroom and then ingest a bottle of deodorizer in an act of self-harm in a closed bathroom. Patient #2 and Patient #10 were both assessed to be at risk for suicide and required additional care as a result of their suicidal actions while on 1:1 constant observation while in the Hospital.

The Hospital failed to ensure that an investigation to track and analyze adverse events was performed in 4 (Patient #1, Patient #2, Patient #10 and Patient #11) of 11 medical records reviewed and corrective actions were implemented after adverse safety evens took place resulting in all four patients requiring additional care and or delayed discharge as a result of the safety events.
Findings Include:

Review of The Patient Care Assessment Plan (PCAP), revised 3/24/21, indicated that the Hospital is committed to its mission of providing high quality health care to its patients and the community it serves. To this end, there must be ongoing, critical review of all aspects of the provision of care to identify problems before they occur and to make possible the implementation of preventative measures designed to minimize or eliminate substandard practice.

Review of the Hospital's Safety Reporting Policy and Guidelines policy, dated 1/2021, indicated that:

a. The person who is accountable for the area/service in which the safety event occurred is responsible for investigating the event unless otherwise advised by the Director, risk management or his/her designee. The investigation and follow-up should include but is not limited to:

i. Interviewing involved staff and identifying factors that might have contributed to the safety event.
ii. Communicating with other hospital departments/staff who might have been directly involved with the safety event.
iii. Initiating action items/changes as a result of the safety event
iv. Ensuring that implemented corrective actions and improvements, if any, are monitored for effectiveness.

1. Patient #1 was admitted to the Hospital Intensive Care Unit (ICU) on 6/25/21 with acute hypoxic hypercarbic (too much carbon dioxide in the blood) respiratory failure and necrotizing left upper lobe pneumonia, and subsequently transferred to the Hospital's cardiac unit.

Review of the Hospital internal investigation indicated it was discovered Registered Nurse (RN)#3 administered the incorrect dose of Augmentin to Patient #1 on 7/9/21 at 2:00 P.M. Patient #1 experienced diarrhea after the medication error had been made and required intravenous (IV) fluids, additional labs, test for c-diff (a bacterium which affects the digestive system), close monitoring of vital signs, and delay of discharge from the Hospital. RN#3 handed the full bottle (75ml (milliliters)) of Augmentin to Patient #1; the Patient drank the whole bottle and received 15 times the ordered dose of Augmentin. RN#3 had never given an oral suspension of Augmentin before.

During an interview on 2/2/22 at 2:30 P.M., the Director of Risk Management said RN#3 administered the wrong dose of Augmentin to Patient #1; RN#3 had not administered liquid Augmentin before. She said the Hospital Pharmacy has implemented single dose vials for oral liquid antibiotics, however, the Hospital is still utilizing multi-dose containers of liquid medications. She said there was no formal education to verify all RNs with the potential to administer these medications had been re-educated.

The Hospital failed to re-educate and put corrective measures in place to prevent a like occurrence from happening in the future.

2. Patient #2 arrived in the Emergency Department in 5/2021 with suicidal ideation after overdosing on antidepressants.
The ED triage note indicated that at 6:54 P.M., Patient #2 endorsed that he/she is suicidal with a plan to overdose on drugs or alcohol. Patient admits to taking Wellbutrin (antidepressant) 5-8 tablets prior to arrival. Patient notes they are 300 mg XR (extended release).

Review of the Hospital's Security Incident Report dated 5/6/2021 written at 9:42 P.M. indicated that the triage nurse told the Security Officer that Patient #2 has suicidal ideation and for the Security Officer to keep an eye on Patient #2. The Security Officer notes indicated that the Security Officer escorted Patient #2 to a hallway bed in the Emergency Department. Once in the Emergency Department hallway, Patient #2 asked to use the bathroom, the Security Officer showed Patient #2 the bathroom and left the door open to continue to observe patient. The Security Officer's report indicated that Patient #2 had his/her bags in the bathroom and was able to ingest pills that were in his/her bag. The Security Officer then took the pills away and left Patient #2 to get the RN #2 who was assigned to the Patient once he/she was brought to the hallway bed. When the Security Officer left to get the nurse, Patient #2 was able to ingest more of his/her own medication from his/her belongings while under the observation of Hospital staff for suicidal ideation.

Review of the Emergency Department Provider Notes dated 5/6/21 at 10:29 P.M. indicated that Patient was then placed on a Section 12 and will require inpatient level of psychiatric care. Patient then had what appeared to be a tonic-clonic movement (seizure activity) and was obtunded, thrashing about. Then had a second episode which lasted for approximately 30 seconds. Patient then had a third seizure and the physician suspected it was delayed onset due to the extended release of the antidepressant that was taken while in the ED. Patient was then intubated, transferred to an ICU at another hospital via helicopter.

During an interview with the Director of Emergency Services, it was identified that the only corrective action was that the Security Officers were re-educated on suicidal patients.

There was no education to the nursing staff on appropriate suicide assessment, obtaining the search order in a timely manner and obtaining orders for constant observation in a timely manner.

3. Patient #10 is a 16-year-old who was admitted to the Inpatient Children's Psychiatric Unit in 4/2021 for depression, borderline personality traits, anxiety and impulsivity with risky behaviors. Patient #10 has a history of suicide attempts, intentionally overdosing on medications and alcohol.

Review of the Registered Nurse's (RN #5) Progress Notes dated 12/9/21 at 11:20 A.M, indicated that Patient #10 was very agitated because he/she was unable to attain the phone number of his/her case manager. Patient #10 left the nurses station in a very angry state and several staff members overheard him/her say that he/she was going to kill him/herself. Patient #10 went into his/her room after leaving the desk. Patient #10 was found in his/her bathroom with a pair of leggings wrapped tightly around his/her neck.
Patient #10 was pulling on the legs in an attempt to strangle him/herself. This writer, with the assistance of two mental health specialists removed the clothing from around his/her neck. Patient #10 struggled during the process. Security was alerted for assistance if needed. Patient #10 left the bathroom and walked to the center of his/her room. Patient #10 dais that he/she would remain safe. Security remained in the area for several minutes.

Review of the Case Management Progress Note date 12/9/21 at 12:15 P.M. indicated that Patient #10 was inpatient on the unit for 224 days. Patient #10 had suicidal thoughts/behaviors, as evidenced by expression of self-destructive thoughts/plans/gestures, non-compliance with therapeutic regimen, poor frustration tolerance, substance use in the context of suicidal ideation, hopelessness, and poor impulse control.

The Case Management Progress note indicated that Patient #10 wrote a letter to the case manager and to another staff member requesting to no longer work with them. Patient #10 refused to check in with the staff members in the morning.
Review of the Significant Event Note dated 12/9/21 at 12:21 P.M. indicated that Patient #10 self-reported to RN #6 that he/she drank a minimum of 2 fluid ounces of the Hospital supplied odor eliminator. Patient was observed to be vomiting and was crying stating "I'm in so much pain and it burns". Patient was reporting feeling difficulty with breathing and with swallowing.

Review of the Rapid Response documentation dated 12/9/21 at 11:51 P.M. indicated that Patient 10 ingested room air freshener, approximately 2-4 fluid ounces. Patient was also tachycardic (increased heart rate) with nausea and vomiting.

Review of the Sitter/Safety Observer Sheet dated 12/9/21 indicated that at 11:30 A.M., Patient #10 was in the bathroom trying to strangle him/herself. Then at 11:45 A.M. Patient #10 was in the bathroom vomiting.

During an interview with the Nurse Director of the Inpatient Child Psychiatric Unit on 2/2/22 at 1:00 P.M., he said that Patient #10 had been there a long time and that the 1:1 staff got lax with their observation of Patient #10. The Nurse Director said that the 1:1 staff should have been more on top of the patient. He said that the policies are there but weren't followed.

The Hospital was unable to provide any education or corrective measures placed as a result of Patient #10's two suicide attempts on 12/9/21 while on 1:1 constant observation. There was no corrective action provided regarding the fact that Patient #10 was able to be in the bathroom, 2 times with out supervision by the constant observer. Formal reeducation was never conducted to any staff members involved to prevent a like occurrence.


4. Patient #11 was admitted to the Hospital telemetry/medical unit on 8/27/21 with diagnoses of altered mental status, pneumonia and chronic kidney disease.

Review of the Hospital's internal investigation indicated it was discovered RN #4 administered the incorrect dose of Keflex to Patient #11 on 9/2/21. RN #4 administered the entire 100ml bottle to Patient #11 instead of the ordered 5ml dose.

Review of Patient #11's Physician orders indicated an order dated 9/2/21 for Keflex 250mg/5ml oral suspension 500mg (10ml) by mouth every 12 hours.

Review of Patient #11's Physician Progress Note dated 9/3/21 indicated Patient #11 received extra doses of cephalexin (Keflex) on 9/2/21 afternoon. Patient #11 received 5 Grams instead of 500mg (10 times the dose). The physician explained about possible side effects to the family including diarrhea, transaminitis, and acute kidney injury. The patient required monitoring for 24 hours and more labs were ordered.

During an interview on 2/2/22 at 2:30 P.M., the Director of Risk Management said the Hospital Pharmacy has implemented single dose vials for oral liquid antibiotics, however, the Hospital is still utilizing multi-dose containers of liquid medications. She said there was no formal sign off/attendance/read back receipts to verify all RNs with the potential to administer these medications had been re-educated.

During an interview on 2/3/22 at 10:43 A.M., the Chief Nursing Officer (CNO) said multi-dose containers for antibiotics have been switched to single dose units by the Hospital pharmacy; other multi-dose containers have not yet been requested for transition to single dose units. He said education for multi-dose medication containers and the five rights of medication administration were developed and sent to nursing staff, however, there was no way to track if all nursing staff had either opened the emails sent or participated in the education.

The Hospital failed to investigate, educate and put preventative measures in place after 2 patients were able to attempt suicide while on suicidal precautions and when 2 patients were administered over doses of medication inadvertently.

The Condition of Participation of Nursing Services was not met.

Findings include:

The Hospital failed to ensure for two patients (Patients #1 and #10), out of 11 sampled patients that the Hospital administered the correct dose of medication as ordered by a physician.

Refer to TAG: A-0405

Based on record review and interview, the Hospital failed to administer the correct dose of liquid Augmentin and Keflex (antibiotic medications) for 2 of 11 patients (#1 and #11), which resulted in delay of discharge and increased monitoring.

Findings include:

Review of the Hospital policy titled Medication Prescribing, Administration, and Dispensing, dated November 2004 and revised June 2020, indicated the following:
-The nurse will be accurate when he/she observes the five rights of drug administration, which are: 1. Right medication, 2. Right dose, 3. Right patient, 4. Right route, 5. Right time.
-If the nurse is using multiple dose containers for medication preparation, the following procedure is followed: May not be brought into patient's room.
-It is recommended that the nurse know the following before administering any medication: Nature of the drug.

1. Patient #1 was admitted to the Hospital Intensive Care Unit (ICU) on 6/25/21 with acute hypoxic hypercarbic respiratory failure and necrotizing left upper lobe pneumonia, and subsequently transferred to the Hospital's cardiac unit.

Review of the Hospital internal investigation indicated it was discovered Registered Nurse (RN)#3 administered the incorrect dose of Augmentin to Patient #1 on 7/9/21 at 2:00 P.M. Patient #1 experienced diarrhea after the medication error had been made and required intravenous (IV) fluids, additional labs, test for c-diff (a bacterium which affects the digestive system), close monitoring of vital signs, and delay of discharge from the Hospital. RN#3 handed the full bottle (75ml (milliliters)) of Augmentin to Patient #1; the Patient drank the whole bottle and received 15 times the ordered dose of Augmentin. RN#3 had never given an oral suspension of Augmentin before.

Review of Patient #1's Physician orders indicated an order dated 7/8/21 for Augmentin 250-62.5mg (milligrams)/5ml, give 250mg (5ml) daily starting 7/9/21. RN#3 administered the Augmentin to Patient #1 on 7/9/21 at 9:07 A.M.

Review of Patient #1's Hospitalist Progress Note dated 7/9/21 indicated Patient #1 was discharged, however, at 9 A.M. RN# made a mistake and gave the Patient 75ml of Augmentin instead of 5ml, shortly thereafter Patient #1 developed diarrhea. Patient #1 was started on IV fluids and antibiotics were held.


During an interview on 2/2/22 at 2:30 P.M., the Director of Risk Management said RN#3 administered the wrong dose of Augmentin to Patient #1; RN#3 had not administered liquid Augmentin before. She said the Hospital Pharmacy has implemented single dose vials for oral liquid antibiotics, however, the Hospital is still utilizing multi-dose containers of liquid medications. She said there was no formal sign off/attendance/read back receipts to verify all RNs with the potential to administer these medications had been re-educated.
The Hospital failed to ensure that the nursing staff had the ability to administer medications according to standards of practice and the five rights of medication administration.

2. Patient #11 was admitted to the Hospital telemetry/medical unit on 8/27/21 with diagnoses of altered mental status, pneumonia and chronic kidney disease.

Review of the Hospital internal investigation indicated it was discovered RN #4 administered the incorrect dose of Keflex to Patient #11 on 9/2/21. RN #4 administered the entire 100ml bottle to Patient #11 instead of the ordered 5ml dose.

Review of the Hospital Collaborative Case Review dated 9/29/21 indicated the following:
-RN #4 had never given oral suspension Keflex before.
-RN #4 had multiple preceptors who taught multiple methods for medication administration.
-The Medication Administration Record (MAR) can be confusing when viewed.
-Re-educate nursing staff regarding administration or oral suspension medications.

Review of Patient #11's Physician orders indicated an order dated 9/2/21 for Keflex 250mg/5ml oral suspension 500mg (10ml) by mouth every 12 hours.

Review of Patient #11's Physician Progress Note dated 9/3/21 indicated Patient #11 received extra doses of cephalexin (Keflex) on 9/2/21 afternoon. Patient #11 received 5 Grams instead of 500mg (10 times the dose). The physician explained about possible side effects to the family including diarrhea, transaminitis, and acute kidney injury. The patient required monitoring for 24 hours and more labs were ordered.

During an interview on 2/2/22 at 2:30 P.M., the Director of Risk Management said the Hospital Pharmacy has implemented single dose vials for oral liquid antibiotics, however, the Hospital is still utilizing multi-dose containers of liquid medications. She said there was no formal sign off/attendance/read back receipts to verify all RNs with the potential to administer these medications had been re-educated.

During an interview on 2/3/22 at 10:43 A.M., the Chief Nursing Officer (CNO) said multi-dose containers for antibiotics have been switched to single dose units by the Hospital pharmacy; other multi-dose containers have not yet been requested for transition to single dose units. He said education for multi-dose medication containers and the five rights of medication administration were developed and sent to nursing staff, however, there was no way to track if all nursing staff had either opened the emails sent or participated in the education.

The Hospital failed to ensure that the nursing staff had the ability to administer medications according to standards of practice and the five rights of medication administration.