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Based on staff interview and document review, it was determined the facility failed to ensure medications were administered in accordance with the orders of the prescriber in two (2) of four (4) medical records reviewed. Medical record #'s 1 and 2.

Findings:

Four (4) Medical Records were reviewed 04/11/23. The medical record for patient #1 contained documentation that the patient was in the Intensive Care Unit (ICU) with acute pancreatitis and alcohol withdrawal, was sedated, and being artificially ventilated. The patient had a physician's order for and was receiving on 03/09/23 Precedex (a medication for sedation) 1.3 mcg/hr to maintain sedation. The patient's Registered Nurse (RN) documented the following at 7:57 PM on 03/09/23: "Patient woke up by stimulation and became very agitated, restless, bucking vent, respiratory rate 40's, heart rate jumped from normal sinus rhythm to 110s-120s. Post lab draw, patient was unable to calm down, patient was given a bolus of sedation to help with elevated HR, restlessness and elevated respiratory rate." The medical record contained no documentation of what medication was given as the "bolus of sedation." The patient's medication administration record contained no documentation of a bolus or any as needed medication given on 03/09/23 between 7:00 PM and 9:00 PM.

The medical record for patient #2 was reviewed and contained the following note by the RN on 3/3/23 at 7:32 AM: "Upon giving morning meds, RN realized D10 bag was never clamped, so from 2200-0600 patient actually received D10 at 75 mL/hr instead of normal saline. Morning blood sugar spot checked at 05:15 was 97 mg/dL. Upon realizing error, D10 was clamped. Blood sugar checked at 07:29 was 64. Report given to day shift RN [name redacted]. States she will notify MD and start continuous D10 infusion at 60 mL/hr per protocol." Review of the patient's medication administration record indicated the patient was ordered Normal Saline, but received Dextrose 10% (D10W) in error. The medical record contain no documentation that the physician was notified or aware of the medication error.

An interview was conducted 04/11/23 with the charge RN (staff member #3) working on 03/09/23. Staff member #3 stated the family member for patient #1 requested to speak with the Charge RN. The patient's family stated the patient was agitated and the nurse "bolused the patient with Precedex, but the patient did not have an order to bolus Precedex." The family member requested the patient be immediately evaluated by a physician. The charge nurse stated she spoke to the bedside nurse who stated the patient was agitated and needed more sedation, so the nurse bolused Precedex from the line with a 10 mL syringe. The charge nurse stated that "we do not bolus Precedex here" and asked the bedside nurse why she gave a Precedex bolus with no order when other medications were available and ordered for agitation for patient #1. The bedside nurse stated, "it was just easier" to give the Precedex as the other medications available were given via a PCA (patient controlled analgesia) pump and the nurse would have needed to find a PCA key to give the medications. Staff member #3 stated the Precedex bolus caused no ill-effects to the patient. The patient's vital signs were stable. The physician was notified. At the time, the physicians were in their shift change report, but the physician came to the patient's bedside after report was finished to assess the patient. The medical record for patient #1 contained no documentation from the physician regarding the medication error or patient's condition after the Precedex was given.

The facility's policy, Medication Events (Adverse Drug Events, Adverse Drug Reactions, and Medication Errors) last revised 11/21, was reviewed and reads in part: "Reporting Errors to Practitioners. 1. Medication errors that have harmed or have the potential to harm (ADE, ADR) the patient must be immediately reported to the attending provider...2. If the outcome of the error is unknown, the provider must be notified without delay, Drug errors that result in no or insignificant harm to the patient must also be documented in the medical record but do not require immediate reporting to the attending physician...Medication Event Reporting Process....2. Examples of medication errors include, but are not limited to:...c. wrong dose (greater or less than prescribed)...i. medication not ordered...The medication administered in error or omitted in error and the action taken shall be promptly recorded in the patient's medical record. The entry in the patient's medical record need not indicate that an error occurred.

Based on staff interview and document review, it was determined the facility failed to ensure all nurses who provide services in the hospital adhered to hospital policies and procedures. Specifically, in two (2) of four (4) medical records reviewed, nursing staff failed to follow hospital policies related to medication errors to include documentation of the error in the patient record, notification of the error to the provider, and completing adverse event reports related to medication errors. Medical record #'s 1 and 2.

Findings:

Four (4) Medical Records were reviewed 04/11/23. The medical record for patient #1 contained documentation that the patient was in the Intensive Care Unit (ICU) with acute pancreatitis and alcohol withdrawal, was sedated, and being artificially ventilated. The patient had a physician's order for and was receiving on 03/09/23 Precedex (a medication for sedation) 1.3 mcg/hr to maintain sedation. The patient's Registered Nurse (RN) documented the following at 7:57 PM on 03/09/23: "Patient woke up by stimulation and became very agitated, restless, bucking vent, respiratory rate 40's, heart rate jumped from normal sinus rhythm to 110s-120s. Post lab draw, patient was unable to calm down, patient was given a bolus of sedation to help with elevated HR, restlessness and elevated respiratory rate." The medical record contained no documentation of what medication was given as the "bolus of sedation." The patient's medication administration record contained no documentation of a bolus or any as needed medication given to patient #1 on 03/09/23 between 7:00 PM and 9:00 PM.

The medical record for patient #2 was reviewed and contained the following note by the RN on 3/3/23 at 7:32 AM: "Upon giving morning meds, RN realized D10 bag was never clamped, so from 2200-0600 patient actually received D10 at 75 mL/hr instead of normal saline. Morning blood sugar spot checked at 05:15 was 97 mg/dL. Upon realizing error, D10 was clamped. Blood sugar checked at 07:29 was 64. Report given to day shift RN [name redacted]. States she will notify MD and start continuous D10 infusion at 60 mL/hr per protocol." Review of the patient's medication administration record indicated the patient was ordered Normal Saline, but received Dextrose 10% (D10W) in error. The medical record contain no documentation that the physician was notified or aware of the medication error.

An interview was conducted 04/11/23 with the charge RN (staff member #3) working on 03/09/23. Staff member #3 stated the family member for patient #1 requested to speak with the Charge RN. The patient's family stated the patient was agitated and the nurse "bolused the patient with Precedex, but the patient did not have an order to bolus Precedex." The family member requested the patient be immediately evaluated by a physician. The charge nurse stated she spoke to the bedside nurse who stated the patient was agitated and needed more sedation, so the nurse bolused Precedex from the line with a 10 mL syringe. The charge nurse stated that "we do not bolus Precedex here" and asked the bedside nurse why she gave a Precedex bolus with no order when other medications were available and ordered for agitation for patient #1. The bedside nurse stated, "it was just easier" to give the Precedex as the other medications available were given via a PCA (patient controlled analgesia) pump and the nurse would have needed to find a PCA key to give the medications. Staff member #3 stated the Precedex bolus caused no ill-effects to the patient. The patient's vital signs were stable. The physician was notified. At the time, the physicians were in their shift change report, but the physician came to the patient's bedside after report was finished to assess the patient. The medical record for patient #1 contained no documentation from the physician regarding the medication error, no documentation that the physician was made aware of the error, or of the patient's condition after the Precedex was given.

The surveyor requested the adverse event reports for the two (2) above noted medication errors. Per staff member #1, the facility had no record of documentation of adverse event reports for the errors.

The facility's policy, Medication Events (Adverse Drug Events, Adverse Drug Reactions, and Medication Errors) last revised 11/21, was reviewed and reads in part: "Reporting Errors to Practitioners. 1. Medication errors that have harmed or have the potential to harm (ADE, ADR) the patient must be immediately reported to the attending provider...2. If the outcome of the error is unknown, the provider must be notified without delay, Drug errors that result in no or insignificant harm to the patient must also be documented in the medical record but do not require immediate reporting to the attending physician...Medication Event Reporting Process....2. Examples of medication errors include, but are not limited to:...c. wrong dose (greater or less than prescribed)...i. medication not ordered...The medication administered in error or omitted in error and the action taken shall be promptly recorded in the patient's medical record. The entry in the patient's medical record need not indicate that an error occurred.

The facility's policy, SAFE Reports, last revised 01/23 was reviewed and reads in part: Content...Any associate or physician who has been involved in a patient event or has direct knowledge of a patient event must complete the appropriate Patient SAFE Report...Process...b. If the event reaches the patient, then the Associate or physician completed the appropriate SAFE report as soon as possible, preferably within 24 hours.