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Based on observation, interview, medical record, and document review, it was determined that the governing body failed to assure safe medication administration practices to their patient population. As demonstrated by examples identified throughout the body of this report, policies and procedures were in place integrating safety measures to assure the right medication is given to the right patient. Elements of the policy are not being followed by the nursing staff. The governing body must assure policy and procedures are developed, implemented and followed to assure patient safety.

The cumulative effect of these systemic problems placed all patients at risk for medication errors and not receiving care in a safe setting.

Reference deficiencies written at Tag A385 - Nursing Services

Based on interviews, document review and medical record review, the Condition of Participation: Nursing Services is substantially not met as evidenced by the following findings. Failure to meet the elements of patient assessment prior to administering medications and safe medication preparation and administration places patients at risk of medication errors.

Findings include:

Patient #1 entered the respondent facility on May 16, 2014 for a surgical procedure. Patient #1 brought in a list of current medications and this list was transcribed correctly to the Medication Reconciliation record by the admitting nurse. This record becomes the physician orders and is signed and dated per the hospital Medication Order policy. This record is then faxed to Pharmacy where the pharmacist transcribes (types/inputs) the order into the computer system. The pharmacist selects the medications from a list of drugs in the computer system and erroneously selected the wrong medication for Patient #1. This wrong medication was displayed on the electronic Medication Administration Record that is used by the nurses to administer medications to the patients. The error was validated by the Pharmacy Manager on 9/9/14.

The patient's home medication included Prozac (fluoxetine) for the treatment of depression. The pharmacist selected furosemide (Lasix) a diuretic (water pill). Both medications are given once a day and the patient received two days of medication. The medical record does not document any negative outcomes from the medication error however potassium levels were monitored by the physician. Based on interview with the patient on August 22, 2014 at 2:00 PM, the patient stated s/he could feel the effects of stopping the fluoxitine while in the hospital since it is supposed to be weaned off slowly. The patient states s/he felt "strange" and knew it was not related to the surgery.

On 5/17/14, the patient's potassium was measured (included in post-operative lab orders) at 3.2 L. "Normal" levels are 3.5 - 5 L depending on the patient situation. Potassium replacement was ordered prior to the medication error based on the post-operative laboratory results. Below normal potassium blood levels can result in serious heart arrhythmias (irregular heart beat). Patient #1 received 10 doses of oral potassium at 20 meg each dose. Patient #1 potassium level on 5/22/14 raised to 3.8 L and the potassium replacement was discontinued by Physician #1.

The error was discovered by Physician #1 on 5/19/14 and discontinued. A quality management report was completed and the error was investigated by hospital leadership. The error was attributed to the pharmacist transcribing the medication incorrectly and no other systemic changes were made at the time of the investigation (5/27/14-5/31/14).

The safety measure placed in the facilities' policy titled Medication System states that the Medication Administration Record (MAR) is sent to the nursing unit and it is the responsibility of the nurse to validate the medication with the original physician order. This did not happen with Nurse #1 for Patient #1.

Seven additional nurses were interviewed on the medication validation process. Nurses #2, #4, and #6 were not able to state that medications were to be checked with the original physician order. When the pharmacist transcribes the original order into the computer system, this order now shows up in the same module as when the physician places the order directly into the computer. Nurses #2, #4 and #6 stated that they check the orders with the information in this module. This eliminates the safety check of the nurse verifying the orders with the original physician order when the pharmacist is the person to transcribe the order into the computer system.

The next safety check included in the Medication System policy states that when Medication Administration Records are used for multiple days, the second and ensuing MAR "is verified by the night shift nurses using the current MAR/physician orders". This step was not completed for Patient #1 resulting in a second day/second dose of the incorrect medication being administered. On interview with Nurses #1 through #7, this process has not been performed since the computer conversion (over 1 year ago) contrary to the current policy.

The medication reconciliation process is outlined in the facility's policy "Medication Reconciliation". The polices states that "Patients shall have all medications reconciled within 24 hours of admission. Nurse, Pharmacist or Physician/Provider shall review the home medication list to verify that each medication was addressed within 24 hours of admission or whenever updated information obtained."
On review of 10 medical records:
Medical record #1 did not have a medication reconciliation record for the inpatient visit of 6/10/14-6/14/14.
Medical record #2 did not have a medication reconciliation record for the inpatient visit of 8/10/14-8/12/14
Medical record #5 did not have a medication reconciliation record for the inpatient visit of 7/10/14-7/15/14
Medical record #6 had a completed medication reconciliation form but not signed or dated by the physician/provider for the inpatient stay 7/1/14-7/2/14.
Medical record # 7 did not have a medication reconciliation record for the inpatient visit of 6/4/14-6/7/14

The above information was verified by the clinical nurse administrator and the manager of the quality department on 9/9/14.

Based on interview and medical record review, the hospital failed to evaluate the nursing care for each patient. Failure to evaluate patients condition, treatment plan and effects of medications places patients at risk for medication errors.

Findings include:

Patient #1 entered the respondent facility on May 16, 2014 for a surgical procedure. Patient #1 brought in a list of current medications and this list was transcribed correctly to the Medication Reconciliation record. This record becomes the physician orders and is signed and dated per the hospital Medication Order policy. This record is then faxed to Pharmacy where the pharmacist transcribes the order into the computer system. The incorrect medication was placed into the computer system.

Prior to administration of medications, the nurse is to have knowledge of the disease process and indications for and effects of the medications. (Stated in the Medication System Policy). The medication error resulted in a medication that would decrease a patient's potassium level. Patient #1 was being treated for low potassium through replacement therapy. There are no nursing notes indicating the medication could be contraindicated and that the physician was questioned prior to administering the medication.

The above information was verified by the clinical nurse administrator and quality department manager on 9/9/14.

Based on interviews, document review and medical record review, the hospital failed to administer medications according to the facility's policy on medication administration. Failure to follow the policy places patients at risk for medication errors.

Findings include:

Patient #1 entered the respondent facility on May 16, 2014 for a surgical procedure. Patient #1 brought in a list of current medications and this list was transcribed correctly to the Medication Reconciliation record. This record becomes the physician orders and is signed and dated per the hospital Medication Order policy. This record is then faxed to Pharmacy where the pharmacist transcribes the order into the computer system. The incorrect medication was placed into the computer system.

The safety measure placed in the facilities' policy titled Medication System states that the medication administration record is sent to the nursing unit and it is the responsibility of the nurse to validate the medication with the original physician order. This did not happen with Nurse #1 for Patient #1.

Seven additional nurses were interviewed on the medication validation process. Nurses #2, #4, and #6 were not able to state that medications were to be checked with the original physician order. When the pharmacist transcribes the original order into the computer system, this order now shows up in the same module as when the physician places the order directly into the computer. Nurses #2, #4 and #6 stated that they check the orders with the information in this module. This eliminates the safety check when the pharmacist transcribes the order.

The next safety check included in the Medication System policy states that when Medication Administration Records are used for multiple days, the second and ensuing MAR "is verified by the night shift nurses using the current MAR/physician orders". This step was not completed for Patient #1. On interview with Nurses #1 through #7, this process has not been performed since the computer conversion contrary to the current policy (over one year ago).

Prior to administration of medications, the nurse is to have knowledge of the disease process and indications for and effects of the medications. (Stated in the Medication System Policy). The medication error resulted in a medication that would decrease a patient's potassium level. Patient #1 was being treated for low potassium through replacement therapy. There are no nursing notes indicating the medication could be contraindicated and that the physician was questioned prior to administering the medication. Nurse #1 failed to assess the effect of the medication on Patient #1 prior to administering the medication.

The medication reconciliation process is outlined in the facility's policy "Medication Reconciliation". The polices states that "Patients shall have all medications reconciled within 24 hours of admission. Nurse, Pharmacist or Physician/Provider shall review the home medication list to verify that each medication was addressed within 24 hours of admission or whenever updated information obtained."
On review of 10 medical records, medical record #1, #2, #5, #6 and #7 did not have the completed medication reconciliation information in the record. (See Tag 0385)

On 5/16/14, Patient #1 returned from surgery with an arterial line for cardiovascular monitoring. The nursing staff documents all central lines, venous and arterial, in the patient's profile on the computer per nursing documentation policy. When Pharmacy receives an order for potassium, the practice is that the pharmacist checks the patient profile for a "central line" instead of clarifying with the primary nurse as to what type of central line the patient had, arterial or venous. This process is not covered in the Medication System Policy and based on interview with the Pharmacy Manager, this near-miss required the pharmacy to review the practice and draft a policy to ensure a failsafe way to identify whether or not the patient has a venous central line prior to processing the medication order. The pharmacy processed the potassium for Patient #1 to be given through a venous central line as they did not did not read the details of what type of central line was present and did not validate the information with the primary nurse. This was verified by the Pharmacy Manager on 9/8/14.

The primary nurse removed the prepared potassium infusion (40 meq in 100 ml of fluid) that is clearly marked "For Central Line Administration" from the medication room. The primary nurse was then called to an emergency on his/her second patient and a hand-off was given to a Nurse #3. Based on interview with Nurse #3, no information regarding the patient venous access options were provided in the hand-off report. When Nurse #3 entered the patient room, s/he discovered the patient did not have a venous central line and explained to the patient that s/he needed to call the physician for a change of order. The error was discovered prior to administering the medication by the nurse. This was verified by the clinical nurse administrator on 9/9/14.

Based on interview and document review, the pharmacy failed to implement a policy standardizing the method to ascertain the correct delivery route for potassium. Failure to standardize a process places patients at risk for medication errors.

Findings include:

On 5/16/14, Patient #1 returned from surgery with an arterial line for cardiovascular monitoring. The nursing staff documents all central lines, venous and arterial, in the patient's profile on the computer per nursing documentation policy. When Pharmacy receives an order for potassium, the practice is that the pharmacist checks the patient profile for a "central line" instead of clarifying with the primary nurse as to what type of central line the patient had, arterial or venous. This process is not covered in the Medication System Policy and based on interview with the Pharmacy Manager, this near-miss required the pharmacy to review the practice and draft a policy to ensure a failsafe way to identify whether or not the patient has a venous central line prior to processing the medication order. The pharmacy processed the potassium for Patient #1 to be given through a venous central line as they did not did not read the details of what type of central line was present and did not validate the information with the primary nurse. This was verified by the Pharmacy Manager on 9/8/14.