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Based on medical record review, staff interview, review of policies and procedures, and review of professional standards of practice, the facility failed to ensure medications were administered as ordered and per accepted standards of practice for 2 of 5 sample patients (#1, #4). The findings were:

1. According to physician orders, patient #1 was admitted on 2/26/11 at 10:26 AM. At 10:33 AM the physician ordered Citracal + D one tablet twice daily. Although the order was accepted by both the RN and the pharmacist, the physician failed to include the dosage to be administered. At 10:48 AM, a pharmacist modified the order to read Calcium 315 mg/Vit D 250 units/tab (the dose the patient was taking at home), and the status was entered as "Discontinued." At 6:57 PM that day, an RN notified pharmacy the above order was discontinued, and at 8:14 PM the pharmacist acknowledged the notification. On 2/27/11 at 8:24 AM the system generated a stop order from the physician, effective at 8:35 AM. Stop orders were also generated by the system at 7:07 PM the evening of 2/27/11, one for an unidentified amount of Calcium and Vitamin D and one for Calcium 600 mg with Vitamin D 400 units. On 2/28/11 at 7:03 PM an RN generated an order to discontinue Calcium 600 mg/Vit D 400 units. On 2/27 and 2/28/11, nursing and pharmacy also ordered and/or approved Caltrate 600 mg/Vit D 400 units, then changed the order to Calcium 600 mg/Vit D 400 units, as that was what was stocked per the formulary, and sent them to the physician for approval.
Review of the patient's MARs showed the patient received Calcium 600 mg with Vit D 400 units at 9 PM on 2/27/11 and 9 AM on 2/28/11, as scheduled. The order was discontinued at 7:03 PM on 2/28/11 and Calcium 600 mg/Vit D 400 units was rescheduled at 9 AM and 5 PM on 2/28/11 at 11:28 PM. The patient also received the medication at 9 AM on 3/1/11 before it was discontinued at 11:26 AM that day. The following concerns were identified:
a. Even though the original order did not include all required elements for an appropriate order, it was accepted by both nursing and pharmacy. Then, instead of being clarified, the order was discontinued by the pharmacist. According to Elkin, Perry, and Potter in "Nursing Interventions & Clinical Skills," 4th Edition, 2007; page 367: physician orders are to include "...The name of the drug...The dose..." According to Smith, Duell, and Martin in "Clinical Nursing Skills: Basic to Advanced Skills," Seventh Editin, 2008; page 568: "If a written order is illegible or is questionable for any reason, the physician must be notified for clarification."
b. The patient did not receive the ordered doses of calcium 315 mg/vitamin D 250 units on 2/26/11, nor of calcium 600 mg/vit D 400 units the morning of 2/27/11. The reasons documented were "Not appropriate at this time" or "Not available from Pharmacy." On 3/16/11 at 2:05 PM the DON and pharmacy manager confirmed the ordered dose was not available.
c. During the aforementioned interview, the DON and pharmacy manager confirmed a local pharmacy was not contacted in order to obtain the correct dose of the medication, even though the pharmacy manager stated it was common practice to obtain medications not stocked in the facility in this way. Neither the DON nor the pharmacy manager could provide a reason for this omission. The DON stated the facility did not have a policy for obtaining medications not stocked by the facility.
d. The physician was not notified of the unavailability of the medication from 2/26/11, when he first ordered it, until 2/27/11 at 5:03 PM.
e. According to the facility's policy and procedure, "Automatic Therapeutic Medication Substitution" Number: 3649, Effective Date: 2/1/2011: "Two or more drug products are considered to be generic equivalents if they contain the same active ingredients and are identical in dosage form, strength, and route of administration." The medication this patient finally received was not the same dose that s/he took at home and was originally ordered.

2. Medical record review showed patient #4 was seen in the emergency department on 2/23/11 and an IV of 1000 ml of normal saline at 100 ml per hour (a 10 hour run time) was ordered. Review of the MAR showed the IV was started at 7:55 AM. Further review of the documentation on the MAR showed that 500 ml of fluid had been infused by 10:30 AM instead of the 250 ml that should have been infused. During an interview on 3/16/11 at 2:05 PM, the DON confirmed the documentation was accurate and that all IV fluids were administered by pump. After reviewing the facility's electronic record, the DON stated there was no other documentation that provided a rationale for the excessive amount of fluid the patient received. She further stated she would interview the nursing staff to determine their rationale for the amount infused. Review of information sent by the facility on 3/21/11 showed the RN "...used nursing judgment to increase fluids. Frequent pain medication was being administered...The medications were bolused, and fluids were increased based on the nurses' knowledge of the pharmacological properties of the medications...and administration of an IV bolus medication." Review of the timeline included with the information showed the patient received pain medication at 7:55, 8:13, 8:40, 9:00, and 9:57 AM that morning. The patient also received one dose of an anti-nausea medication at 8:13 AM, for a total of six different medications. According to information faxed by the facility on 3/23/11 from Lippincott, Williams, Wilkins in "Lippincott Manual of Nursing Practice," 9th edition, 2010: an IV bolus is the same as an IV push (IVP) medication, and the IV should be flushed "with saline before and after administration of a drug." Since the IV already running was normal saline, there was no need to flush the tubing before administration of the medications. Interview with the DON on 3/23/11 at 10:05 AM revealed staff were to administer IVP medications in the closest port to the IV site. According to Elkin, Perry, and Potter "Nursing Interventions & Clinical Skills" 4th Edition, 2007, page 627: IV medications should be followed with 5 ml of normal saline to flush the line. This would result in a maximum amount of 30 ml of fluid instead of 250 ml.
Review of the orders after the patient was admitted to acute care on 2/23/11 at 10:34 AM showed the order for IV fluids was changed to 1000 ml of Normal Saline to run at 125 ml per hour (an 8 hour run time). Review of the MAR showed an IV was hung at 6:34 AM on 2/24/11, but it was not infused until 8:20 PM that evening, almost 14 hours later. During interview on 3/16/11 at 2:05 PM, the DON confirmed the documented infusion time was correct and that all IVs were on pumps. She was unable to find any evidence in the electronic record that explained this discrepancy. On 3/24/11 at 10:03 AM the DON stated that the patient received two IV piggyback medications to run one hour each, but this still did not explain the time discrepancy of a 12 hour run time. She further stated there was no evidence the physician was notified or that a new order was received.
Finally, the IV initially hung in the emergency department at 7:55 AM on 2/23/11 was completed at 7 PM that evening, but there was no evidence another IV was started at that time. Although IV piggyback medications were hung at 8:09 PM on 2/23/11 and at 2:05 on 2/24/11, each ordered to be infused within an hour, the facility was unable to provide evidence that another main IV of normal saline was infusing before 6:34 AM on 2/24/11.