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Based on medical record reviews, policy and procedure reviews, physician credential file reviews, hospital documentation reviews, physician and staff interviews the hospital's Governing Body failed provide oversight and assure the Medical Staff developed and implemented effective systems to ensure the administration of methadone tapers to patients for opioid withdrawal in a safe and effective manner; failed to ensure physician's were privileged by the Medical Staff and approved by the Governing Body to prescribe methadone tapers for opioid withdrawal; and failed to develop and maintain an effective, hospital-wide, data-driven quality assessment and performance improvement program to ensure the safe and effective administration of methadone tapers to patients for opioid withdrawal.

The findings include:

1. The hospital failed to assure the patient's right to care in a safe setting for patients receiving Methadone tapers for opioid withdrawal in the Opioid Treatment Program (OTP).

~Cross refer to 482.13 Patients' Rights, Condition Tag A0115.

2. The Medical Staff (MS) failed to ensure that physicians providing care in OTP using Methadone tapers for opioid withdrawal were qualified and granted privileges per the MS Bylaws.

~Cross refer to 482.22 Medical Staff, Condition Tag A0338.

3. The Quality Assessment Performance Improvement program failed to ensure corrective action plans implemented for the safe administration of Methadone tapers to patients for opioid withdrawal in the OTP were monitored and evaluated for effectiveness.

~Cross refer to 482.21 Quality Assessment Performance Improvement, Condition Tag A0263.

Based on medical record reviews, review of Emergency Medical Services call report record, Clinical Director, Medical Director, Physician and staff interviews and review of the Report of Autopsy Examination, the hospital failed to assure the protection and promotion of patient's right to care in a safe setting for patients receiving Methadone in the Opioid Treatment Program (OTP) for opioid withdrawal/detoxification.

The findings include:

The hospital failed to ensure safe delivery of Methadone in the Opioid Treatment Program (OTP) to patients receiving Methadone for opioid withdrawal/detoxification for 1 of 1 patients that expired (#8).

~cross refer to 482.13(c)(2) Patient Rights Standard: Care in a Safe Setting, Tag A0144

Based on medical record reviews, review of Emergency Medical Services call report record, Clinical Director, Medical Director, Physician and staff interviews and review of the Report of Autopsy Examination, the hospital failed to ensure safe delivery of Methadone in the Opioid Treatment Program (OTP) to patients receiving Methadone for opioid withdrawal/detoxification for 1 of 1 patients that expired (#8).

The findings include:

Medical record review of Patient #8 revealed a 42 year old male patient admitted to the ADATC (Alcohol, Drug Abuse Treatment Center) on 8-12-09 for a diagnosis of opioid (heroin) dependence. Record review of the admission assessment completed by Physician #2 on 8-12-09 at 1445 revealed the patient's chief complaint was "withdrawal from heroin." Record review revealed the patient told the staff on admission that he had not been using cocaine and was using approximately 1 gram of heroin a day. Review of the nursing admission assessment revealed the patient told the staff that Methadone made his pain better and he needed Methadone 50 mg. Review of the legend for the parameters for Clinical Opiate Withdrawal Scale (form used to assess and rate signs and symptoms of withdrawal the patient is exhibiting) revealed a score of 5-12 was mild, 13-24 was moderate, 25-36 was moderately severe, and more than 36 was severe withdrawal. Review of the Clinical Opiate Withdrawal Scale (COWS) on 8-12-09 at 1640 revealed the total COWS Score was "9," mild per the facility parameters. Record review revealed Physician #2 ordered a urine drug screen (UDS) on admission and an initial dose of Methadone 20 mg by mouth to be given to the patient. The initial dose of Methadone was administered to the patient at 1749 (the patient rated mild signs of withdrawal per the facility previously at 1640). Medical record review revealed the physician ordered a Methadone taper to be started the next day (8-13-09) for Methadone 10 mg by mouth four times per day, Methadone 10 mg by mouth three times per day on 8-14-09, Methadone 5 mg by mouth four times per day on 8-15-09, Methadone 5 mg by mouth three times per day on 8-16-09, Methadone 5 mg by mouth two times per day on 8-17-09 and 5 mg by mouth every morning on 8-18-09. Record review revealed no documentation of of the urine drug screen being obtained prior to the administration of the initial dose of Methadone given to the patient.

Record review revealed the urine was obtained for the UDS on 8-13-09 at 0610. Record review revealed Physician #1 examined the patient the morning of 8-13-09. The physician wrote an order on 8-13-09 at 1000 to discontinue Methadone and an order to give the patient "Methadone detox - 10 mg po (by mouth) x 1 as soon as possible." Further review revealed Physician #1 continued the written order for the "methadone detox" for 20 mg by mouth three times per day for 8-13-09, 20 mg by mouth three times per day for 8-14-09, 20 mg by mouth every morning, 20 mg by mouth at 1400 and 10 mg at bed time on 8-15-09, 10 mg by mouth four times per day on 8-16-09, 10 mg by mouth three times per day for 8-17-09 and "will write further orders p (after) 8-17." Review of the Clinical Opiate Withdrawal Scale (COWS) on 8-13-09 at 0755 revealed the Total COWS Score was "14," moderate symptoms of withdrawal per the facility parameters. Record review revealed the UDS results were available at 0900 on 8-13-09. Review of the UDS revealed it was negative for opiates (Heroin), positive high for Cocaine at 1,140, (841 above negative; normal/negative equal to or less than 299), positive high for Methadone at 929 (650 above negative; normal/negative amount equal to or less than 299) and positive High for Cannabinoid at 83, (64 above negative; normal/negative amount equal to or less than 19). Review of the UDS revealed initials of Physician #1 without date or time noted. Record review revealed the patient had received 20 mg of Methadone on 8-12-09 at 1749 prior to the time the urine was obtained for the UDS. Record review revealed on 8-13-09 the patient was administered Methadone 10 mg by mouth at 0829, Methadone 10 mg by mouth at 1131 and Methadone 20 mg by mouth at 1428. Record review revealed a COWS assessment of the patient on 8-13-09 at 1545, resulting in a score of 8, mild symptoms of withdrawal per the facility parameters. Record review revealed the patient was administered Methadone 20 mg at 2124 on 8-13-09. Record review revealed the patient was given Methadone 60 mg after the urine was obtained and after the results were positive high for Methadone at 929 (650 above negative (normal/negative amount equal to or less than 299). Record review revealed at 0045 on 8-14-09 the patient was found in the bathroom non-responsive with a faint pulse. Documentation by the nursing staff revealed the patient was placed on the floor and cardiopulmonary resuscitation was started (CPR). Documentation revealed a "Code" was called at 0047. Nursing documentation revealed "911" was called. Record review revealed no further documentation until 0410. The nurse accompanied the patient on transport to the hospital. The nurse documented the patient had been transported to the local acute care hospital and the patient was admitted to the Intensive Care Unit.

Interview with administrative staff on 3-8-2010 at 1030 revealed documentation of the care provided by the nursing staff during the code was not available. The interview revealed the documentation was missing.

Review of the Emergency Medical Services (EMS) call report record revealed EMS was called for a cardiac arrest at the hospital at 0104. Review revealed EMS arrived at the hospital at 0110 finding the patient on the floor with hospital staff performing CPR. EMS "took over" CPR and placed the patient on a heart monitor. The heart monitor showed the patient was in a heart rhythm that would not sustain life (PEA Pulseless Electrical Activity). Documentation revealed EMS gave the patient Narcan twice (medication used to reverse overdose of narcotics). Documentation revealed the patient "got a heart beat back." EMS transported the patient to a local acute care hospital.

Interview with the Clinical Director of the OTP on 3-5-2010 at 1430 revealed she had reviewed the medical record of Patient #8. The interview revealed Patient #8 had expired after transfer to the local hospital. The interview revealed she had been made aware of concerns with the care of Patient #8 by the Medical Director. The interview revealed Patient #8's care had been peer reviewed and a Root Cause Analysis (RCA) had been completed to evaluate what happened and what could be done to prevent a similar event. The interview revealed the facility did not have a specific protocol or policy for Methadone withdrawal/detoxification prior to the death of Patient #8. The interview revealed after a review of the case (Patient # 8) it was noted that the Methadone had been given to the patient prior to the results of the urine drug screen (UDS). The interview revealed the Methadone withdrawal/detoxification orders had been initiated based on the patient's subjective complaints. The interview revealed all orders should be initiated after subjective and objective data was obtained. The interview revealed a physician should not "cave in to" the patient's demands. The interview revealed the standard of practice is that Methadone for withdrawal/detoxification should be given after knowing the results of the UDS.

Interview with the Medical Director of the OTP on 3-5-09 at 1430 revealed he was aware of the patient death (Patient #8) when he called the local acute care hospital that the patient was transferred. The interview revealed the patient expired on 8-15-09. The interview revealed he (Medical Director) had immediately looked at Patient's #8's record due to the patient having a negative outcome when the patient coded at the ADATC. The interview revealed he had concerns when he saw the UDS was negative for opiates (heroin) and positive for cocaine. The interview revealed giving Methadone to a patient with cocaine in their system was serious since the two drugs preferably should not be given together (contraindicated). The interview revealed Physician #1 may not have reviewed the UDS results even though the results were available on computer. Interview revealed lab reports are sent to a central location before being sent to the nursing units. The interview revealed there was no time documented when the UDS results were placed on the medical record. The interview revealed Physician #1 had been "counseled" regarding Patient #8 being given Methadone based on subjective data and prior to the UDS results were known. The interview revealed there was no documentation available for the counseling and none would be found in the credential file. Interview revealed in August 2009 the facility did not have a protocol or policy for Methadone usage in withdrawal/detoxification. The interview revealed after the RCA was conducted, multiple policies were put in place. The interview revealed the standard of practice is that Methadone for withdrawal/detoxification should be given after knowing the results of the UDS.

Interview with Physician #1 on 3-8-09 at 1126 revealed the physician was the physician of record for Patient #8. The interview revealed he did not review the UDS until 8-14-09 (the morning after the patient coded). The interview revealed he had ordered on the morning of 8-13-09 a Methadone taper and increased the individual dosage to 20 mg (double the original admission dosage of 10 mg) because of the patient complaining most of the night and requesting from the staff more medications for withdrawal symptoms.

Interview with the Clinical Director of the OTP on 3-8-09 at 1159 revealed she thought in August, 2009 that the facility had a protocol/policy for Methadone usage in opiate withdrawal. The interview revealed since Patient #8's death she had learned there was no formal policy for Methadone usage. The interview revealed this policy came from physicians practicing for years and the practice was passed down by word of mouth. The interview revealed the facility should have had a formal policy and procedure for opiate withdrawal protocols.

Review of the "Report of Autopsy Examination" for Patient #8 revealed "It appears likely that he mislead the treatment center in regard to his heroin abuse since a negative urine screen for opiates 12 hours after admission is unlikely if he had been using heroin at the level he had claimed positive cocaine results indicate that he had been using cocaine just prior to his admission and raises the possibility that his complaints might have been related to withdrawal from that drug...administration of 80 mg of methadone in a little less than 26 hours could have contributed to his arrest...The most likely scenario is that an acute cardiac event led to his anoxic brain injury. He had been abusing cocaine which has cardiotoxic properties and methadone can also have adverse cardiac effects. In our opinion it is reasonable to conclude that his death was the consequence of cocaine and methadone toxicity through a cardiac mechanism."

Based on medical record reviews, policy and procedure reviews, physician credential file reviews, hospital documentation reviews, physician and staff interviews the hospital's leadership staff failed to maintain an effective, hospital-wide, data-driven quality assessment and performance improvement program to ensure the safe and effective administration of Methadone tapers in the opioid treatment program to patients for opioid withdrawal.

The findings include:

The hospital's leadership failed to have systems in place to guide, monitor and ensure oversight of the medical staff prescribing methadone tapers for opioid withdrawal in the opioid treatment program.

~cross refer to 482.21(c)(3) QAPI Standard: QAPI Improvement Measures, Tag A0290

Based on interviews with the Clinical Director and Medical Director of the Alcohol, Drug Abuse Treatment Center (ADATC), review of physician team meeting minutes and review of Performance Improvement (PI) data, the Medical Staff failed to monitor improvement actions taken after a patient being treated for opioid detoxification died (#8).

The findings include:

Interview with the Clinical Director of the ADATC on 3-5-2010 at 1430 revealed she had reviewed the medical record of Patient #8. The interview revealed Patient #8 had expired after transfer to the local hospital. The interview revealed she had been made aware of concerns with the care of Patient #8 by the Medical Director. The interview revealed Patient #8's care had been peer reviewed and a Root Cause Analysis (RCA) had been completed to evaluate what happened and what could be done to prevent a similar event. The interview revealed the facility did not have a specific protocol or policy for Methadone withdrawal/detoxification prior to the death of Patient #8. The interview revealed after a review of the case (Patient # 8) it was noted that the Methadone had been given to the patient prior to the results of the urine drug screen (UDS). The interview revealed the Methadone withdrawal/detoxification orders had been initiated based on the patient's subjective complaints. The interview revealed all orders should be initiated after subjective and objective data was obtained. The interview revealed a physician should not "cave in to" the patient's demands. The interview revealed the standard of practice is that Methadone for withdrawal/detoxification should be given after knowing the results of the UDS. The interview revealed policy and procedures were put into place for opiate withdrawal within 2 weeks. The interview revealed a "new" policy was instituted regarding labeling high risk patients. The interview revealed the polices required changes as late as December 2009.

Interview with the Medical Director of the ADATC on 3-5-09 at 1430 revealed he was aware of the patient death (Patient #8) when he called the local acute care hospital that the patient was transferred to. The interview revealed the patient expired on 8-15-09. The interview revealed he (Medical Director) had immediately looked at Patient's #8's record due to the patient having a negative outcome when the patient coded at the ADATC. The interview revealed he had concerns when he saw the UDS was negative for opiates (heroin) and positive for cocaine. The interview revealed giving Methadone to a patient with cocaine in their system was serious since the two drugs preferably should not be given together (contraindicated). The interview revealed Physician #1 may not have reviewed the UDS results even though the results were available on computer. Interview revealed lab reports are sent to a central location before being sent to the nursing units. The interview revealed there was no time documented when the UDS results were placed on the medical record. The interview revealed Physician #1 had been "counseled" regarding Patient #8 being given Methadone based on subjective data and prior to the UDS results were known. The interview revealed there was no documentation available for the counseling and none would be found in the credential file. Interview revealed in August 2009 the facility did not have a protocol or policy for Methadone usage in withdrawal/detoxification. The interview revealed after the RCA was conducted, multiple policies were put in place. The interview revealed the standard of practice is that Methadone for withdrawal/detoxification should be given after knowing the results of the UDS.

Interview with the Clinical Director of the ADATC on 3-8-09 at 1159 revealed she thought in August, 2009 that the facility had a protocol/policy for Methadone usage in opiate withdrawal. The interview revealed since Patient #8's death she had learned there was no formal policy for Methadone usage. The interview revealed this policy came from physicians practicing for years and the practice was passed down by word of mouth. The interview revealed the facility should have had a formal policy and procedure for opiate withdrawal protocols. The interview revealed the staff had started monitoring the corrective actions put in place for some of the policies. The interview revealed the nursing staff are to track that UDS is completed. From this list she will review 100% of these records. The interview revealed they had not been "diligent" about tracking all the patients on opiate withdrawal and she was unsure of the exact number of patients. The interview revealed they had just started the Performance Improvement but they did not have data yet to see if the policies and procedures that had been put in place were working.

Review of the ADATC Physician Team meeting minutes for 2-8-2010 revealed discussion of "Policy labeling high-risk patients was discussed, unclear as to whether this is being implemented...Dr.AAA (Clinical Director) will contact "YYY" for information concerning how the system is progressing...Dr. (Clinical Director) is working on an audit tool to verify that OTP policy is being followed."

Review of Performance Improvement data revealed the data was completed 2-25-2010 for the 4th Quarter 2009 (Oct-Dec) from 10-26-09 through 2-25-2010. Review of the data revealed the nursing audit tool "hindering identification of chart requiring an MD review. In this quarter, audit revealed 7 cases where opioid was ordered for detoxification, but only 4 cases could be identified for reviews." Further review revealed conclusions that OTP policy needed to be improved and laboratory results were missing from the charts.

Based on Medical Staff Bylaws and Credential Manual review, physician credential file reviews, Clinical and Medical Director interviews, and medical record review, the Medical Staff (MS) failed to ensure that physicians prescribing methadone tapers for opioid withdrawal were qualified and granted privileges per the MS Bylaws.

The findings include:

The Medical Staff (MS) failed to ensure physicians providing care in the Opioid Treatment Program (OTP) using methadone tapers for opioid withdrawal were qualified and granted privileges per the MS Bylaws.

~Cross refer to 482.22(c)(6) Medical Staff: Standard: Criteria for Medical Staff Privileging, Tag A0363.

Based on Medical Staff Bylaws and Credential Manual review, physician credential file reviews, Clinical and Medical Director interviews, and medical record review, the Medical Staff (MS) failed to ensure that physicians providing care in the Opioid Treatment Program (OTP) using methadone for opioid withdrawal were qualified and granted privileges per the MS Bylaws for 2 of 2 physicians providing care to patients (Physicians #1 and #2).

The findings include:

Review of the MS Bylaws and Credential Manual review (revised 2-26-09) revealed "B. Addiction Medicine Privileges: 4. Unless board certified in Addiction Psychiatry, the physician must complete an eight (8) hour online certification training on Buprenorphine and Office-Based Dependence Treatment through the American Society of Addiction Medicine...Service Definitions 2. Services for which privileges may be granted:...b. Psychiatry Subspecialties: (1)Addiction Psychiatry...b. Psychiatry Subspecialties (1) Addiction psychiatry: Practitioners privileged in this category have special qualifications to perform and serve as a subspecialty consultant in evaluation and consultant psychosocial treatment, and biological and behavioral basis of practice in addiction disorders." Further review of the Credential Manual "Privilege Request Section" revealed a MS applicant is to complete the privileges requested section and specific privileges for the following areas of hospital: Hospital Wide Psychiatry, Psychiatry Subspecialty, General Medicine, Specialized Diagnostic/Therapeutic Procedures and Other to be specified by the applicant. The Credentials Committee are to complete the "Approved, Denied or Deleted/Deferred" sections with initials and date of action. The level of privileges are to be designated also either Independent or Supervision. Review of the application revealed the following specialties privileges designated for request: Psychiatry, Internal Medicine, General Medicine, Addiction Medicine and Psychiatric Trainee.

1. Credential file review of Physician #2 on 3-5-2010 revealed the physician requested privileges for General Psychiatry on 7-15-09 and received appointment to the MS on 7-18-09. File review revealed no documentation of request for or privileges granted for addictive psychiatry. File review did not reveal any documentation of training/education for addiction psychiatry.

Interview with the Clinical Director and Medical Director of the ADATC on 3-5-2010 at 1430 revealed Physician #2 was no longer a member on the MS of the ADATC. The interview revealed addiction psychiatry included performance of opioid tapers for detoxification /withdrawal. The interview revealed Physician #2 did not have privileges granted to perform opioid tapers inclusive of Methadone usage for withdrawal/detoxification. The interview revealed there was no documentation available of training or education for Physician #2 regarding opioid tapers. The interview revealed Physician #2 was the admission (8-12-09) physician for patient #8 and had ordered the initial dose of Methadone given to the patient and had written orders for the admission Methadone taper. The interview revealed Physician #2 had performed opioid tapers and he did not have approved privileges to perform opioid tapers. The interview revealed both Directors stating the credentialing process needed to be improved.

Medical Record review of Patient #8 revealed Physician #2 admitted the patient on 8-12-09 for the principal diagnosis of opiate (heroin) dependence. Record review revealed the physician ordered a urine drug screen on admission and the initial dose of Methadone 20 mg by mouth to be given to the patient. The initial dose of Methadone was administered to the patient at 1749. Medical record review revealed the physician ordered Methadone taper to be started the next day (8-13-09) for Methadone 10 mg by mouth four times per day, Methadone 10 mg by mouth three times per day on 8-14-09, Methadone 5 mg by mouth four times per day on 8-15-09, Methadone 5 mg by mouth three times per day on 8-16-09, Methadone 5 mg by mouth two times per day on 8-17-09 and 5 mg by mouth every morning on 8-18-09.

2. Credential file review of Physician #1 on 3-5-2010 at 1100 revealed the physician applied for membership to the MS on 4-12-07. Review of the application revealed under Professional Data documentation of "Board Certification NONE". Review of the application revealed physician #1 requested privileges for psychiatry and was granted the privilege on 6-15-07. File review revealed documentation on 7-2-07 that "Dr. XXX(name of physician #1) will be working as a psychiatrist at ADATC and presently does not have privileges to perform opioid tapers. Until such time as he completes the appropriate requirements he will not be doing opioid tapers. He will be able to perform all of the functions that a staff psychiatrist performs." The documentation was signed by the clinical director for JUH. File review revealed an application for reappointment completed by physician #1. Review of the application revealed physician #1 requested privileges on 5-20-09 for "Hospital Wide Psychiatry General Psychiatry" and for "Psychiatry Subspecialties Addiction Psychiatry". Review of the application's "Medical Staff/Governing Body Action" page (this page documents by signature the approvals/denials of the requested privileges from the Governing Bodies). Review revealed the Facility Director/Center Director on "behalf of the Governing Body" signed the section but there was no documentation of the approval or denial of the requested privileges. Review of the documentation revealed the areas for APPROVED/DENIED" were blank.

Interview with the Clinical Director and Medical Director of the ADATC on 3-5-2010 at 1430 revealed Physician #1 was a current member on the MS of the ADATC. The interview revealed Physician #1 was the physician for patient #8 starting the date after admission (8-13-09) and until the patient was transferred to an acute care hospital (8-14-09). The interview revealed Physician #1 had to complete continuing education after his initial appointment to be granted the privilege of performing opioid tapers. The interview revealed the Directors thought Physician #1 had completed training to qualify the physician to be granted the privilege to perform opioid tapers inclusive of usage of methadone for detoxification/withdrawal. The interview revealed there was no documentation in the credential file to confirm this. The interview revealed there was no documentation of the approval for the additional privilege to perform opioid tapers for appointment period 2007-2009. The interview revealed for the reappointment period beginning 6-15-09 there was lack of documentation of the approval for privileges by the Governing Body . The interview revealed both Directors stating the credentialing process needed to be improved.

Interview with the Clinical Director on 3-5-2010 at 1600 revealed documentation had been found that Physician #1 had completed on line training. Review of the documentation presented revealed Physician #1 had completed on line training "Buprenorphine for Office-Based Treatment of Opiate Dependent Patients" on 7-20-07. The interview revealed this training covered the usage of Buprenorphine in an Office-Based practice. The interview revealed the training did not cover the usage Methadone for an opioid taper in detoxification/withdrawal. The interview revealed the MS had approved this on line training to be sufficient to qualify a physician competent to perform opioid tapers in the inpatient setting. The interview revealed the on line training did not include the use of Methadone.

Interview with the Clinical Director of the hospital on 3-8-2010 at 1545 revealed the on line training "Buprenorphine for Office-Based Treatment of Opiate Dependent Patients" was "not relevant" as training for the usage of Methadone in detoxification/withdrawal treatments for inpatients.

Medical Record review of Patient #8 revealed the patient was admitted on 8-12-09 for the principal diagnosis of opiate (heroin) dependence. Record review revealed Physician #1 examined the patient the morning of 8-13-09. The physician wrote an order on 8-13-09 at 1000 to discontinue Methadone and an order for "Methadone detox - 10 mg po (by mouth) x 1 as soon as possible." Further review revealed Physician #1 continued the written order for the methadone detox for 20 mg by mouth three times per day for 8-13-09, 20 mg by mouth three times per day for 8-14-09, 20 mg by mouth every morning, 20 mg by mouth at 1400 and 10 mg at bed time on 8-15-09, 10 mg by mouth four times per day on 8-16-09, 10 mg by mouth three times per day for 8-17-09 and "will write further orders p (after) 8-17."

Based on medical record reviews and staff interview the nursing staff failed to obtain vital signs prior to Methadone administration per the hospital policy in 1 of 3 patients receiving a Methadone taper (# 8).

The findings include:

Medical record review of Patient #8 revealed a 42 year old male patient admitted to the ADATC (Alcohol, Drug Abuse Treatment Center) on 8-12-09 for a diagnosis of opioid (heroin) dependence. Record review revealed Physician #1 examined the patient the morning of 8-13-09. The physician wrote an order on 8-13-09 at 1000 to discontinue Methadone and an order to give the patient "Methadone detox - 10 mg po (by mouth) x 1 as soon as possible." Further review revealed Physician #1 continued the written order for the "methadone detox" for 20 mg by mouth three times per day for 8-13-09, 20 mg by mouth three times per day for 8-14-09, 20 mg by mouth every morning, 20 mg by mouth at 1400 and 10 mg at bed time on 8-15-09, 10 mg by mouth four times per day on 8-16-09, 10 mg by mouth three times per day for 8-17-09 and "will write further orders p (after) 8-17." Review of the Medication Administration Record revealed for the administration of Methadone "HOLD IF SEDATED-RR (respiration rate) < 12, S/DBP (Systolic/Diastolic blood pressure) <90/60, P (pulse) <50. Record review revealed on 8-13-09 the patient was administered Methadone 10 mg by mouth at 1131 and 20 mg by mouth at 1428. Record review revealed no documentation of the patient's respirations, blood pressure or pulse for the Methadone administration at 1131 or 1428.

Interview with administrative staff on 3-8-09 at 1130 revealed the hospital policy per the Medication Administration Record is that the patient's respiration rate, blood pressure or pulse rate is to be checked prior to the administration of Methadone. The interview revealed there was no documentation available of the patient's vital signs being checked on 8-13-09 prior to Methadone administration at 1131 or 1428. Interview revealed the nursing staff failed to follow the hospital policy.

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