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Based on interview and document review, the hospital failed to ensure that staff administered medications within the parameters ordered by the medical provider, for 5 of 11 patients reviewed (P1, P2, P5, P9, and P10), where staff either administered medications without any assessment of the patient's vital signs or weight to determine if the medication should be given or held per physician's orders, or failed to properly document assessments in each patient's medical record. None of the patients experienced negative outcomes.

Findings include:

P1's medical record indicated that prior to P1's admission to Anoka Metro Regional Treatment Center (AMRTC), P1 had been hospitalized for two months at another acute care hospital from 02/24/17 - 04/11/17 for inpatient psychiatric services complicated by numerous medical co-morbidities, including stage IV kidney disease with chronic anemia, systolic heart failure, diabetes, obstructive sleep apnea, and vascular dementia. P1 was medically fragile. P1 also had a history of traumatic brain injury with behavior disturbance and schizoaffective disorder. While hospitalized, P1 was Committed with court-ordered medications to control physically and sexually aggressive behavior. At the time of P1's transfer to AMRTC on 04/11/17, P1 took twenty different medications to address his complex mental health and medical problems. Several of P1's medications targeted cardiac issues, including Hydralazine (Apresoline) for blood pressure control. P1 took Hydralazine 100 mg three times daily, unless his systolic blood pressure was below 116.

P1's progress notes indicated that P1 was admitted to AMRTC on the afternoon of 04/11/17 to Unit B, the hospital's inpatient psychiatric unit for patients who also have medical needs. On admission and throughout P1's three-day stay, P1 was unable to walk, needed two staff for transfers due to balance problems, and was completely dependent for care except for eating. P1 was alert, oriented to person and place, weak, and appeared fatigued. P1 was usually sleepy and tired, stayed in bed most of the time, and got up only for meals. P1 used CPAP at night.

P1's physician's orders, dated 04/11/17, indicated that AMRTC continued all of the medications recommended on P1's acute care hospital discharge summary, including Hydralazine 100 mg three times daily; staff were to assess P1's blood pressure prior to giving the medication and if P1's systolic blood pressure was less than 116, staff were to hold the medication and not administer it.

A medication error report, dated 04/14/17, indicated that LPN/B administered P1's 8:00 a.m. dose of Hydralazine when P1's blood pressure was 107/61.

P1's progress notes on 04/14/17 at 11:29 a.m. indicated that P1 was lethargic with a blood pressure of 62/42. P1's respirations were 28 with oxygen saturations 87 - 92%. P1 was not short of breath. P1's pulse was 53. Staff contacted the medical provider and called 911. Emergency responders arrived during the medical provider's examination of P1. P1's blood pressure was 62/46. P1's color was ashen. P1 had no active movement, opened his eyes slightly, was slow to respond, and difficult to understand. P1 was unable to sit, stand, or transfer, as compared to the previous day when he was able to stand and transfer with a two-person assist. At 11:55 a.m., P1 was transferred to an acute care hospital for emergency care.

P1's emergency department (ED) record, dated 04/14/17, indicated that on arrival at 11:59 a.m., P1's blood pressure was 119/60. P1's pulse, respirations, and oxygen saturations were within normal limits. P1 was somnolent, pale, oriented to self and place, and mumbled when asked questions. P1's pupils were pinpoint which suggested opioid toxicity but P1's somnolence did not respond to Narcan administration. P1's diagnostic studies showed that P1's symptoms were a result of chronic systolic heart failure, chronic anemia, worsening kidney disease, and use of multiple sedating medications to manage medical and mental health issues. P1 was admitted for further evaluation of chronic illnesses complicated by the use of numerous sedating medications. P1 remained hospitalized until 04/19/17 when he was discharged back to AMRTC. P1's discharge diagnoses included altered mental status, likely medication-related, some behavioral component. At the time of discharge, several of the sedating medications P1 formerly took for mental health issues were either discontinued or decreased. P1's Hydralazine, which also has sedating effects, was decreased to 50 mg three times daily.

The progress notes on 04/19/17 indicated that P1 was re-admitted back to AMRTC at 4:30 p.m. On re-admission, P1 was oriented to self and sleepy. P1 denied pain but was groaning in bed and restless. P1 stated he was thirsty but was unable to sit up even with the head of the bed elevated. P1's blood sugar was 253. P1 had two episodes of incontinence with loose stool and was unable to tolerate care, due to labored breathing; P1 requested the CPAP. P1 continued to be uncomfortable and restless, despite being re-positioned frequently for comfort. At 9:30 p.m., P1 was transferred back to the ED due to restlessness and shortness of breath.

P1's ED record on 04/19/17 indicated that P1 was re-admitted for hospitalization at 10:00 p.m. for a breathing problem, anemia, and uncooperative behavior. While hospitalized, P1 expressed he wanted to focus on comfort and not undergo further testing and procedures. Palliative care was consulted. P1 was enrolled in Hospice. Medications were stopped. P1 was discharged to hospice care on 04/28/17.

An interview was conducted with RN/J on 05/23/17 at 2:30 p.m. RN/J stated he was the treatment nurse during the day shift of 04/14/17. It is the responsibility of the treatment nurse to take patients' vital signs in the morning, which is usually completed during the morning medication pass. The treatment nurse posts the vital signs on a clipboard kept at the nurse's station. It is the responsibility of the medication nurse to check the clipboard for any vital sign parameters connected to medication administration. On the morning of 04/14/17, RN/J obtained all of the patients' vital signs and posted them on the clipboard around 8:00 a.m. P1's blood pressure was 107/61. RN/J was unsure whose responsibility it was to transcribe vital signs from the clipboard to each patient's medical record.

An interview was conducted with LPN/K on 05/24/17 at 1:03 p.m. LPN/K stated he was the medication nurse during the day shift of 04/14/17. Medications are delivered through Omnicell; the MAR (medication administration record) is a replica of the physician's order so any parameters for medication administration are listed on the MAR. P1's need to have his Hydralazine held if his systolic blood pressure was less than 116 was identified on the MAR. It is the responsibility of the medication nurse to check the clipboard and ensure that the patient's vital sign are within the parameters specified by the medical provider, prior to administering medications. On 04/14/17, LPN/K withdrew P1's Hydralazine from the Omnicell at 8:59 a.m. and administered it to P1, without ensuring P1's systolic blood pressure was in the acceptable range. LPN/K stated he overlooked checking the clipboard for P1's morning blood pressure on 04/14/17. After LPN/K administered P1's Hydralazine on 04/14/17, LPN/K next saw P1 shortly before lunch on 04/14/17. P1 was more sleepy than usual and couldn't sit up in bed, stand, or transfer. LPN/K contacted P1's medical provider who examined P1 and sent P1 to the ED. LPN/K acknowledged responsibility for the medication error. All nurses participated in mandatory re-education regarding safe handling of medications that have designated parameters for administration, with a focus on the role and responsibility of the medication nurse to ensure compliance with any medication parameters. LPN/K was unsure whose responsibility it was to transcribe vital signs from the clipboard to each patient's medical record.

P2's physician orders dated 4/14/17, directed staff to check the patients vital signs daily and notify the physician if the blood pressure was above 160/100, below 90/50, a temperature over 100.4, oxygen saturations less than 92%, respirations greater than 20, or pulse greater than 90. P2's Physician orders also directed to obtain a weight three times per week. Specific instruction included to ensure the weights were completed in the morning after the resident used the bathroom and prior to breakfast. Staff were directed to notify the physician if there was a weight gain over three pounds between weights, and/ or a weight gain of over five pounds in a week.

P2's Vital signs and weights were reviewed from 4/14/17 to 5/23/17. P2's weight was 259 pounds on 4/15/17, and 266 pounds on 4/17/17. There was no documentation the physician was updated on the weight gain of seven pounds in a two day period. P2 had no documentation a temperature was checked on 4/23/17, 4/24/17, 4/25/17, 4/26/17, 4/27/17, 4/28/17, 4/30/17, 5/1/17, 5/3/17, 5/7/17, 5/8/17, 5/11/17, 5/12/17, 5/14/17, 5/15/17, 5/18/17, and 5/21/17. P2 had no documentation oxygen saturations were checked on 4/25/17, 4/26/17, 4/27/17, 4/28/17, 4/30/17, 5/1/17, 5/3/17, 5/8/17, 5/11/17, 5/12/17, 5/14/17, and 5/18/17. P2 had no documentation respirations were checked on 4/25/17, 4/26/17, 4/27/17, 4/28/17, 4/30/17, 5/1/17, 5/3/17, 5/8/17, 5/11/17, 5/14/17, and 5/18/17. P2 had no documentation a pulse was checked on 5/3/17 or 5/11/17. P2 had no documentation a blood pressure was checked on 5/3/17, or 5/11/17.

P4's physician orders dated 4/28/17, included Inderal 20 mg tablet three times a day. Specific instructions included to check pulse and blood pressure prior to administering the medication, and to hold the medication if the patients blood pressure was less than 100/56, and/ or if pulse was less than 60.

P4's vital signs and medication administration record (MAR) were reviewed from 4/28/17 to 5/23/17. There was no documentation blood pressure or pulse were checked prior to administration of Inderal 20 mg the evening dose on 5/5/17, or prior to the morning dose on 5/6/17.

P5's physician orders dated 5/10/17, directed staff to check the patients vital signs every day and notify the physician if blood pressure was over 140/90 or less than 90/50. Specific instructions included if the patient refused vital signs to attempt to obtain them each shift.

P5's Vital signs were reviewed from 5/10/17, to 5/23/17. There was no documentation of vital signs completed on 5/10/17, 5/11/17, 5/12/17, 5/13/17, 5/14/17, 5/15/17, 5/16/17, 5/17/17, 5/18/17, and 5/20/17. Although P5's physician orders directed staff to attempt vital signs each shift if the patient refused, there was no documentation the facility attempted to reapproach the patient each shift to obtain vital signs.

P9's physicians orders dated 4/3/17, directed staff to check vital signs daily whenever the patient agreed to have them taken. Specific instructions directed staff to notify the physician if the patients pulse was over 130, if the systolic blood pressure was over 160, or under 90, and if the patient refused, staff were to attempt to obtain the vital signs each shift.

P9's vital signs were reviewed from 4/1/17 to 5/23/17. There was no documentation of blood pressure checks 4/1/17 to 4/6/17, 4/9/17 to 4/23/17, and 4/25/17 to 5/23/17. There was no documentation a pulse was completed on 4/1/17 to 4/6/17, 4/9/17 to 4/22/17, 4/25, 4/28/17, 5/1/17, 5/3/17 to 5/5/17, 5/8/17 to 5/18/17, and 5/20/17. Although P9's physician orders directed staff to attempt vital signs each shift if the patient refused, there was no documentation the facility attempted to reapproach the patient each shift to obtain vital signs if he refused.

P10's physician orders dated 2/13/17, indicated the patient was receiving Lisinopril 20 mg daily for hypertension (high blood pressure). The physician order contained specific instructions to hold the Lisinopril if the systolic blood pressure was less than 100.

P10's MAR was reviewed from April 1, 2017- May 23, 2017. P10 had no doses of Lisinopril held and received the medication daily.

P10's blood pressures were reviewed from 4/1/17 to 5/23/17. P10 had no blood pressure readings documented prior to the administration of Lisinopril on 4/11/17, 5/2/17, 5/15/17, or 5/16/17.

An interview was conducted with RN/H on 5/23/17 at 12:45 p.m. RN/H verified the missing vital signs for P2, P4, P5, P9, and P10. RN/H stated the electronic MAR contained an alert for certain medications if vital signs needed to be checked prior to administration. On Unit B, one nurse is assigned to obtain vital signs and another nurse is assigned to administer medications; it is the responsibility of the nurse administering medications to ensure compliance with any medication parameters by verifying the patient's vital signs written on the clipboard. RN/H was unsure whose responsibility it was to transcribe vital signs from the clipboard to each patient's medical record.

An interview was conducted with RN/C on 05/23/17 at 3:00 p.m. RN/C stated that staff had obtained many of the vital signs missing in the medical records of P2, P4, P5, P9, and P10 which were documented on the clipboard vital sign sheets, but not transcribed into the patients' medical records. RN/C acknowledged that the vital sign flow sheets on the clipboard are staff's working tool and not a permananet part of the patient's medical record. It is the role of the nurse obtaining vital signs to document them in each patient's medical record. During the investigation, RN/C initiated immediate re-education of all nurses regarding their documentation responsibilities; Nurse Supervisors on the units are auditing all medical records at the end of every shift for compliance with documentation protocols.

The hospital's policy on Medication Administration, dated 12/06/16, indicated that "an order by a (medical provider)is required for all medications...nurses administering medications are responsible to be knowledgeable regarding the use, side effects, special warnings, or specific directions particular to that medication...remember the rights of medication administration: (1) right patient, (2) right medications, (3) right dose, (4) right route, (5) right date/time; (6) right documentation; (7) right reason, (8) right response."


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