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Based on interview and record review, the hospital failed to ensure a system was in place to monitor and prevent large doses of central nervous system (CNS) medications from being accessed from the automated medication dispensing system (AMDS) by overriding the warnings and prior approval from the pharmacist. This affected one (Patient #1) of 10 patient records reviewed. (A491)

The failure to prevent patients from receiving a large dose of CNS medications resulted in a determination of immediate jeopardy. The facility census was 249.

Based on interview and record review, the hospital failed to ensure a system was in place to monitor and prevent large doses of central nervous system (CNS) medications from being accessed from the automated medication dispensing system (AMDS) by overriding the warnings and prior approval from the pharmacist. This affected one (Patient #1) of 10 patient records reviewed. This deficient practice had the potential to affect all patients receiving services at the facility. The facility census was 249.

Findings include:

1. During interview on 01/24/19 at 9:40 A.M., Pharmacist B stated nursing staff can now only override to dispense one dose of Fentanyl 250 micrograms (mcg) in an emergency. Nursing staff can still override the AMDS, before pharmacy review and approval, for other opiate drugs including Dilaudid and Morphine.

2. Review of the medical record for Patient #1 revealed the patient was admitted to the hospital on 10/12/17 at 1:21 P.M. due to cardiac arrest. Nurse Practitioner A documented on 10/12/17 at 4:30 P.M. a conversation was held with the patient's spouse, who agreed to not resuscitate the patient in the event the heart stopped.

On 10/13/17 at 7:19 A.M., a physician progress note by Physician A stated the family was in full agreement to withdraw care. On 10/13/17 at 7:19 A.M. an order was placed by Physician A for Fentanyl 500 mcg IV push; at 7:20 A.M., Versed 6 mg IV push; and at 7:21 A.M., Dilaudid 6 mg IV push. All medication orders were verified by Pharmacist B on 10/13/17 at 7:33 A.M. Review of the medication administration record revealed on 10/13/17 at 8:01 A.M., Fentanyl 500 mcg was administered; there was no evidence the Versed or Dilaudid were administered. Patient #1 was pronounced dead at 8:20 A.M. There was no documentation in the medical record stating when Patient #1 was removed from the ventilator.

During interview on 01/23/19 at 2:20 P.M., Staff B verified the above information.