HospitalInspections.org

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to implement revised performance improvement interventions related to the facility's compliance with the use of foam and antimicrobial soap before and after patient contact for three of seven patient care units surveyed (Medical Surgical D6, Telemetry D8 and Trauma Services), and failed to ensure the contracted dialysis service completed additional observations to ensure the patients' access and face were uncovered and visible during renal replacement and apheresis therapy (removal of whole blood from a patient).

Findings include:

Review on August 11, 2015, of the facility's "GCMC [Geisinger-Community Medical Center] Performance Improvement Program" policy, last reviewed September 22, 2014, revealed "Purpose: To continuously improve the performance of important functions, processes and outcomes through measurement and evaluation using current performance improvement models. This is in concert with Geisinger's mission to enhance quality of life through an integrated health service organization based on a balanced program of patient care, education, research and community services. It is also supportive of Geisinger's commitment to the pursuit of high quality care and the welfare and safety of our patients, employees, medical staff and visitors. Persons Affected: Geisinger Community Medical Center, (hereinafter referred to as "GCMC") Program Goals and Objectives: ... 9. To take actions aimed at performance improvement and, after implementing those actions, the hospital measures its success, and tracks performance to ensure that improvements are sustained. ..."

Interview with EMP3, EMP4 and EMP5 on August 12, 2015, at approximately 10:00 AM revealed the facility's expected compliance rate was 90 percent or greater for the Hand Hygiene compliance study on each patient care unit each month. Further interview with EMP3, EMP4 and EMP5 revealed if the patient care unit compliance rate was less than 90 percent, the unit was required to submit an action plan to increase compliance.

1) Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Medical Surgical D6 patient care unit revealed the compliance rate for April 2015 was 82 percent. Further review revealed the facility implemented new interventions in May 2015 which included: a new hand hygiene campaign, empowered staff to address individuals who were non-compliant and ensuring all hygiene dispensers were properly working.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Medical Surgical D6 patient care unit revealed the compliance rate for May 2015 was 80 percent. There was no documentation the facility implemented new interventions in June 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Medical Surgical D6 patient care unit revealed the compliance rate for June 2015 was 59 percent. There was no documentation the facility implemented new interventions in July 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Medical Surgical D6 patient care unit revealed the compliance rate for July 2015 was 56 percent. There was no documentation the facility implemented new interventions in August to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Interview with EMP3, EMP4 and EMP5 on August 12, 2015, at approximately 10:35 AM confirmed the above compliance rates for the Medical Surgical D6 patient care unit. Further interview with EMP3, EMP4 and EMP5 confirmed there was no documentation the facility implemented new interventions in June, July and August 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Telemetry D8 patient care unit revealed the compliance rate for April 2015 was 87 percent. Further review revealed the facility implemented new interventions in May 2015 which included: a new hand hygiene campaign, empowered staff to address individuals who were non-compliant, the engagement of hand hygiene champions on alternate shifts and ensuring all hygiene dispensers were properly working.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Telemetry D8 patient care unit revealed the compliance rate for May 2015 was 82 percent. There was no documentation the facility implemented new interventions in June 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Telemetry D8 patient care unit revealed the compliance rate for June was 49 percent. There was no documentation the facility implemented new interventions in July 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Telemetry D8 patient care unit revealed the compliance rate for July was 87 percent. There was no documentation the facility implemented new interventions in August 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Interview with EMP3, EMP4 and EMP5 on August 12, 2015, at approximately 10:40 AM confirmed the above compliance rates for the Telemetry D8 patient care unit. Further interview with EMP3, EMP4 and EMP5 confirmed there was no documentation the facility implemented new interventions in June, July and August 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Trauma Services patient care unit revealed the compliance rate for April 2015 was 85 percent. Further review revealed the facility implemented new interventions in May 2015 which included: monitoring staff and ancillary employees entering and exiting rooms using proper hand hygiene and assigned a hand hygiene video to staff to reinforce importance of proper hand hygiene.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Trauma Services patient care unit revealed the compliance rate for May 2015 was 82 percent. There was no documentation the facility implemented new interventions in June 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Trauma Services patient care unit revealed the compliance rate for June 2015 was 83 percent. There was no documentation the facility implemented new interventions in July 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Trauma Services patient care unit revealed the compliance rate for July 2015 was 65 percent. There was no documentation the facility implemented new interventions in August 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Interview with EMP3, EMP4 and EMP5 on August 12, 2015, at approximately 10:45 AM confirmed the above compliance rates for the Trauma Services patient care unit. Further interview with EMP3, EMP4 and EMP5 confirmed there was no documentation the facility implemented new interventions in June, July and August 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

2) Review on August 11, 2015, of the facility's contracted dialysis service Patient Safety Observation Audit dated June 19, 2015, revealed the audit for "Patient access/face are uncovered and visible during renal replacement and apheresis therapy" was not met. Further review revealed no documentation the contracted dialysis service completed additional observations to determine further reoccurrences of non-compliance.

Interview with EMP6 and EMP7 on August 12, 2015, at approximately 1:45 PM confirmed the Patient Safety Observation Audit dated June 19, 2015, revealed the audit for "Patient access/face are uncovered and visible during renal replacement and apheresis therapy" was not met. Further interview with EMP6 confirmed there was no documentation the contracted dialysis service completed additional observations to determine further reoccurrences of non-compliance.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure Quality Assessment and Performance Improvement (QAPI) program monitoring was performed for all services provided under contract with an outside company.

Findings include:

Review on August 11, 2015, of the facility's "GCMC [Geisinger-Community Medical Center] Performance Improvement Program" policy, last reviewed September 22, 2014, revealed "Purpose: To continuously improve the performance of important functions, processes and outcomes through measurement and evaluation using current performance improvement models. This is in concert with Geisinger's mission to enhance quality of life through an integrated health service organization based on a balanced program of patient care, education, research and community services. It is also supportive of Geisinger's commitment to the pursuit of high quality care and the welfare and safety of our patients, employees, medical staff and visitors. Persons Affected: Geisinger Community Medical Center, (hereinafter referred to as "GCMC") Program Goals and Objectives: ... 6. To provide consistent measurement, collection, and analysis of data to drive improvements related to quality and safety. ... Responsibilities: ... C. Performance Improvement Committee The Performance Improvement Committee is the oversight committee for performance improvement activities for the hospital. This committee is responsible for the coordinated systematic, organization with approach to improving patient care and services. ... Report: Every Department Director, Operations Manager, or designee will submit a performance improvement report to the Performance Improvement Committee. The Performance Improvement Committee will review these reports and disseminate this information to the Medical Executive Committee and the Board of Directors. ..."

Review on August 11, 2015, of the facility's contracted services revealed the dialysis service was provided to the facility under contract with an outside company.

Review on August 11, 2015, of the dialysis service contract dated June 15, 2010, revealed "... 1.07 Provider agrees to maintain an ongoing Quality Management Program which Provider intends to be confidential and protected pursuant to applicable state and federal law including peer review; such Quality Management Program included the following activities: continuous quality improvement, safety and infection control, and risk management. Hospital also maintains an ongoing quality assurance program which Hospital intends to be confidential and protected pursuant to applicable state and federal law including peer review. Provider shall participate in any quality assurance programs for Services furnished hereunder by Provider, which may be required or developed by Hospital. Each party acknowledges and agrees that that [sic] such party may participate in the other party's quality assurance activities related to Services rendered hereunder. ..."

Review on August 11, 2015, of the facility's Performance Improvement Committee reporting schedule 2015 revealed no documentation the contracted dialysis service reported performance improvement activities to the Performance Improvement Committee.

Review on August 11, 2015, of the contracted dialysis service revealed this service completed observation audits for Patient Safety, Infection Control and Catheter Site Care each quarter from the first quarter 2013 through the second quarter 2015.

Review on August 11, 2015, of the facility's Performance Improvement Committee meeting minutes for the first quarter 2013 through the second quarter 2015 revealed no documentation the contracted dialysis service reported the results of the observation audits to the Performance Improvement Committee.

Interview with EMP1, EMP6, EMP7 and EMP8 on August 12, 2015, at approximately 2:15 PM confirmed the dialysis service was provided to the facility under contract with an outside company. EMP1, EMP6, EMP7 and EMP8 confirmed the facility's Performance Improvement Committee reporting schedule 2015 revealed no documentation the contracted dialysis service reported performance improvement activities to the Performance Improvement Committee. EMP1, EMP6, EMP7 and EMP8 confirmed the contracted dialysis service completed observation audits for Patient Safety, Infection Control and Catheter Site Care each quarter from the first quarter 2013 through the second quarter 2015, and there was no documentation the contracted dialysis service reported the results of the observation audits to the Performance Improvement Committee.

Based on review of facility policies, medical records (MR), and employee interviews (EMP), it was determined the facility failed to document actions taken when a patient repeatedly refused a medication for one of one applicable medical records reviewed (MR1).

Findings include:

Review on August 12, 2015, of the facility policy "Medication Administration," last reviewed September 9, 2014, revealed "Purpose: The purpose of the Medication Administration policy is to ensure the patient will receive ordered medications in a safe and therapeutic manner. ...II. Timing of Medication Administration ... The provider must be notified when a patient refuses a medication but does not require a [name of facility incident report]. C. Patient Safety ... 12. Discuss any unresolved, significant concerns about the medication with the patient's physician and/or relevant staff involved with the patient's care, treatment and services. ..."

Interview with EMP1 and EMP8 at approximately 10:00 AM on August 12, 2015, confirmed the "Medication Administration" policy did not address documentation of physician notification of medication refusals.

Review on August 11, 2015, of MR1 revealed the patient was admitted on March 13, 2015, with leg weakness. On March 15, 2015, at 11:15 AM, the patient was ordered Primidone (anticonvulsant also used to treat tremors) 50 mg (milligrams) to be given four times a day. Review of MR1's Medication Administration Record (MAR) from 12:00 PM on March 15, 2015, to 10:00 PM on March 16, 2015, revealed MR1 took a total of seven doses of Primidone 50 mg.

Continued review of MR1's MAR revealed the following:

At 8:00 AM on March 17, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 12:00 PM on March 17, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 4:00 PM on March 17, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 8:40 PM on March 17, 2015, the patient refused the Primidone. Nursing documentation at 8:40 PM on March 17, 2015, noted "patient does not like the way it makes [them] feel." Further review revealed no nursing documentation the physician was notified of the medication refusal.

At 8:00 AM on March 18, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 12:00 PM on March 18, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 4:00 PM on March 18, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 10:00 PM on March 18, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 8:00 AM on March 19, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 12:00 PM on March 19, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 4:00 PM on March 19, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

Interview with EMP9 at approximately 2:30 PM on August 11, 2015, confirmed there was no documentation why the Primidone was refused and no documentation the physician was notified of the Primidone refusals.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to implement revised performance improvement interventions related to the facility's compliance with the use of foam and antimicrobial soap before and after patient contact for three of seven patient care units surveyed (Medical Surgical D6, Telemetry D8 and Trauma Services), and failed to ensure the contracted dialysis service completed additional observations to ensure the patients' access and face were uncovered and visible during renal replacement and apheresis therapy (removal of whole blood from a patient).

Findings include:

Review on August 11, 2015, of the facility's "GCMC [Geisinger-Community Medical Center] Performance Improvement Program" policy, last reviewed September 22, 2014, revealed "Purpose: To continuously improve the performance of important functions, processes and outcomes through measurement and evaluation using current performance improvement models. This is in concert with Geisinger's mission to enhance quality of life through an integrated health service organization based on a balanced program of patient care, education, research and community services. It is also supportive of Geisinger's commitment to the pursuit of high quality care and the welfare and safety of our patients, employees, medical staff and visitors. Persons Affected: Geisinger Community Medical Center, (hereinafter referred to as "GCMC") Program Goals and Objectives: ... 9. To take actions aimed at performance improvement and, after implementing those actions, the hospital measures its success, and tracks performance to ensure that improvements are sustained. ..."

Interview with EMP3, EMP4 and EMP5 on August 12, 2015, at approximately 10:00 AM revealed the facility's expected compliance rate was 90 percent or greater for the Hand Hygiene compliance study on each patient care unit each month. Further interview with EMP3, EMP4 and EMP5 revealed if the patient care unit compliance rate was less than 90 percent, the unit was required to submit an action plan to increase compliance.

1) Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Medical Surgical D6 patient care unit revealed the compliance rate for April 2015 was 82 percent. Further review revealed the facility implemented new interventions in May 2015 which included: a new hand hygiene campaign, empowered staff to address individuals who were non-compliant and ensuring all hygiene dispensers were properly working.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Medical Surgical D6 patient care unit revealed the compliance rate for May 2015 was 80 percent. There was no documentation the facility implemented new interventions in June 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Medical Surgical D6 patient care unit revealed the compliance rate for June 2015 was 59 percent. There was no documentation the facility implemented new interventions in July 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Medical Surgical D6 patient care unit revealed the compliance rate for July 2015 was 56 percent. There was no documentation the facility implemented new interventions in August to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Interview with EMP3, EMP4 and EMP5 on August 12, 2015, at approximately 10:35 AM confirmed the above compliance rates for the Medical Surgical D6 patient care unit. Further interview with EMP3, EMP4 and EMP5 confirmed there was no documentation the facility implemented new interventions in June, July and August 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Telemetry D8 patient care unit revealed the compliance rate for April 2015 was 87 percent. Further review revealed the facility implemented new interventions in May 2015 which included: a new hand hygiene campaign, empowered staff to address individuals who were non-compliant, the engagement of hand hygiene champions on alternate shifts and ensuring all hygiene dispensers were properly working.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Telemetry D8 patient care unit revealed the compliance rate for May 2015 was 82 percent. There was no documentation the facility implemented new interventions in June 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Telemetry D8 patient care unit revealed the compliance rate for June was 49 percent. There was no documentation the facility implemented new interventions in July 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Telemetry D8 patient care unit revealed the compliance rate for July was 87 percent. There was no documentation the facility implemented new interventions in August 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Interview with EMP3, EMP4 and EMP5 on August 12, 2015, at approximately 10:40 AM confirmed the above compliance rates for the Telemetry D8 patient care unit. Further interview with EMP3, EMP4 and EMP5 confirmed there was no documentation the facility implemented new interventions in June, July and August 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Trauma Services patient care unit revealed the compliance rate for April 2015 was 85 percent. Further review revealed the facility implemented new interventions in May 2015 which included: monitoring staff and ancillary employees entering and exiting rooms using proper hand hygiene and assigned a hand hygiene video to staff to reinforce importance of proper hand hygiene.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Trauma Services patient care unit revealed the compliance rate for May 2015 was 82 percent. There was no documentation the facility implemented new interventions in June 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Trauma Services patient care unit revealed the compliance rate for June 2015 was 83 percent. There was no documentation the facility implemented new interventions in July 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Review on August 12, 2015, of the facility's Hand Hygiene compliance study for the Trauma Services patient care unit revealed the compliance rate for July 2015 was 65 percent. There was no documentation the facility implemented new interventions in August 2015 to improve compliance with the use of foam and antimicrobial soap before and after patient contact on this patient care unit.

Interview with EMP3, EMP4 and EMP5 on August 12, 2015, at approximately 10:45 AM confirmed the above compliance rates for the Trauma Services patient care unit. Further interview with EMP3, EMP4 and EMP5 confirmed there was no documentation the facility implemented new interventions in June, July and August 2015 to improve co

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure Quality Assessment and Performance Improvement (QAPI) program monitoring was performed for all services provided under contract with an outside company.

Findings include:

Review on August 11, 2015, of the facility's "GCMC [Geisinger-Community Medical Center] Performance Improvement Program" policy, last reviewed September 22, 2014, revealed "Purpose: To continuously improve the performance of important functions, processes and outcomes through measurement and evaluation using current performance improvement models. This is in concert with Geisinger's mission to enhance quality of life through an integrated health service organization based on a balanced program of patient care, education, research and community services. It is also supportive of Geisinger's commitment to the pursuit of high quality care and the welfare and safety of our patients, employees, medical staff and visitors. Persons Affected: Geisinger Community Medical Center, (hereinafter referred to as "GCMC") Program Goals and Objectives: ... 6. To provide consistent measurement, collection, and analysis of data to drive improvements related to quality and safety. ... Responsibilities: ... C. Performance Improvement Committee The Performance Improvement Committee is the oversight committee for performance improvement activities for the hospital. This committee is responsible for the coordinated systematic, organization with approach to improving patient care and services. ... Report: Every Department Director, Operations Manager, or designee will submit a performance improvement report to the Performance Improvement Committee. The Performance Improvement Committee will review these reports and disseminate this information to the Medical Executive Committee and the Board of Directors. ..."

Review on August 11, 2015, of the facility's contracted services revealed the dialysis service was provided to the facility under contract with an outside company.

Review on August 11, 2015, of the dialysis service contract dated June 15, 2010, revealed "... 1.07 Provider agrees to maintain an ongoing Quality Management Program which Provider intends to be confidential and protected pursuant to applicable state and federal law including peer review; such Quality Management Program included the following activities: continuous quality improvement, safety and infection control, and risk management. Hospital also maintains an ongoing quality assurance program which Hospital intends to be confidential and protected pursuant to applicable state and federal law including peer review. Provider shall participate in any quality assurance programs for Services furnished hereunder by Provider, which may be required or developed by Hospital. Each party acknowledges and agrees that that [sic] such party may participate in the other party's quality assurance activities related to Services rendered hereunder. ..."

Review on August 11, 2015, of the facility's Performance Improvement Committee reporting schedule 2015 revealed no documentation the contracted dialysis service reported performance improvement activities to the Performance Improvement Committee.

Review on August 11, 2015, of the contracted dialysis service revealed this service completed observation audits for Patient Safety, Infection Control and Catheter Site Care each quarter from the first quarter 2013 through the second quarter 2015.

Review on August 11, 2015, of the facility's Performance Improvement Committee meeting minutes for the first quarter 2013 through the second quarter 2015 revealed no documentation the contracted dialysis service reported the results of the observation audits to the Performance Improvement Committee.

Interview with EMP1, EMP6, EMP7 and EMP8 on August 12, 2015, at approximately 2:15 PM confirmed the dialysis service was provided to the facility under contract with an outside company. EMP1, EMP6, EMP7 and EMP8 confirmed the facility's Performance Improvement Committee reporting schedule 2015 revealed no documentation the contracted dialysis service reported performance improvement activities to the Performance Improvement Committee. EMP1, EMP6, EMP7 and EMP8 confirmed the contracted dialysis service completed observation audits for Patient Safety, Infection Control and Catheter Site Care each quarter from the first quarter 2013 through the second quarter 2015, and there was no documentation the contracted dialysis service reported the results of the observation audits to the Performance Improvement Committee.

Based on review of facility policies, medical records (MR), and employee interviews (EMP), it was determined the facility failed to document actions taken when a patient repeatedly refused a medication for one of one applicable medical records reviewed (MR1).

Findings include:

Review on August 12, 2015, of the facility policy "Medication Administration," last reviewed September 9, 2014, revealed "Purpose: The purpose of the Medication Administration policy is to ensure the patient will receive ordered medications in a safe and therapeutic manner. ...II. Timing of Medication Administration ... The provider must be notified when a patient refuses a medication but does not require a [name of facility incident report]. C. Patient Safety ... 12. Discuss any unresolved, significant concerns about the medication with the patient's physician and/or relevant staff involved with the patient's care, treatment and services. ..."

Interview with EMP1 and EMP8 at approximately 10:00 AM on August 12, 2015, confirmed the "Medication Administration" policy did not address documentation of physician notification of medication refusals.

Review on August 11, 2015, of MR1 revealed the patient was admitted on March 13, 2015, with leg weakness. On March 15, 2015, at 11:15 AM, the patient was ordered Primidone (anticonvulsant also used to treat tremors) 50 mg (milligrams) to be given four times a day. Review of MR1's Medication Administration Record (MAR) from 12:00 PM on March 15, 2015, to 10:00 PM on March 16, 2015, revealed MR1 took a total of seven doses of Primidone 50 mg.

Continued review of MR1's MAR revealed the following:

At 8:00 AM on March 17, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 12:00 PM on March 17, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 4:00 PM on March 17, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 8:40 PM on March 17, 2015, the patient refused the Primidone. Nursing documentation at 8:40 PM on March 17, 2015, noted "patient does not like the way it makes [them] feel." Further review revealed no nursing documentation the physician was notified of the medication refusal.

At 8:00 AM on March 18, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 12:00 PM on March 18, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 4:00 PM on March 18, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 10:00 PM on March 18, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 8:00 AM on March 19, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 12:00 PM on March 19, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

At 4:00 PM on March 19, 2015, the patient refused the Primidone. There was no nursing documentation stating why the patient refused the Primidone or that the physician was notified of the medication refusal.

Interview with EMP9 at approximately 2:30 PM on August 11, 2015, confirmed there was no documentation why the Primidone was refused and no documentation the physician was notified of the Primidone refusals.