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Based on a review of 5 clinical records, interview with administrative and clinical staff, review of policy and procedures related to medications and assessments, the facility failed to ensure the medication practices of the hospital staff were present to ensure safe, effective and as per physician's orders for medication administration for 2 of the patients reviewed. The lack of a systematic mechanism to provide checks and balances to the medication system for administration place all of the patients in the hospital at risk for receiving incorrect and unnecessary medication, potential side effects from these medications and possible death. This has the potential to affect the health, safety and well-being of all the patients the hospital serves.

The findings include:

A review of Patients #1 and #3's medications revealed medications were not given as ordered nor discontinued as ordered. The check and balances in place for the safe administration of medications were not effective to ensure medications were administered to the patient's only as ordered for 2 patients. (Refer to A405)

Based on a review of clinical records, review of policy and procedure and interview with clinical and administrative staff, the hospital failed to ensure medication was provided in accordance with physician's orders for 2 (Patients #1 and #3) of 4 patient's reviewed.

The findings include:

1. A review of the hospital's practice of transcription of physician's orders was performed. When a patient enters the hospital, a list of the patient's medications from home is obtained from the patient. This list is confirmed with the physician on a drug reconciliation form as either yes the drug is to continue or no, the drug is not to continue. All other new medications are entered on the order page. Both of these are then faxed to the pharmacy for filling and documented as being faxed.

The pharmacy then reviews the medications, fills them as necessary for floor use or established use in the medication carts and establishes the Medication Administration Record (MAR) for use by the nurses. Prior to the MAR being made in the computer the nurses will use a written form as a "Working copy" of the MAR. The working copy does not become a part of the record. All documentation of medications occurs in the computer as point of entry. The drug is scanned into the computer, the patient's arm band is confirmed by the computer and the computer assures there is an order for the medication in the computer.

All orders are verified by the nurse at the time of transcription of the physician's orders to assure their accuracy. Every night, the orders are again verified as accurate by the nurse as a 24 hour review to ensure the patient orders are being accurately implemented. This process was confirmed with the Chief Nursing officer, and 2 staff nurses for accuracy. This was also verified with the policy and procedure for "Physician's orders: transcription and verification."

2. Patient #3 was admitted to the hospital's care on 10/28/10 for pneumonia. At the time of admission, the patient was ordered an antibiotic of Cefepime 1 gram in 100 ml (milliliters) of sodium chloride daily. Review of the documentation in the clinical record on 12/16/10, revealed on 11/7/10, there was a physician's order to discontinue the Cefepime. Review of the order page revealed there was no nurse's signature to indicate she reviewed the order. There was nothing indicating the order was faxed to pharmacy and there was no 24 hour review done by any staff to review for implementation of the order. This medication continued to be given daily.

On 11/8/10, there was again a physician's order to discontinue the Cefepime. Again, there was no documentation to indicate the nurse signed off this order as being reviewed and implemented. There was documentation to indicate the 24 hour chart check was done. There was another order dated 11/17/10 that was not signed off by the nurse as being confirmed and implemented. This order however, contained no medications.

On 11/13/10 a form named Medication Continuation order was placed in the clinical record. This was a list of the medications currently being taken and had a yes or no check box in front of each medication the doctor was supposed to check each medication and sign. In this case the physician again indicated the Cefepime was supposed to be discontinued. This list was scanned to the pharmacy for implementation. The pages are just numbered as 1, 2 and 3. There was nothing to indicate the total number of pages included such as 1 of 3, 2 of 3 and 3 of 3.

The medication continued to be administered daily by the nursing staff, and the order continued to remain in the computer despite the multiple orders to discontinue this medications. The patient received the medication on 11/8/10, 11/9/10, 11/10/10, 11/11/10, 11/12/10, 11/13/10; no medication was given on 11/14/10 as the patient refused it. It was again given on 11/15/10 and 11/16/10. This patient received an additional 8 doses of the antibiotic after it was discontinued by the physician as an unnecessary drug. The patient was discharged on 11/17/10.

Interview with the Chief Nursing officer on 12/16/10 at 1:00 p.m., indicated agreement the nursing staff did not properly ensure the orders were transcribed and implemented correctly. Also the 24 hour audits were not being conducted accurately to ensure the physician's orders were being accurately implemented.

Interview with the pharmacy head at 12:53 p.m. on 12/16/10, indicated the reconciliation form dated on 11/13/10 was received by the pharmacy, but they only received 1 page of it and it did not contain the discontinued medications. The other 2 pages did not get received by the pharmacy. He indicated he has to assume the nursing staff sent the entire reconciliation form to the pharmacy when it is sent.

3. Patient #1 was admitted to the hospital through the emergency room on 7/17/10. At the time of admission the patient was diagnosed as having cellulites and chest pain.

A review of the clinical record on 12/15/10 revealed the following information: Among the admission orders the patient was to receive Ancef (an antibiotic) 1 gram intravenous every 8 hours, Aspirin 325 mg every day, Lopressor 25 mg 2 times a day, Nitroglycerine 1 inch every 6 hours, and Ambien 5 mg every hour of sleep as necessary. These were orders all taken off the standing orders for "Acute Coronary Syndrome Admission Orders page 1 and 2." This order form has places with boxes for the physician to check the orders if desired. If the orders are not indicated the physician crosses them out.

Also of note is section 16 for antiplatelet therapy. Included in the orders for this box is the Aspirin. Also in this box was "4 chewable 81 mg aspirin po STAT then" (crossed off clearly in the order) leaving "asprin 325 mg enteric coasted po (orally) daily and an order for Plavix 300 mg (milligrams) to be given STAT (as soon as possible) and then follow by 75 mg every day which was no checked to indicate phsyician ordered. Both of these order pages were sent to the pharmacy. The physician had never intended the patient to receive the Plavix (lack of check mark). In fact the Plavix (a drug used to keep blood from clumping together) was transcribed into the computer for administration at 9:00 a.m. on the 7/17/10 through 7/18/10 MAR by the pharmacy. The nurse never administered this drug to the patient.

Also included in this patient's record was the drug reconciliation form for the patient's home medications. Included in this form, verified by the nurse with the physician on 7/17/10 at 12:40 a.m., were the following medications: Ambien 10 mg every hours of sleep (for use for sleep), Buspar 20 mg three times a day (anti anxiety medication), Cymbalta 60 mg every day (antidepressant use for treatment of major depression), Lovastatin 20 mg (for the control of cholesterol), Soma (a muscle relaxant) 350 mg 4 times a day, Vicodin 10/325mg (pain pill) every 4 hours prn (as needed) for pain, Wellbutrin XL (used for treatment of a major depressive disorder) 450 mg daily, and Zyrtec (antihistamine) 10mg 2 times a day. Additionally on this list was Lyrica 300 mg 2 times a day that was not supposed to be continued by the patient as it was marked "no." This drug is used to treat nerve pain.

The documentation in the nursing note for this patient stated the patient arrived on the floor at 1:40 a.m. on 7/17/10. The documentation in the record indicated at 3:10 a.m., the patient was given pain medication as ordered. The patient was administered both the Soma and a Percocet. There was no order for the Percocet; the patient was to receive a Vicodin instead. Also the ordered antibiotic was never given on this shift. By the time the patient was discharged, he should have received 2 doses of antibiotic. This was confirmed with both the Chief Nursing officer and the Chief of Pharmacy on 12/15/10 at 2:00 p.m.

The documentation in the MAR reviewed the patient was given the Aspirin, Wellbutrin, Clariton (for the Zyrtec), and Cymbalta. The Nitroglycerine paste was scheduled to be given at 12 noon, but the patient had already discharged himself against medical advice. The patient's Lopressor was to be given at 9:00 a.m., but was not done due to vital sign "Warrant," however, there was no blood pressure documented for this patient in the nursing notes. There was ordered on the MAR the Ancef to be given at 8:00 a.m. There was no documentation indicating this medication had been given. In fact, there was no documentation of any nursing staff administering this medication and it was not charged out through pharmacy. The patient was also to receive Buspar, but there was no documentation indicating this medication was given.

Also on the list was the patient's Lyrica which was not to be given per the reconciliation sheet. It did appear on the MAR. However, this medication was not in the hospital formulary and the MAR indicated this medication was to be the patient's own medication. There was no documentation indicating any staff discussed this issue with the patient.

Interview with the Clinical Manager on 12/15/10 at 2:30 p.m., revealed the pharmacy has a policy about this issue. A review of the policy labeled, "Administration of Drugs Patient's personal drugs" included the following statement: "Drugs brought into the facility by patients will not be administered unless the drugs have been absolutely identified, their quality and integrity is not questionable. Identification of the patient's personal drugs must be by the attending physician, another responsible prescribing practitioner, or a pharmacist (preferably the facility's pharmacist)."

There was no mention in the policy about the discussion with the patient about the formulary medications, the need to bring the drug from home and who was responsible for communicating and ensuring the medication was brought from home or found another way. An attempt was made to interview the nurse who cared for the patient on the day shift, but the nurse was unable to remember the patient. The documentation in the clinical note indicated the patient was unhappy about the medications and left the hospital as against medical advice.

Interview with the Chief Nursing Officer and the Risk Manager on 12/15/10 at 1:30 p.m., indicated an investigation was done about this patient's medications. However, not all of the issues identified were addressed. The Chief Nursing Officer agreed the medications for this patient were an problem.

Based on observation during the survey and interview with environmental and administrative staff, the hospital failed to ensure the environment was maintained in a clean and sanitary manner.

The findings include:

1. Observation on 12/15/10 at 9:00 a.m., of the floor in the emergency room where the receptionist sit was observed to be dirty and had black streaks on it. The bathroom in the emergency room for the use of people in the waiting room had a dirty appearance in the area next to the toilet and the wall. There was one cleaned stretcher in room B that had blood located on the side rail. The toilet in the emergency room bathroom had staining beneath the sink and onto the floor molding. The area to the right of the toilet between the toilet and the wall also was dirty. The flooring in the waiting room did not appear to be clean.

Interview with the Head of Materials Management on 12/15/10 at 9:30 a.m., indicated the floor in the waiting room was a poor choice of colors as, despite cleaning, the speckles in the tile make it appear to be dirty. He indicated this floor was just cleaned and waxed over the weekend so he knows it's clean. The Chief Nursing Officer present during this part of the tour indicated agreement that the areas were not as clean as they could be.

2. A tour was done on the second and third floors on 12/15/10 at 1:00 p.m. During this tour it was noted the floor in the bathrooms by the showers and around the toilets were stained and dirty appearing for the following rooms: 327, 320, 326, 220 and 224. This was confirmed with the clinical manager present during this part of the tour. Also noted the hallways in the 2nd and 3rd floors did not appear to be clean.

Interview with the material management head at 3:30 p.m., indicated agreement that there are issues about the calking around the toilets and showers. He stated he was in the process of doing these areas but has not completed them. He stated he is down in staff right at the moment.