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Based on observation, interview, record review, and policy review the facility failed to:
- Supervise and prevent one patient (#17) from hoarding his medications and providing his medications (Valium, a sedating medication to treat anxiety) to another patient (#5), which caused Patient #5 to be oversedated to the point of requiring administration of a reversal drug (Narcan) and an off-site emergency department visit. (A-0395)
- Administer the correct dosage of a medication (Librium, an anti-anxiety) used to prevent detoxification (detox, the process of removing toxic substances, such as alcohol or drugs, from the body) symptoms as directed by the facility's policy/protocol and/or physician's orders for one current patient (#2) and one discharged patient (#5) of 11 patients reviewed that were in detox. (A-0395)
- Awaken Patient #5 on two occasions for CIWA (Clinical Institute Withdrawal Assessment for Alcohol scale) assessment as their policy states. (A-0395)
- Conduct an internal investigation to determine exact causation, and plan of action to prevent recurrence of medication hoarding and/or giving medications to other patients. (A-0395)

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). The facility census was 89, including 25 of which were receiving detoxification treatment.

On 03/05/18, the facility was notified of the IJ. Facility staff created educational tools and began educating all staff, as well as put interventions into place to protect all patients.

On 03/06/18, the facility provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Immediate face-to-face patient care education which included policy and procedural revisions related to medication administration and ensuring the patient ingests medication administered.
- Immediate face-to-face patient care education related to completion of the CIWA on patients at all times, even while sleeping, as per facility policy.
- Immediate face-to-face patient care education related to maximum dosage limits for Librium, and the steps to take if additional medication is necessary.
- Immediate face-to-face patient care education related to appropriate steps to take if a patient is suspected or found to have shared medications with another patient.
- Immediate initiation of room searches for contraband, to be assigned to a responsible staff member, and completed each shift.
- Immediate face-to-face patient care education related to revision of detoxification and nursing care policy, to include observations for withdrawal symptoms, safety needs and proper notification of physician, if indicated.
- Increased surveillance with medication administration and observation of possible oversedation.
- Immediate face-to-face patient care education related to revision of the CIWA scale to include signs and/or symptoms of oversedation and the steps to follow if it occurs.
- Immediate face-to-face patient care education related to revision of the pre-printed Alcohol Detox Orders to include maximum allowed limit of Librium dosing and to contact the physician if signs and symptoms of oversedation occurs.
- Immediate face-to-face patient care education for revision of policy related to the withholding of prescribed medications and physician notification for signs and symptoms of oversedation.
- Physician education related to maximum Librium dosing, revision of detox order sets, and the steps to take if a patient shows signs and symptoms of oversedation.
- Increased frequency of assessment of patients who are on the detox protocol.
- Real time monitoring of medication administration, rounding with contraband checks, detox order and Librium administration compliance, with reporting to the Quality Council and integrated into the hospital's Quality Assurance Performance Improvement plan.

Based on observation, interview, record review and policy review, the facility failed to:
- Supervise and prevent one patient (#17) from hoarding his medications and providing his medications (Valium, a sedating medication to treat anxiety) to another patient (#5), which caused Patient #5 to be oversedated to the point of requiring administration of a reversal drug (Narcan) and an off-site emergency department visit.
- Administer the correct dosage of a medication (Librium, an anti-anxiety) used to prevent detoxification (detox, the process of removing toxic substances, such as alcohol or drugs, from the body) symptoms as directed by the facility's policy/protocol and/or physician's orders for one current patient (#2) and one discharged patient (#5) of 11 patients reviewed that were in detox.
- Awaken Patient #5 on two occasions for CIWA (Clinical Institute Withdrawal Assessment for Alcohol scale) assessment as their policy states.
- Conduct an internal investigation to determine exact causation, and plan of action to prevent recurrence of medication hoarding and/or giving medications to other patients.
These failures had the potential to affect all patients admitted for detox, and can cause harm if over/under utilized and not supervised appropriately. The facility identified 25 current patients receiving detox treatment. The facility census was 89.

Findings included:

1. Review of the facility's policies titled, "Medication Preparation & Administration-Oral Products," and "Medication Administration," reviewed 11/03/16, showed:
- Self administration of medications was prohibited.
- An oral medication will be given to the patient with suitable liquid to swallow the medication.
- The licensed nurse verifies the right dose, right route and right time by reading the label three times.
- The licensed nurse assesses and monitors the patient's response to medications.

2. Review of the facility's policy titled, "Recognition and Reporting Changes in a Patient Condition," revised 11/09/17, showed:
- The licensed nurse was responsible to assess the patient each shift.
- Changes in medical condition included changes in level of consciousness.
- If a change in condition is noted, a re-assessment is required, with notification of the nursing supervisor, attending physician, or the physician on-call.

During an interview on 02/22/18 at 10:50 AM, Staff F, Registered Nurse (RN), stated that it was the night shift nurses' responsibility to review the Medication Administration Records (MARs) with orders to verify accuracy.

During an interview on 02/22/18 at 2:45 PM, Staff U, Chief Executive Officer (CEO), and RN stated that she would expect her staff to observe patients taking their medications and verify swallowing of them.

During an interview on 02/22/18 at 3:50 PM, Staff D, Director of Nurses (DON), stated that their drug seeking patient population got very inventive with cheeking (hiding medication between cheek and gums), palming (acting like they put the medication in their mouth, but did not), and hoarding of their medications. Staff were supposed to check patient's mouths to ensure swallowing of the medications.

3. Review of discharged Patient #5's History and Physical (H&P) showed the patient was admitted on 01/17/18 for alcohol and heroin dependence.

Review of medical record for Patient #5 on 01/22/18 showed:
- At 6:45 AM CIWA was 18 and Librium 50 milligrams (mg) was given.
- At 8:00 AM patient in bed very lethargic, can barely hold eyes open and speech was slurred.
- At 10:00 AM NP and House Supervisor notified patient remains lethargic but does awaken.
- At noon remains very lethargic
- At 2:00 PM very lethargic, awakened but with difficulty.
- At 4:51 PM Staff A, RN documented, "Patient was in chair in hallway. Staff approached patient in order to have her come to room to change in to scrubs. Patient was not responding, eyes shut, head to the side of wall. Staff did sternum rub [applying pain to the middle of the chest by rubbing the knuckles of a closed fist firmly and vigorously to gain a response] for approximately 20 seconds before patient gave any response. Patient had shallow respirations and slurred speech. Code Blue [an emergency situation announced in a facility for a team of providers to assist in immediate resuscitative efforts] was called. Code Team arrived. Narcan was given intramuscularly [IM-injection in the muscle]. Staff L, MD, CMO, was present, supervisor present. Vital signs obtained. Emergency Medical System [EMS, ambulance service] arrived and took patient at 4:45 PM. Paperwork completed, report called to the Emergency Room [ER]".

During an interview on 02/21/18 at 10:45 AM and on 02/22/18 at 10:50 AM, Staff F, RN stated:
- She had cared for Patient #5 about a month prior, she felt that the patient had received too much Librium, and was sent to the Emergency Room.
- Patient was difficult to wake that morning.
- When she arrived to her shift that morning she recognize/d the patient was too sedated.
- Patient was rating herself too high on CIWA as she was too sleepy.
- Patient was on Detox Protocol but she refused to give the patient any Librium.
- Patient's sedation symptoms became worse later in the shift.
- At 3:00 PM, someone went in to do vitals and the patient was extremely hard to wake up.

During an interview on 02/22/18 at 2:00 PM, Staff A, RN, stated:
- On 01/22/18 she was getting ready to leave for the day and saw the patient sitting in a chair in the hallway.
- Staff A turned around, and when she turned back, the patient was slumped over sliding down the wall.
-The patient had been lethargic off and on all day.

During an interview on 02/22/18 at 9:00 AM, Staff I, NP, stated that Patient #5 told staff she had taken Valium from Patient #17 and it was documented in the chart. She was unable to find it in the chart at the time.

During an interview on 02/22/18 at 2:00 PM, Staff A, RN, stated that she had heard through the grapevine, about four days after the sedation incident, Patient #5 told one of the technicians (tech, nursing assistant) on the floor that she had taken Valium from Patient #17's coat. She did not see that documented anywhere.

Review of Patient #17's MAR dated 01/24/18, showed the patient had an order for Valium 15 mg three times daily. The MAR indicated that the pharmacy supplied the Valium in 5 mg tablets so the patient would need three tablets three times daily, or nine per day.

4. Review of the facility's assessment protocol titled, "Alcohol/Opiate Detox Orders" showed directives for staff to perform assessments using the Alcohol Withdrawal Assessment Scoring Guidelines CIWA (Clinical Institute Withdrawal Assessment for Alcohol scale) and the use of the medication Librium (a sedative medication to treat alcohol withdrawal symptoms and tremors) showed:
-Assess and rate each of the following criteria: nausea/vomiting, tremors (an involuntary, rhythmic muscle contraction leading to shaking movements in one or more parts of the body), anxiety, agitation, paroxysmal sweats (a sudden occurrence of sweating), orientation, tactile disturbances (sensitive to touch), auditory disturbances (sensitive to noises), visual disturbances, and headache;
-After rating each of the 10 criteria, total the score to achieve a CIWA score;
-If the CIWA score was greater than 10 and patient is 125 pounds or greater administer Librium 50 mg PO (by mouth) every two hours until the score is less than 10
- If the CIWA score was greater than 10 and patient is less than 125 pounds or greater administer Librium 25 mg every two hours until the score is less than 10.
- Always awaken the patient when administering the CIWA.
- Do not hesitate to call the Doctor for any concerns, questions or if symptoms persist despite above orders.

Review of a Nursing Assessment dated 01/17/18 showed the patient's weight was hand written and had been written over several times and appeared as 124.

Review of Admit Orders/Medication Reconciliation dated 01/17/18 showed the patient's weight was hand written and had been written over several times and appeared as 125.

Review of a Medication Administration Record dated 01/17/18, timed 10:49 PM, showed the patient's weight was 125.

During an interview on 02/22/18 at 9:00 AM, Staff I, Nurse Practitioner (NP), stated that when she dictated the patient's H&P she used the weight that was listed on the Nursing Assessment which she interpreted as 124.

During an interview on 02/21/18 at 4:40 PM, Staff H, Pharmacist, stated that she used the patient's weight that was documented on the Physician's Admission Orders which was 125 pounds.

During an interview on 02/22/18 at 10:50 AM, Staff K, Psychiatrist, stated:
- The weights were just a rough guideline
- Nurses were responsible for weighing the patient.
- Adding the patient's weight to the detox orders would be valuable.

Review of Patient #5's progress notes, medication administration record, physician orders, and CIWA assessments showed:
- 01/17/18 at 7:18 PM patient sleeping not scored
- 01/17/18 at 11:10 PM patient sleeping not scored
- 01/19/18 at 12:30 AM score was 0. Vital sign shift. BP 93/50, Pulse 67, Respirations 14. Fluids encouraged. RN did not notify Physician or Nurse Practitioner (NP).
- 01/20/18 at noon score was 6. RN note: Patient's speech slurred, in bed sleeping and cannot open eyes. RN did not notify Physician or NP. Even though the Detox Protocol directed the staff to wake the patient to perform CIWA Score, the staff failed to wake the patient on two occasions.

Review of the patient's MARs from admission through discharge on 01/31/18, directed staff that there was a maximum dose of 300 mg of Librium in 24-hours. "Contact prescriber for approval if the patient has reached 300 mg and need more."

- On 01/21/18 the patient was given Librium 50 mg seven times for a total dose of 350 mg in 13 hours:
- 7:40 AM CIWA score was 25
- 9:40 AM CIWA score was 32
- 12:26 PM CIWA score was 24
- 2:34 PM CIWA score was 20
- 4:59 PM CIWA score was 22
- 7:00 PM CIWA score was 12
- 9:00 PM CIWA score was 20
- The staff did not notify prescriber for approval to go beyond the 300 mg of Librium.

During an interview on 02/22/18 at 9:00 AM, Staff I, NP, stated that she did not know about the 300 mg maximum dose in 24-hours.

During an interview on 02/22/18 at 9:45 AM, Staff J, Psychiatrist, stated that he was aware of the 300 mg maximum dose in 24-hours. He would expect the nurses to follow the Detox Protocol and CIWA assessment and call him If they find the patient over sedated.

During an interview on 02/21/18 at 9:40 AM, Staff F, RN, stated, "Nurses were concerned only with the CIWA score and were terrified to not give the Librium."

During an interview on 02/22/18 at 2:00 PM, Staff A, RN, and Lead Charge for the Acute Adult Unit, stated that there had to be an order if you were giving more than 300 mg of Librium in a 24-hour period.

During an interview on 02/22/18 at 10:48 AM, Staff F, RN, stated that the 300 mg maximum dose of Librium in 24-hours had not been clear to nurses.

On 02/22/18 at approximately 2:45 PM, Staff U produced a Social Worker note dated 01/24/18 that stated, "Social Worker received info from Charge Nurse that a patient who was discharged (#17) gave Patient #5 four Valium. Social Worker discussed with patient. Initially, patient denied. Patient #5 admitted to taking four Valium prior to being sent out to the Emergency Room. She took all four pills. Social Worker notified Director of Nursing".

Even though requested on 02/21/18, the facility failed to provide evidence that the over sedation incident with Patient #5 had been investigated or measures put in place to prevent recurrence.

5. Review of current Patient #2's H&P dated 02/16/18, showed the patient was admitted on 02/15/18 for alcohol abuse and detoxification treatment.

Review of the patient's admission orders dated 02/15/18, showed the patient was placed on the facility's detox protocol which included the use of Librium based on her weight of 155 pounds, or a dosage of 50 mg every two hours, as needed, if her CIWA score was over "10," until her score was below "10."

Review of the patient's printed MARs from admission through 02/21/18 directed staff that there was a maximum dose of 300 mg of Librium in a 24-hour period. "Contact prescriber for approval if Pt has reached 300 mg and needs more."

Review of the Librium doses delivered on 02/16/18, showed the patient had received 350 mg in approximately 12 hours, because her CIWA scores were over "10." The facility could not provide evidence the physician was notified prior to administration of more than the 300 mg maximum. The facility failed to follow their own guidelines for maximum dosage.

During interviews on 02/21/18 at 3:30, 3:50, and 4:13 PM, Staff D, DON, stated the following:
- Patient #2 received seven doses (350 mg) of Librium from 8:30 AM to 10:57 PM.
- There was no documentation as to why this much Librium was given (other than the CIWA scores).
- There was no documentation that the physician was notified prior to the 10:57 PM dose.
- The nurse that gave the 10:57 PM dose, would have been responsible for the assessment of the patient and the contact of the physician prior to administering the Librium, along with documentation of all the findings.
- The nurse responsible for the 10:57 PM dose was not available for interview.

During an interview on 02/21/18 at 4:40 PM, Staff H, Pharmacist, stated that in September, 2017, the DON and the Chief Medical Officer (CMO) requested she research the recommended maximum dosage of Librium in 24-hours. She did so, and added the manufacturer's guidelines to the MAR.

During an interview on 02/22/18 at 10:10 AM, Staff K, Psychiatrist, stated that he would expect the nurses to call him if more than 300 mg of Librium was needed in 24-hours.

During an interview on 02/22/18 at 10:50 AM, Staff F, RN, stated that the physician should be called if more than 300 mg of Librium was needed in a 24-hour, or less, period. Staff F stated that the 300 maximum dose in 24-hours was not clear to a lot of nurses employed at this facility, as evidenced by conversations she had with others.

During an interview on 02/22/18 at 11:22 AM, Staff L, CMO, Psychiatrist, stated that the physician should be called if the nurse felt the patient needed more than the 300 mg of Librium within the 24-hour period.

The facility failed to identify the patient had received more than the recommended dosage of Librium in 24-hours on 02/16/18, until surveyor inquiry on 02/21/18.












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