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Based on record review and interview, the hospital failed to ensure the Quality Assurance (QA) Program tracked medical errors and implemented preventive actions. This was evidenced by the failure to measure, analyze and track medications errors. Findings:

Review of the occurrence reports provided by SF2DON for the past 30 days revealed two medication errors were reported in September 2015. On 09/13/15, the wrong dosage of medication was administered and on 09/24/15, a medication was administered twice due to lack of documentation from a nurse.

In an interview with SF2DON on 10/06/15 at 1:20 p.m., she stated that she signs off on the variance reports, but that just means that she spoke to the nurse about the incident. When asked for her QA data related to the medication errors, SF2DON stated that she had none. SF2DON confirmed that the medication errors were not analyzed and that preventive actions were not implemented to prevent further errors.


Review of medical records revealed the following medication administration errors were identified for 2 (#F7, #F8) of 5 current medical records reviewed during the survey:

Review of the medication administration record for Patient #F7 dated 10/02/15 revealed the following medication had been circled by the nurse to indicate it had not been given: Lasix 20 mg (circled on 10/02/15 at 9:11 p.m. with "held" noted). Review of the medication administration record for Patient #F7 dated 10/03/15 revealed the following medication had been circled by the nurse to indicate it had not been given: Lasix 20 mg (circled on 10/03/15 at 9:10 p.m. with "held" noted).

Review of the medication administration record for Patient #F8 dated 09/29/15 revealed the following medications had been circled by the nurse to indicate they had not been given: Amaryl 4 mg (circled at 8:31 p.m. with "fsbs 92" noted) and Metformin 1000 mg (circled at 8:32 p.m. with "fsbs 92" noted.

On 10/06/15 at 3:00 p.m., an interview with SF2DON revealed that since 08/27/15 (last survey date), she had been auditing patient records. SF2DON further stated that medication errors was not an area she was auditing the records for. She further confirmed that the above medication errors should have been identified.




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Based upon record review and interview, the hospital failed to conduct performance improvement projects. This was evidenced by the failure to conduct annually distinct improvements projects related to the scope of services furnished at the hospital for 2014 and 2015. Findings:

Review of the Quality Assurance Program data revealed there failed to be documented evidence the hospital developed distinct Quality Assurance Improvement Projects for 2014 and 2015.

In an interview on 10/05/15 at 2:00 p.m., FS3QA/ICN (Quality Assurance/Infection Control Nurse) indicated that no hospital wide QA projects had been implemented for 2014 and 2015 she was not aware of the hospital having a QAPI Improvement Projects for 2014 and 2015.

In an interview on 10/05/15 at 3:00 p.m., FS2DON (Director of Nursing) indicated that the hospital's PI projects were patient falls and physician orders (date/time). FS2DON presented a file folder with selected Physician orders. There was no documented evidence of monitoring, tracking and trending of patients' falls and Physician orders.

Based on record review and interview, the hospital failed to ensure medications were administered in accordance with the orders of the practitioner responsible for the patient's care. This deficient practice is evidenced by the nursing staff holding patient's ordered medications without a physician's order for 2 (#F7, #F8) of 5 patients reviewed for medication administration out of a total sample of 10 patients. Findings:

Review of the hospital policy titled Withholding Medications (no policy number/dated 10/01/15) presented as current by SF2DON revealed that no medication is to be held unless directly specified by attending physician and/or if parameters are written to hold that specific drug.

Patient #F7
Review of the medication administration record for Patient #F7 dated 10/02/15 revealed the following medication had been circled by the nurse to indicate it had not been given: Lasix 20mg (circled on 10/02/15 at 9:11 p.m. with "held" noted).

Review of the medication administration record for Patient #F7 dated 10/03/15 revealed the following medication had been circled by the nurse to indicate it had not been given: Lasix 20mg (circled on 10/03/15 at 9:10 p.m. with "held" noted).

Review medical record revealed no documented evidence that the physician had been notified of the above held medications (10/2 & 10/03) that were ordered for the patient.

Patient #F8
Review of the medication administration record for Patient #F8 dated 09/29/15 revealed the following medications had been circled by the nurse to indicate they had not been given: Amaryl 4mg (circled at 8:31 p.m. with "fsbs 92" noted) and Metformin 1000mg (circled at 8:32 p.m. with "fsbs 92" noted. There was no documented evidence in the medical record that the physician had been notified of the held medications.

In an interview on 10/06/15 at 3:00 p.m. with SF2DON, she stated that the above medications should not have been held without a physician order. At that time, SF2DON reviewed the records of patients #F7 and #F8 and confirmed that there was no documented evidence that their physician was notified of the medications not being given as ordered. Further interview with SF2DON revealed that this deficient practice was noted during the last survey (08/27/15) and was an ongoing problem. She indicated that the hospital had not implemented the holding of medications and the lack of physician notification into the hospital's QAPI Program.

Based on record review and interview, the facility failed to ensure drug administration errors were reported immediately to the attending physician and documented in the patient's medical record for 2 of 2 (#F9, #F10) sampled patients with medication variances reviewed with known medication errors out of a total sample of 10. Findings:

Review of the hospital policy titled Medication and Treatment Variances (review date of 09/09/15) and presented as currently by SF2DON revealed that the nurse responsible for the medication variance will document in the nurses notes briefly the drug involved, MD notified and outcome/pt condition.

SF2DON provided the occurrence reports that occurred in the past 30 days. Review of these reports revealed that patient #F9 was administered incorrect medication on 09/13/15 and patient #F10 was also administered incorrect medication on 09/24/15. Further review of the occurrence reports revealed no documented evidence that the patients' physician was notified of the medication error. Review of the medical records for patients #F9 and #F10 revealed no documented evidence that the above medication errors or physician notification of the errors were documented.

In an interview on 10/06/15 at 1:20 p.m., SF2DON reviewed the occurrence reports and medical records for patient #F9 and patient #F10. SF2DON confirmed that the medication errors and physician notification of the errors were not documented in the patient's medical records and should have been. Further interview with SF2DON at that time revealed that this deficiency was cited on the last survey dated 08/27/15, but no QA or preventive actions had been put into place.

Based on record review and interview, the hospital failed to ensure that an updated examination, that included any changes in the patient's condition, was completed and documented immediately prior to and before the patient's surgical procedure and/or procedure requiring anesthesia services as evidenced by no documentation of an updated examination for 4 of 4 (Patients #F2, #F3, #F4, #F6) patient medical records reviewed for updated examinations prior to their surgery/procedure out of a total sample of 10. Findings:
Patient #F2
Review of the medical record revealed the patient was admitted on 09/22/15 for an Endoscopic procedure with SF4MD on 09/22/15. Further review of patient #F2's medical record revealed no documented evidence of an updated examination prior to her procedure.

Patient #F3
Review of the medical record revealed the patient was admitted on 09/23/15 for a mass excision surgical procedure with SF4MD on 09/23/15. Further review of patient #F3's medical record revealed no documented evidence of an updated examination prior to her surgical procedure.

Patient #F4
Review of the medical record revealed the patient was admitted on 09/25/15 for a permanent sterilization with SF4MD on 09/25/15. Further review of patient #F4's medical record revealed no documented evidence of an updated examination prior to her surgical procedure.

Patient #F6
Review of the medical record revealed the patient was admitted on 09/25/15 for an Endoscopic procedure with SF4MD on 09/25/15. Further review of patient #F6's medical record revealed no documented evidence of an updated examination prior to his surgical procedure.

On 10/06/15 at 9:45 a.m., SF5RN reviewed the medical records for patients #F2, #F3, #F4, and #F6. She confirmed that the patients did not have documented evidence of an updated examination by the physician prior to their surgical procedures. SF5RN further revealed that this deficiency was cited on the last survey dated 08/27/15, but no policy and procedure was developed and no QA tool was implemented to ensure that updated examinations were completed prior to each patients' surgery.


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