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Based on staff interviews and record review the Conditon of Nursing Services was not met as evidenced by staff failure to provide patient care in accordance with the facility's policy and protocols and to conduct ongoing health status assessments when there is an identified change in patient condition.


Refer to A-0395 and A-0405

Based on staff interview and record review nursing staff failed to follow the facility's policies and protocol for medication administration and safety searches, and failed to assure the ongoing evaluation and assessment of patient care needs and health status for 2 patients. (Patient's #1 and #2). Findings include:

1. Per record review staff failed to follow the facility's policy titled Administration and Scheduled Time of Medication, last revised and approved in July of 2011, which stated: III. Verifications, Education and Discussion: "Before administering medication staff will: Verify that there is no contraindication for administering the medication." In addition the facility's protocol for responding to missing medication, titled Safety Searches - Unit Lock-down for Contraband, dated June 2006, which stated; "All medication passes are to be halted and no medication may be given until cleared with the Unit Manager or Supervisor", was not followed.

Per record review Patient #1, who was admitted to the Tyler 2 Unit on 1/18/12 for treatment of suicidal ideation and alcohol detox., was able to obtain and ingest the Methadone (opiate) prescribed for Patient #2 during a medication (med) pass on the morning of 1/19/12. Per interview, at 3:20 PM on 1/24/12, Nurse #1 who was responsible for med pass for all patients on Tyler 2 on 1/19/12, stated that s/he was inside the med room that morning with the bottom half of the Dutch style door to the room closed. S/he stated s/he had prepared medications for several patients and placed the meds in individual plastic med cups, identified by patient name, on the top of the med cart which was located next to the door and within arm's reach of someone standing outside the door. Nurse #1 stated that Patient #1 presented at the med room door for his/her medication at approximately 9:00 or 9:30 AM that day. S/he stated that the patient, who was on an alcohol detox program had an assessment conducted by his/her primary nurse, in accordance with the Alcohol Detox protocol, that identified a score which required administration of 75 mg of Librium (benzodiazipine used to relieve anxiety and control agitation caused by alcohol withdrawal) . Nurse #1 stated that s/he administered the Librium and Patient #1 continued to stand leaning on the shelf of the half door repeatedly requesting Ritalin, for which there was no physician order, while other patients lined up in the hallway awaiting their turns for med administration. Nurse #1 stated that s/he had turned his/her head away from the patient for a short period just once during the exchange with Patient #1. Following the exchange, Patient #1 left the area of the med room and the nurse continued to administer meds to other patients. Nurse #1 stated it was within 15 minutes of the exchange with Patient #1 that Patient #2 presented to the med room door asking for their daily maintenance dose of 110 mg of Methadone and the nurse was not able to find the pre-poured medication. S/he stated s/he had previously prepared the (2) 40 mg wafers and (6) 5 mg tablets to total the 110 mg dose, placed them in a plastic med cup with another plastic med cup covering it and placed it on top of the med cart. Nurse #1 stated that s/he alerted other staff and the Pharmacy that the Methadone was missing. S/he stated that, with the assistance of a pharmacy technician, they searched, unsuccessfully, throughout the med room for the Methadone. The protocol for Safety Searches - Unit Lock down for Contraband was implemented immediately following the identification of missing Methadone; patients were gathered in the community area as individual room searches were conducted and the process of obtaining urine for drug screening was initiated on all patients. Nurse #1 stated that, during this time, although s/he had not consulted Patient #2's attending physician, s/he did speak with a Pharmacist about providing the maintenance dose of Methadone to Patient #2 who had still not received the medication. Despite the fact that administration of Methadone to Patient #2 was contraindicated because staff had not been able to account for the missing Methadone, it was not in accordance with the protocol that stated to halt all medication administration, and, finally, without consulting with the attending physician or Nurse Manager, Nurse #1 confirmed that s/he administered 110 mg of Methadone to Patient #2 (at 9:30 AM according to the Medication Administration Record). In addition Nurse #1 stated that s/he continued to administer medication to the 3 or 4 patients that had still not received their scheduled medications.

During interview, at 3:45 PM on 1/24/12, Nurse #2, the Charge Nurse on Tyler 2 on 1/19/12, confirmed that following the identification of the missing Methadone the Nurse Manager, Supervisor and Physicians on the unit were all notified; the patients were gathered in the community area and room searches were conducted on the individual patient rooms. Nurse #2 stated that during this period Patient #1 approached him/her and admitted that s/he had found a white pill (a 40 mg wafer of Methadone) on the floor of the bathroom that morning and had ingested it. A body search was then conducted on Patient #1 and during the contraband search of Patient #1's room s/he revealed a 5 mg tablet of Methadone that had been taped to the underside of a drawer. Patient #1 was placed on 1:1 observation status and after beginning to exhibit symptoms of Methadone overdose, including slurred speech, decreased respirations, increasing lethargy and constricted pupils, s/he was transferred, at 11:55 AM, to the ER (Emergency Room) for treatment. Patient #1 returned to the facility approximately 3 and a half hours later at 3:30 PM, was transferred to the Tyler I Unit and subsequently returned to the ER at approximately 5:00 PM that evening as a result of continuing to exhibit symptoms associated with Methadone overdose.

Per interview, at 12:53 PM on 1/25/12, the Tyler II Nurse Manager confirmed that Nurse #1 had continued to administer meds to patients after Methadone had gone missing and further stated that s/he had told Nurse #1 and all staff that medication administration had to be halted because they could not account for the missing Methadone.

2. Per record review staff failed to provide ongoing assessments of health status for Patient #1 who was readmitted to the facility on the afternoon of 1/20/12, following an acute care stay in the ICU (Intensive Care Unit) for monitoring and treatment of Methadone overdose. Per review of documentation completed at the hospital during Patient #1's acute care stay from 1/19/12 through 1/20/12, a nurse's note, dated 1/20/12 at 6:15 AM stated the patients's O2 (oxygen) saturation had dropped into the 80's when asleep requiring the use of oxygen to increase the saturation to a more normal level of 94-97%. The note also revealed that the patient had stated, "I have sleep apnea".

Although a history and physical had been conducted by medical staff upon the Patient's return to the facility on the evening of 1/20/12 , there was no evidence that facility staff were aware of the recent history of low O2 sats during sleep and the patient identified sleep apnea. The patient received 800 mg of Ibuprofen at 3:30 PM, (at which time his/her temperature was recorded as 100.1 degrees Fahrenheit), for complaints of a sore throat associated with a diagnosis of acute Uvulitis. Patient #1 was admitted to Tyler 1 at 6:40 PM and placed on observation status that included every 15 minute checks. The patient's temperature was taken on just two subsequent occasions and was recorded as 99.7 at 6:45 PM and 98.4 at 9:30 PM, respectively. Per review of the Nursing Observation Flow Sheet, dated 1/20/12, the patient was ambulating about the unit and talking with the nurse and other patients during the evening hours following admission, and was noted to be awake until approximately 12:30 AM. During the time period between 4:00 - 5:30 AM the patient was noted, every 15 minutes, to be yelling in sleep and snoring loudly. An Addendum for 1/21/12, documented by MHW (Mental Health Worker #2) on 1/24/12 at 2:20 AM, stated that, between 4:15 AM and 5:00 AM Patient #1 was doing " a lot of yelling in....sleep.. It sounded angry almost as if growling" and staff questioned if patient was having a nightmare. The record also stated that staff had attempted to awaken Patient #1 "numerous times as a means to get (patient) out of the dream or whatever was going on. This was done by calling (patient) name repeatedly with 1 response of "huh". Despite the previous recent history of low O2 sats during sleep, the patient's statement that s/he had sleep apnea, as well as the diagnosis of acute Uvulitis and elevated temperature on admission, and the noted change in Patient #1's condition exhibited by symptoms of intermittent yelling during sleep for a prolonged period, with difficulty arousing the patient, there was no evidence that nursing staff had conducted any health status assessment of the patient after 9:30 PM. During a subsequent visual check at 5:43 AM the patient was found unresponsive and without respirations, a Code Blue was called, CPR (Cardiopulmonary Resuscitation) was initiated and Patient #1 was subsequently transferred to the ER where s/he expired.

During separate interviews, conducted at 7:50 AM on 1/25/12 and 11:02 AM on 1/26/12, respectively, MHWs (Mental Health Workers) #1 and #2, both of whom had worked the Tyler I unit on the 11:00 PM - 7:00 AM shift on the night of 1/20/12 through 1/21/12 confirmed that Patient #1 had begun yelling in his/her sleep at approximately 4:00 AM and continued to do so until 5:35 AM. They stated that the night light was on in the patient's room providing enough light to determine that the patient's color remained good throughout the night. Patient #1 was described as yelling frequently and loud enough at times to awaken other patients. The MHWs stated that they had attempted to arouse the patient when s/he yelled and, although s/he would stop yelling the patient never awoke. MHW #2 stated that the patient "was obviously having a hard time." and s/he voiced concerns about Patient #1, to Nurse #3, the Charge Nurse on Tyler I during the 11:00 PM - 7:00 AM shift at the time. Nurse #3 told MHW #2 to just continue checking on the patient. At 5:35 AM Patient #1 was yelling again and was checked by both the MHWs. MHW #1 next conducted a visual check of Patient #1 approximately 8 minutes later at 5:43 AM and found the patient unresponsive.

Nurse #3, stated during interview at 11:02 AM on 1/25/12, that, although s/he does not routinely perform visual checks of patients during the night, s/he had visually checked on Patient #1 at least 4 times during the shift because of the concerns by MHWs regarding the patient's prolonged intermittent yelling. Nurse #3 stated that, although the patient's color was good, and the patient was moving about in bed, s/he "was screaming and hollering at times", and even woke up other patients s/he "was so loud". S/he further stated that s/he did not attempt to awaken Patient #1. Nurse #3 stated that, although s/he had received report that Patient #1 had been readmitted to the unit following acute care treatment for Methadone overdose, s/he had not been aware of Patient #1's elevated temperature or diagnosis of Uvulitis, and confirmed that s/he had not conducted any assessment of the patient's health status. Nurse #3 stated that s/he was called to Patient #1's room at approximately 5:43 AM and found the patient unresponsive and without respirations or pulse. S/he stated that CPR was initiated and a Code Blue was called. Patient #1 was subsequently transferred to the ER by ambulance at approximately 6:20 AM.
During interview, at 9:42 AM on the morning of 1/26/12, the Senior Vice President of Patient Care Services and CNO (Chief Nursing Officer) confirmed the lack of health status assessment for Patient #1 and stated that s/he would have expected nursing staff to conduct an assessment of the patient related to the patient's change in condition exhibited by prolonged yelling out and lack of response to staff attempts to arouse him/her during the night of 1/21/12.

Based on staff interview and record review nursing staff failed to administer medications in accordance with established policies and protocols and resulting in the potential for and actual negative outcome for 2 patients. (Patients #1 and #2). Findings include:

Per record review staff failed to follow the facility's policies which included: the policy for Medication Procurement, Distribution, Storage and Disposition, last revised in July 2011 and which stated: Medication Storage and Disposition; When a medication is delivered to a unit it shall be locked in the designated location in the medication room unless it is to be administered immediately.....All Controlled Substances stored on the unit shall be secured and locked inside the medication cart drawer or a cabinet; the policy titled Administration and Scheduled Time of Medication, last revised and approved in July of 2011, which stated: III. Verifications, Education and Discussion: "Before administering medication staff will: Verify that there is no contraindication for administering the medication"; and the protocol for responding to missing medication, titled Safety Searches - Unit Lock-down for Contraband, dated June 2006, which stated; "All medication passes are to be halted and no medication may be given until cleared with the Unit Manager or Supervisor".

Patient #1, who was admitted to the Tyler 2 Unit on 1/18/12 for treatment of suicidal ideation and alcohol detox., was able to obtain and ingest the Methadone (opiate) prescribed for Patient #2 during a medication (med) pass on the morning of 1/19/12. Per interview, at 3:20 PM on 1/24/12, Nurse #1, who was responsible for med pass for all patients on Tyler 2 on 1/19/12, stated that s/he was inside the med room that morning with the bottom half of the Dutch style door to the room closed. Although the facility's policy for storage of medication specifies that medication delivered to a unit shall be locked in the designated location in the med room unless it is to be administered immediately, and all Controlled Substances, like Methadone, stored on the unit shall be secured and locked inside the medication cart drawer or a cabinet, Nurse #1 stated that s/he had prepared medications for several patients, placed the meds in individual plastic med cups, identified by patient name, and lined the cups up on the top of the med cart which was located next to the door and reachable by someone standing outside the door. Nurse #1 stated that Patient #1 presented at the med room door for his/her medication at approximately 9:00 or 9:30 AM that day. S/he stated that the patient, who was on an alcohol detox program, received 75 mg of Librium (benzodiazipine used to relieve anxiety and control agitation caused by alcohol withdrawal) at that time but continued to stand at the door, leaning on the shelf of the half door and repeatedly asking for Ritalin, for which there was no physician order, while other patients lined up in the hallway awaiting their turns for med administration. Nurse #1 stated that s/he had turned his/her head away from the Patient #1 for a short period just once during the exchange. Patient #1 left the area of the med room and the nurse continued to administer meds to other patients. Nurse #1 stated it was within 15 minutes of the exchange with Patient #1 that Patient #2 presented to the med room door asking for their daily maintenance dose of 110 mg of Methadone and the nurse was not able to find the pre-poured medication. S/he stated s/he had previously prepared the (2) 40 mg wafers and (6) 5 mg tablets totaling the 110 mg dose, placed them in a plastic med cup with another plastic med cup covering it and placed it on top of the med cart prior to the exchange with Patient #1. Nurse #1 stated that s/he alerted other staff and the Pharmacy that the Methadone was missing. S/he stated that, with the assistance of a pharmacy technician, they searched, unsuccessfully, throughout the med room for the Methadone. The protocol for Safety Searches - Unit Lock down for Contraband was implemented immediately following the identification of missing Methadone; and patients were gathered in the community area.. Nurse #1 stated that, during this time, although s/he had not consulted Patient #2's attending physician, s/he did speak with Pharmacist #1 about providing the maintenance dose of Methadone to Patient #2 who had still not received the medication and the Pharmacist told Nurse #1 that Patient #2 needed the medication. Despite the fact that administration of Methadone to Patient #2 was contraindicated because staff had not been able to account for the missing Methadone, and it was a violation of the protocol that stated to halt all medication administration, and, finally, without consulting the attending physician, Nurse #1 confirmed that s/he administered 110 mg of Methadone to Patient #2 (at 9:30 AM according to the Medication Administration Record). In addition Nurse #1 stated that s/he continued to administer medication to the 3 or 4 patients that had still not received their scheduled medications.

Nurse #2 stated during interview at 3:45 PM on 1/24/12, that while all patients were gathered in the community area of the unit, Patient #1 approached him/her and admitted that s/he had found a white pill (a 40 mg wafer of Methadone) on the floor of the bathroom that morning and had ingested it. A body search was then conducted on Patient #1 and during the contraband search of Patient #1's room s/he revealed a 5 mg tablet of Methadone that had been taped to the underside of a drawer. Patient #1 was placed on 1:1 observation status and after beginning to exhibit symptoms of Methadone overdose, including slurred speech, decreased respirations, increasing lethargy and constricted pupils, s/he was transferred, at 11:55 AM, to the ER (Emergency Room) for treatment. Patient #1 returned to the facility approximately 3 and a half hours later at 3:30 PM, was transferred to the Tyler I Unit and subsequently returned to the ER at approximately 5:00 PM that evening as a result of continuing to exhibit symptoms associated with Methadone overdose.

Per interview, at 12:53 PM on 1/25/12, the Tyler II Nurse Manager confirmed that Nurse #1 had continued to administer meds to patients after Methadone had gone missing and further stated that s/he had told Nurse #1 and all staff that medication administration had to be halted because they could not account for the missing Methadone.

Based on staff interviews and record review the Condition of Pharmacy Services is not met as evidenced by the failure to ensure safe and secure storage of all drugs in accordance with established policies and protocols, to prevent access by patients, and resulting in a negative patient outcome. In addition there was a failure to assure that pharmacy staff provided information to nursing staff in a manner that would promote safe medication use in accordance with established policies and protocols.






Refer to tag A-0502

Based on staff interview and record review the Pharmacy Department failed to ensure that all Controlled drugs were securely stored in a manner that prevented unauthorized access by patients, and failed to assure that medications were administered in a manner consistent with facility Policies and Procedures. Findings include:

Per record review staff failed to follow the facility's policies which included: the policy for Medication Procurement, Distribution, Storage and Disposition, last revised in July 2011 and which stated: Medication Storage and Disposition; When a medication is delivered to a unit it shall be locked in the designated location in the medication room unless it is to be administered immediately.....All Controlled Substances stored on the unit shall be secured and locked inside the medication cart drawer or a cabinet; the policy titled Administration and Scheduled Time of Medication, last revised and approved in July of 2011, which stated: III. Verifications, Education and Discussion: "Before administering medication staff will: Verify that there is no contraindication for administering the medication"; and the protocol for responding to missing medication, titled Safety Searches - Unit Lock-down for Contraband, dated June 2006, which stated; "All medication passes are to be halted and no medication may be given until cleared with the Unit Manager or Supervisor".

Patient #1, who was admitted to the Tyler 2 Unit on 1/18/12 for treatment of suicidal ideation and alcohol detox., was able to obtain and ingest the Methadone (opiate) prescribed for Patient #2 during a medication (med) pass on the morning of 1/19/12. Per interview, at 3:20 PM on 1/24/12, Nurse #1, who was responsible for med pass for all patients on Tyler 2 on 1/19/12, stated that s/he was inside the med room that morning with the bottom half of the Dutch style door to the room closed. Although the facility's policy for storage of medication specifies that medication delivered to a unit shall be locked in the designated location in the med room unless it is to be administered immediately Nurse #1 stated that s/he had prepared medications for several patients, placed the meds in individual plastic med cups, identified by patient name, and lined the cups up on the top of the med cart which was located next to the door and reachable by someone standing outside the door. Nurse #1 stated that Patient #1 presented at the med room door for his/her medication at approximately 9:00 or 9:30 AM that day. S/he stated that the patient, who was on an alcohol detox program, received 75 mg of Librium (benzodiazipine used to relieve anxiety and control agitation caused by alcohol withdrawal) at that time but continued to stand at the door, leaning on the shelf of the half door and repeatedly asking for Ritalin, for which there was no physician order, while other patients lined up in the hallway awaiting their turns for med administration. Nurse #1 stated that s/he had turned his/her head away from the Patient #1 for a short period just once during the exchange. Patient #1 left the area of the med room and the nurse continued to administer meds to other patients. Nurse #1 stated it was within 15 minutes of the exchange with Patient #1 that Patient #2 presented to the med room door asking for their daily maintenance dose of 110 mg of Methadone and the nurse was not able to find the pre-poured medication. S/he stated s/he had previously prepared the (2) 40 mg wafers and (6) 5 mg tablets totaling the 110 mg dose, placed them in a plastic med cup with another plastic med cup covering it and placed it on top of the med cart prior to the exchange with Patient #1. Nurse #1 stated that s/he alerted other staff and the Pharmacy that the Methadone was missing. S/he stated that, with the assistance of a pharmacy technician, they searched, unsuccessfully, throughout the med room for the Methadone. The protocol for Safety Searches - Unit Lock down for Contraband was implemented immediately following the identification of missing Methadone; and patients were gathered in the community area.. Nurse #1 stated that, during this time, although s/he had not consulted Patient #2's attending physician, s/he did speak with Pharmacist #1 about providing the maintenance dose of Methadone to Patient #2 who had still not received the medication and the Pharmacist told Nurse #1 that Patient #2 needed the medication. Despite the fact that administration of Methadone to Patient #2 was contraindicated because staff had not been able to account for the missing Methadone, and it was a violation of the protocol that stated to halt all medication administration, and, finally, without consulting the attending physician, Nurse #1 confirmed that s/he administered 110 mg of Methadone to Patient #2 (at 9:30 AM according to the Medication Administration Record). In addition Nurse #1 stated that s/he continued to administer medication to the 3 or 4 patients that had still not received their scheduled medications.

Nurse #2 stated, during interview at 3:45 PM on 1/24/12, that while all patients were gathered in the community area of the unit, Patient #1 approached him/her and admitted that s/he had found a white pill (a 40 mg wafer of Methadone) on the floor of the bathroom that morning and had ingested it. A body search was then conducted on Patient #1 and during the contraband search of Patient #1's room s/he revealed a 5 mg tablet of Methadone that had been taped to the underside of a drawer. Patient #1 was placed on 1:1 observation status and after beginning to exhibit symptoms of Methadone overdose, including slurred speech, decreased respirations, increasing lethargy and constricted pupils, s/he was transferred, at 11:55 AM, to the ER (Emergency Room) for treatment. Patient #1 returned to the facility approximately 3 and a half hours later at 3:30 PM, was transferred to the Tyler I Unit and subsequently returned to the ER at approximately 5:00 PM that evening as a result of continuing to exhibit symptoms associated with Methadone overdose.

During interview, at 10:14 AM on 1/25/12, Pharmacist #1 confirmed that Nurse #1 had contacted him/her on the morning of 1/19/12 to report that Methadone was missing. The Pharmacist stated that during the conversation the question came up about giving Patient #2 their prescribed Methadone. S/he stated that Nurse #1 had expressed that s/he was sure Patient #2 had not taken the Methadone and the Pharmacist told Nurse #1 that s/he would give the Methadone if positive Patient #2 hadn't had it.

The Director of Pharmacy Services agreed, during interview at 9:50 AM on 1/25/12, that there was a potential for Methadone overdose to occur if a patient receiving a daily maintenance dose of 110 mg were given more than the maintenance dose. During a subsequent interview, at 9:55 AM on 1/26/12, the Director of Pharmacy Services agreed that administration of medication should be halted, in accordance with the facility's established protocol for Safety Searches - Unit Lock-down for Contraband during any event when staff are not able to account for missing patient medications. S/he further agreed that response by pharmacy staff to questions posed regarding medication administration during an event requiring a unit lock-down should reflect the directives in the protocol.