HospitalInspections.org

Based on document review and interview, it was determined that the facility staff failed to order and administer medications for one (1) of one (1) Patients (Patient # 1).

The findings include:

On October 17, 2023 at 10:00 a.m., a clinical record review for Patient # 1 revealed the following:

ED (Emergency Department) Provider Note dated September 26, 2023 at 5:31 p.m., reads in part "[Patient # 1] with a history of asthma and polymyositis presenting to the emergency department due to depression and suicidal ideation.
Current Outpatient Medications:
Mobic (nonsteriodal anti-inflammatory)
protonix (proton-pump inhibitor heartburn)
farxiga (diabetes)
lasix (diuretic)
toprol xl (beta blocker high blood pressure)
aldactone (diuretic)
robaxin (muscle relaxant)
minipress (antihypertensive)
cyanocobalamin (vitamin B12 deficiencies)
azelastine (antihistamine)
abilify (antipsychotic)
spiriva (bronchodilator)
proventil (bronchodilator)
lipitor (statin - cholesterol)
vitamin D (vitamin)
klonopin (seizures)
prozac (depression)
haldol (antipsychotic)
junel fe (birth control)
prilosec (proton pump inhibitor - heartburn)

Provider Notes (Medical Decision Making):
Patient presenting to the emergency department due to suicidal ideations, depression, and hallucinations. On exam, patient is alert, oriented x 3, in no acute distress. Heart regular rate and rhythm. No murmurs appreciated. No lower extremity edema. Lungs clear to auscultation bilaterally. Abdomen is soft and nontender. Patient reports visual and auditory hallucinations. Patient with blunted affect. Admits to suicidal ideation with current plan to throw self down the stairs or cut wrists. Denies any homicidal ideation. Will obtain baseline labs for medical clearance."

ED Provider note dated September 26, 2023 at 5:31 p.m. reads in part "Pt (Patient) is medically cleared to be evaluated by crisis."

Medication Administration Report (MAR) dated September 26, 2023 through September 29, 2023 reads in part:
"Potassium 40 mEq PO at 9:29 p.m. on 9/26/2023, 7:14 p.m. on 9/27/2023 and 3:34 a.m. on 09/27/2023,
Potassium 10 mEq IV at 9:42 p.m. on 9/26/2023 and
Sodium Chloride 1000 ml at 9:44 p.m. on 9/26/2023."

There was no documentation of any home medication administration between September 26, 2023 and September 29, 2023 while Patient # 1 was in the ED.

On October 11, 2023 at 11:00 a.m., an interview with Staff Member # 1 revealed "the only medications given were Potassium and fluids. It is best practice to administer home medications while the Patient is in observation for several days."

A review of the facility ' s policy titled "Medication Reconciliation" reads in part "For admitted patients, observation patients and surgery patients: Within 24 hours of admission, a provider will be responsible for continuing, discontinuing, or modifying medications upon review of the patient ' s clinical status."

On October 11, 2023, the findings were discussed with Staff Members # 1, # 3, # 4, # 8 and # 9 during the exit interview.