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8550 HUEBNER ROAD

SAN ANTONIO, TX 78240

REPORTING ADVERSE REACTIONS AND ERRORS

Tag No.: A0411

Based on record review and interview, the facility failed to enforce their policy and procedure for reporting one of one medication errors on an Incident Report for a patient (Patient #1).

This had the potential to affect all patients who were receiving medications.

Findings included:

Review on 03/25/2021 of Patient #1's medical record revealed but was not limited to the following:
1. Review of Patient #1's Patient Registration Form, dated 02/12/2020 time not documented, revealed she was 16 years old and was suicidal and found with a belt around her neck.
2. Review of Physician Progress Note, dated 02/19/2020, revealed "patient received wrong patient's medication this morning this morning. Currently denying any ADRs (Adverse Drug Reactions)"
3. Review of Nurse's Medication Notes, dated 01/19/2020 AM, Vyvanse 40 mg given to patient by mouth. She received wrong dose and monitored for 2 hours No ADRs (Adverse Drug Reactions) Doctor and Patient's aunt notified.
4. Review of Patient #1's Physician's Orders from 02/13/2021 thru 02/19/2021 did not reveal an order for Vyvanse.

Review of facility Policy entitled "Incident Report/Performance Improvement, revised 01/25/2017, revealed but was not limited to the following: "the purpose of this policy is to establish consistent guidelines to report and document adverse care events or other accidential occurrences involving patients and visits at the facillity. An incident report is to be completed for every occurrence which meets the following definition: any happening not consistent with the routine care or operation of the facility, or the desired routine care of the patient/or operation of the facility, which places the company at an increased risk for liability. The Incident Report must be completed immediately following an event which meets the above-mentioned reporting definition. The Incident Report must be completed by the employee (s) who witnessed the event or discovered the event. Medication variance/Medication variance-adverse drug reaction are listed as categories to be reported on the Incident Report. All completed Incident Reports must be maintained for Minors seven years after the minor becomes 18 years old."

Interview on 03/25/2021 with facility administrative staff revealed they were unable to find a copy of the Incident Report on the above referenced medication variance for Patient #1.

Interview on 03/25/2021 with facility licensed vocational nurse (LVN) #1 revealed she had made the medication error by putting the medication at the nurse's station, looking away when someone called her name and Patient #1 took the Vyvanse instead of the patient who was prescribed the Vyvanse. She stated she immediately recognized the error and made the charge nurse aware. She was unable to state who completed the Incident Report but she believed it was the charge nurse. She further stated the charge nurse and the house supervisor were involved in monitoring the patient by taking her vital signs for at least two hours after the medication error.

CONTENT OF RECORD: ORDERS,NOTES,REPORTS

Tag No.: A0467

Based on record review and interviews, the facility failed to ensure nursing staff documented the vital signs results of monitoring of a patient (Patient #1) for adverse medical reactions after a medication error occurred.

This had the potential to affect all patients who were receiving medications.

Findings included:

Review on 03/25/2021 of Patient #1's medical record revealed but was not limited to the following:

1. Review of Physician Progress Note, dated 02/19/2020, revealed "patient received wrong patient's medication this morning. Currently denying any ADRs (Adverse Drug Reactions)"
2.. Review of Nurse's Medication Notes, dated 01/19/2020 AM, Vyvanse 40 mg given to patient by mouth. She received wrong dose and monitored for 2 hours No ADRs (Adverse Drug Reactions) Doctor and Patient's aunt notified.
3. Review of Patient #1's Physician's Orders from 02/13/2021 thru 02/19/2021 did not reveal an order for Vyvanse.
4. Review of Vital Signs Chart revealed documentation of AM and PM vital signs including blood pressure, pulse, temperatur, respiration and oxygen for the following dates: 2/13/2020, 02/14/2020, 02/15/2020, 02/16/2020, 02/17/2020, 02/18/2020, and 02/20/2020. There was no documentaion for 02/19/2020, the date of the medication error.

Interview on 03/25/2021 with facility Director of Nursing confirmed there was no documentation available of the nursing staff monitoring Patient #1's vital signs after the medication error.