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Based on clinical record and policy review and staff interview it was determined the facility failed to monitor and ensure a safe, effective. and appropriate administration of medications by the nursing staff. This practice may result in a potential delay in discharge, serious injury, or death.

Findings include:

1. The facility failed to ensure accurate medication administration by the nursing staff in four 40% (#1, #6, #8, #9) of the ten sample records. Five of the 10 sampled records were open records. Of the five open records, three 60% (#6, #8, #9) had nursing medication administration errors. (Refer to A0404).

2. The facility failed to follow the procedure for reporting errors in administration of medications for 4 (#1, #6, #8, #9) of 10 sampled patients. The facility failed to ensure that Quality Assessment Performance Improvement regularly monitored medication irregularities or errors, their nature, frequency and the corrective action taken. (Refer to A0410).


3. Facility failure to develop and keep current a nursing care plan for 4 ( #1, #3, #4, #5) of 10 sampled patients. (Refer to A0396).

4. The facility failed to ensure physician orders were obtained as verbal orders or written orders were signed by the physician for 1 (#1) of 10. (Refer to A0406).

Due to the cumulative effect of these systemic problems, it was determined that the Condition of Participation for Nursing Services was not in compliance.

Based on clinical record review, staff interview and policy review it was determined the nursing staff failed to develop and keeps current a nursing care plan for 4 (#1, #3, #4, #5) of 10 sampled patients . The practice does not ensure patient goals are met.

Findings include:

1. Patient #1 was admitted on 4/14/11 with a Subdural Hematoma and discharged to a Skilled Nursing Facility on 4/22/11. A review of the Plan of Care and Discharge Instruction Record revealed the Plan of Care Problems had not been "Met" or resolved prior to the patient's discharge.

2. Patient #3 was admitted on 5/22/11 with Altered Mental Status and Hypotension. A review of the Plan of Care and Discharge Instructions Record revealed the Plan of Care Problems had not been "Met" or resolved prior to the patient's discharge.

3. Patient #4 was admitted on 4/11/11 with an acute left foot, ankle and proximal fibula fractures, acute neck/back pain, diffuse idiopathic skeletal hyperostosis of the cervical and lumbar spine, and a head injury. A review of the patient's Plan of Care and Discharge Instructions Record revealed the Plan of Care Problems had not been "Met" or resolved prior to the patient's discharge.

4. Patient #5 was admitted on 4/12/11 for uncontrolled blood sugars and seizures. A review of the Plan of Care and the Discharge Instructions Record revealed the Plan of Care Problems had not been "met" prior to the discharge.

An interview with the Risk Manager was conducted on 5/31/11 at 3:30 p.m. during the review of the above records. The Risk Manager confirmed the above findings.

A review of the facility's policy, "Patient Care Process", policy # 100.185.74, effective 8/2009, revealed "Patient care is provided based upon an assessment of the patient/family, problem/outcome identification, interdisciplinary planning, the provision of interventions and evaluations of the patients response to, or outcomes resulting from the care provided.
Further review of the policy, page 3 of 3, paragraph titled "Evaluation", 1) The RN will review/update the Plan of Care/Problem List once every 24 hours, 2) Evaluation will include observations and analysis of the patient's immediate response to interventions as well as response over a period of time, 3) Priorities may be changed . If expected outcomes have been achieved, the problem is resolved and noted as "Met", and 6) Problems not resolved at discharge will be referred as appropriate.

Based on policy and clinical record review and staff interview it was determined the nursing staff failed to administer medications according to physician orders for 4 (#1, #6, #8, #9) of 10 sampled patients. The continued use of this practice may result in a potential delay in discharge, serious injury, or death.

Findings include:

1. Patient #1 was admitted on 4/14/11 at 1:29 p.m. with a diagnosis of Subdural Hematoma. A review of the physician orders dated 4/14/11 at 4:40 p.m. revealed an order for a moderate Insulin coverage sliding scale with blood sugars to be done before meals and in the evening. Review of the Medication Administration Record (MAR) revealed on 4/20/11 at 11:30 a.m. (before meal) the blood sugar was 264 and the patient received 6 units of insulin per the sliding scale. At 1:50 p.m. (post meal) the blood sugar was obtained again and was 309 with the patient receiving an additional 8 units of insulin.
A review of the medical record was conducted on 5/31/11 at approximately 2:30 p.m. with the Risk Manager and the Clinical Informatics Application Analyst. After a thorough review of the patient's record it was confirmed the patient had received an additional blood sugar test and insulin coverage. There was no physician order related to the additional test or dose of insulin.

2. Patient #6 was admitted to the facility on 5/30/11 with a diagnosis of Subdural Hematoma. Review of the admission orders revealed an order for Protonix 40 milligrams intravenously daily. Review of the MAR revealed Protonix 40 milligrams was administered at 2:55 a.m. on 5/30/11 and was administered again at 9:11 a.m. on 5/30/11.
During interview on 5/31/11 at approximately 11:00 a.m. the nurse manager confirmed the medication was administered a second time in error.

3. Patient #8 was admitted to the facility on 5/28/11 with the diagnosis of pneumonia. Review of the physician orders revealed an order for Zosyn 4.5 grams intravenously every 8 hours. Review of the MAR revealed the first dose was administered at 10:20 p.m. on 5/28/11. The next dose was not administered until 10:43 a.m. on 5/29/11, approximately twelve hours later. The Clinical Leader for the unit was present during the record review on 5/31/11 at approximately 1:30 p.m. and confirmed that the medication was administered 4 hours late.

4. Patient #9 was admitted to the facility on 5/29/11 with the diagnosis of diabetes. Review of physician orders revealed the blood sugar was to be measured before meals and at night with coverage of a low dose insulin sliding scale. Review of the documentation revealed the blood sugar was 178 on 5/30/11 at 6:13 a.m. The patient should have received 1 unit of regular insulin per the sliding scale. Review of the MAR revealed no insulin was administered. The nurse manager was present during the record review on 5/31/11 at approximately 12:00 p.m. and confirmed there was no evidence the insulin was administered as ordered.

Review of the facility's policy, "Medications: Ordering, Processing, Dispensing and Administration," #100.126.07, effective 12/2010, page 3 of 5, section for medication administration, paragraph 2, Nursing Guidelines revealed "medications will be administered in accordance with Physician Orders and in adherence to the five rights: the right medication; right dose;right patient; right time and right route."

Based on clinical record review, policy review and staff interview it was determined the facility failed to follow the policy for medication administration for 1 (#1) of 10 sampled patients. This practice does no ensure effective medication therapy and may cause injury or death.

Findings include

1. Patient #1 physician order for Potassium Magnesium Phosphorous- Adult- treatment to be used if level indicated was not dated or signed by the physician. The ordered was scanned at 12:14 p.m. and noted by nursing.

2. Patient #1's Non-violent, non self-destructive physician restraint orders and Assessment dated 4/17/11 at 1:00 a.m. was not signed by the physician. The review of the documentation revealed the patient was in restraints from 1:00 a.m. to 6:00 p.m.

An interview with the Risk Manager during the chart review on 5/31/11 at 3:30 p.m. confirmed the findings.

A review of the policy, "Medications- ordering, processing, dispensing and administration", policy # 100.126.07, effective 12/10, states " Medications shall be dispensed and/or administered only upon orders of an individual who is legally entitled to order medications and/or who has been assigned clinical privileges.

Based on clinical record review, policy review and staff interview it was determined the facility failed to follow the procedure for reporting errors in administration of medications for 4 (#1, #6, #8, #9) of 10 sampled patients. The facility failed to ensure that Quality Assessment Performance Improvement regularly monitored medication irregularities or errors, their nature, frequency and the corrective action taken. The lack of monitoring and corrective action plan for medication errors may result in a prolonged hospital stay, injury or death.

Findings include:

1. During review of 10 sampled records, medication errors were noted in four 40% (#1, #6, #8, #9) of the sample selection. Five of the 10 sampled records were open records. Of the five open records, three 60% (#6, #8, #9) had nursing administration medication errors.

2. The facility failed to ensure that staff followed the policy for filing medication errors within 24 hours for 4 (#1, #6, #8, #9) of 10 sampled (1 discharged/3 current) patients. A review of facility documentation for the months of April and May 2011 revealed 25 medication errors had occurred. The 25 medication errors are a combination of Pharmacy related errors, transcribing errors and administration errors. Five of the 25 were related to medication administration. The log did not contain any of the medication errors discovered during the ten record review.
A review of the facility's policy " Event Reporting", policy # BC RSK 103, dated 11/19/2010, page 2 of 3, paragraph 2. section a) section i) the team member discovering the event completes the on-line Prism Report before the end of their shift. When the team member is using the on-line reporting format, the system will automatically forward the report to Risk Management. ii) when using the paper reporting format, the team member will complete the event form by the end of the shift, the event report is to be received by the Risk Management Department within 24 hours of when the event occurred.

3. An interview with the Risk Manager and Director of Nursing was conducted on 5/31/11 at 5:30 p.m. During the interview the Quality Assessment Performance Improvement was requested by the surveyors to ascertain how the facility was tracking and trending the medication errors. The Director of Nursing stated the Pharmacy did not track and trend the medication errors. They presented graphs showing the comparison of the facility against its sister facilities and how medication errors had improved from 2009 to 2010. The Risk Manager was unable to produce what bench marks and/or indicators were being tracked and trended related to the dispensing, administration, omissions, adverse reactions, etc.