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Based on record review and interviews, the facility failed to ensure that a patient with clinical diagnosis including cor pulmonale and advanced lung stage diesease received appropriate assessments and monitoring based on an established plan of care designed to manage known respiratory risk factors associated with the patient's clinical status and the impact prescribed central nervous system depresssants ( narcotics) would have on a compromised respiratory status for one of 3 sampled patients. ( Patient #1)

Findings include:

1) A review of the closed clinical record of Patient #1 reveals an admission date of 3/4/11 and transfer on 3/13/11 to a local hospital for inpatient Hospice services.

Review of the History and Physical dated 3/4/11 reveals that Patient #1 pertinent diagnoses including the following:
? Chronic pneumonia with atypical Mycobacterium, Pseudomonas and MRSA.
? Anemia
? Dysphagia due to CA of the throat with Peg tube for feedings due to chronic aspiration syndrome.
? Chronic Left upper extremity swelling
? Wounds to the left hand and left ear with cellulitis.
? Severe COPD
? Chronic pain
? Anxiety and Insomnia
? Hypothyroidism post radiation.

Consults were ordered and completed as follows:
? 3/7/11 Infectious disease for chronic respiratory failure
? 3/7/11 Pulmonology for end stage chronic lung disease with bronchiectasis right sided heart failure /cor pulmonale and hemoptysis.
? 3/7/11 Psychiatry for chronic depression and anxiety
? 3/7/11 Cardiology for chest wall pain secondary to severe cough
? 3/8/11 Nephrology for anasarca, alkalemia secondary to respiratory compromise, secondary to advanced lung disease, azotemia with pre renal component, end stage lung disease.
? 3/8/11 Pain Consult

A detailed review of the Pain Consult dated 3/8/11 revealed that Patient #1 clinical impression of " chronic pneumonia with atypical mycobacterium in addition to pseudomonas and MRSA, respiratory failure, dysphagia, anemia, leg edema, chronic thoracic wall pain secondary to hacking cough, low back pain and anxiety disorder. I would recommend continuing with the Duragesic patch that was started at another local hospital at 50mcg every 72 hours and utilize Percocet or hydrocodone 500 mg prn for breakthrough pain. Alternatively we could use small amounts of methadone 5 to 10 mg via the peg and discontinue the Duragesic. "

Review of the Physician Orders for pain medication reveals the following:
? 3/4/11 Vicodin 5/500 mg via Peg give 1 every 3 hours prn pain
? 3/7/11 1735 Methadone 10 mg via Peg every 12 hours prn pain
? 3/7/11 1804 Fentanyl patch 50 mcg/ hr every 72 hours for pain
? 3/9/11 1555 Narcan 0.4 mg IV now
? 3/9/11 1624 Discontinue Methadone 10 mg and Fentanyl patch
? 3/9/1653 Give total 2 doses of Narcan after removing Fentanyl patch
? 3/9/11 1833 Methadone 5 mg every 24 hours for pain

A comparison of the Medication Administration Record to the Physician Orders and the Controlled Substance Log was conducted with the Nurse Manager and the Pharmacy Manager at 1:00 PM which revealed the following:
? 3/4/11 1730 received a dose of Percocet without an order to administer
? 3/5/11 Received Vicodin as ordered at 1222am, 0645 am, 5:55 Pm and 10:50 PM
? 3/6/11 Received Vicodin as ordered at 1:00 are, 8:00 are, 1:00 Pm, 4:25 PM and 9:10 PM.
? 3/7/11 Received Vicodin as ordered at 6:12 am, 1:48 pm, 5:57 pm and 9:56 PM.
? 3/7/11 Received Methadone 10 mg at 9:01 am and 9:56 pm.
? 3/8/11 Received Methadone 10 mg at 9:01 am and 9:56 pm
? 3/8/11 Received Vicodin at 6:12 am, 1:48 pm, 5:57 pm and 9:56 pm.
? 3/8/11 Fentanyl 50 mcg per hour patch started at 9:01 am
? 3/8/11 Received Xanax 0.25 mg at 1800 without a Physician ' s order
? 3/9/11 Received Methadone 10 mg at 9:17 am
? 3/9/11 Fentanyl patch discontinued at 4:24 pm and Narcan administered at 4:45 pm.
? 3/9/11 Methadone 5mg administered at 9:20 pm
? 3/10/11 Narcan 0/4mg IV administered at 0512 am 1mg administered at 12:15 PM.
3/12/11 0930 am Xanax 0.25mg without a physicians order
? No pain medications administered on 3/10, 3/11, 3/12 or 3/13/11

The Nurse Manager stated that she was asked to review the methadone administration due to a grievance on 3/15/11. She reviewed the orders for Methadone and determined that the Methadone 10 mg order was discontinued on 3/9/11 and no further doses were administered. Her review did not identify that the patient received Methadone 5mg on 3/9/11 at 9:20 pm. She also confirmed that she did not review all of the pain medications that were being administered concurrently to Patient #1 and /or review the issue with the Pharmacy.

Interviews could not be obtained with the Nurses who administered the Methadone, Fentanyl patch and Vicodin to Patient #1 as they were no longer employed by the facility. The Nurse Manager did confirm that the Nursing staff should have questioned the administration of multiple narcotics when Patient #1's compromised respiratory condition deteriorated requiring the use of a non-rebreather mask on 3/8/11. The patient's conditon continued to deteriorate on 3/9/11 resulting in the resident requiring the use of BIPAP ventillatory assist. The resident's deteriorating respiratory condition required the continuous use of BIPAP until his transfer on 3/13/11 for Hospice services. The Nurse Manager confirmed that the nurses who cared for Patient #1 on 3/7- 3/9/11 failed to adequately monitor the patients response to the administration of multiple narcotics and their impact on his compromised respiratory condition.

Based on record review and interviews, the facility failed to ensure that medications were ordered by a physician and reviewed by a pharmacist prior to administration for one of three sampled patients. ( Patient #1)

Findings include:
1) A comparison of the Medication Administration Record of Patient #1 to the Physician Orders and the Controlled Substance Log was conducted with the Nurse Manager and the Pharmacy Manager at 1:00 PM which revealed the following:
? 3/4/11 1730 received a dose of Percocet without a Physician's order
? 3/8/11 Received Xanax 0.25 mg at 1800 without a Physician ' s order
? 3/12/11 0930 am Received Xanax 0.25 mg without a physician's order

A review of the Pharmacy variance reports dated 3/7 to 4/25/11 did not reveal evidence that the Pharmacist had reviewed the inappropriate administration of Percocet and Xanax. The Pharmacist stated that she had recently completed her initial review and audits of control substance medications and failed to identify that the Percocet and Xanax were administered to Patient #1 without an order. She then checked the Pharmacy system and confirmed that there were no orders for Percocet or Xanax in the system for patient #1. The Pharmacist was asked how a patient could receive a dose of Percocet and two doses of Xanax without a Physician ' s order and this not be identified as a variance. She stated that if there was no Physician ' s order, when the Nurse tried to enter the administration into the computer system, it would not allow her to do so. If the nurse did not then report the error, a medication variance report would not be generated.