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Based on record review and interview, the hospital failed to ensure that all patients who request a copy of their medical record are provided with a complete copy that contains all clinical information documented in the medical record. This was evidenced by the hospital's failure to identify that a clinical nursing documentation pathway was not interfacing with the "completed" or "discharged" medical record resulting in incomplete medical records. Findings:

On 9/13/10 at 1:50 p.m., the medical record of Patient #2 was requested for review. S2 (Director of Quality) presented a copy of Patient #2's medical record. Upon review of the medical record of Patient #2, this surveyor discovered that the complete medical record was not provided as there was missing nursing documentation. This discovery was found after discrepancies were identified while comparing documentation in the medical record of Patient #2 with the Pyxis medication dispensing record that identified the medications pulled from the Pyxis Unit for administration to Patient #2. Review of the Pyxis medication dispensing record revealed 4mg of Zofran was pulled from the Pyxis Unit on 4/23/10 at 5:46 a.m. and 2mg of Dilaudid was pulled from the Pyxis Unit on 4/23/10 at 5:48 a.m. Review of the medical record of Patient #2 that was initially provided for review failed to contain documentation relating to the administration of the Zofran and/or Dilaudid on 4/23/10. When questioned if the medications (Zofran and Dilaudid) had been administered to Patient #2 after being pulled from the Pyxis Unit, S2 reviewed Patient #2's medical record and reported that she was unable to find any documentation to indicate that the medications (Zofran and Dilaudid) had been administered on 4/23/10 to Patient #2. S2 indicated that she would have someone look in the computerized medical record for more information relating to the administration of these medications.

On 9/14/10, S2 presented additional nursing documentation that included information relating to the administration of 1mg of Dilaudid to Patient #2 on 4/23/10 that was not included in the initial copy of Patient #2's medical record that was provided to this surveyor for review. S2 reported that she was unable to explain why this information was not included in the initial copy of Patient #2's medical record that was provided for review.

In an interview on 9/15/10 at 9:45 a.m., the HIM Director (S20) confirmed that the initial medical record of Patient #2 that was provided to this surveyor for review on 9/13/10 was not the complete medical record of Patient #2. S20 explained that the patient's medical record at Ochsner Medical Center is known as the Horizon Patient Folder. S20 indicated that the Horizon Patient Folder should contain all information relating to the care and services provided. S20 indicated that the Horizon Patient Folder consists of various pathways that cross over or interface to make up the complete medical record. S20 indicated that the HIS Pathway that contained the nursing documentation relating to the administration of the Dilaudid on 4/23/10 failed to cross over to the Horizon Patient Folder. S20 reported that she was unaware (prior to this survey) that this HIS Pathway was not crossing over to the Horizon Patient Folder. S20 confirmed that based on the information in this HIS Pathway not crossing over to the Horizon Patient Folder, some information may not be included in the copies of medical records provided to patients who request a complete copy of their medical record. S20 reported that she was not aware of any other pathways not crossing over to the Horizon Patient Folder.

Based on record review and interview, the hospital failed to implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program as evidenced by failing to set priorities for its performance improvement activities that focused on high-risk or problem-prone areas that affect health outcomes, safety, and/or quality of care as evidenced by:

1. Failing to identify that a clinical nursing documentation pathway was not interfacing with the "completed" or "discharged" medical record resulting in incomplete medical records being provided to patients who request a copy of their medical record. Findings:

Upon review of the medical record of Patient #2, this surveyor discovered that the complete medical record was not provided as there was missing nursing documentation. This discovery was found after discrepancies were identified while comparing documentation in the medical record of Patient #2 with the Pyxis medication dispensing record that identified medications pulled from the Pyxis Unit for administration to Patient #2. Review of the Pyxis medication dispensing record revealed 4mg of Zofran was pulled from the Pyxis Unit on 4/23/10 at 5:46 a.m. and 2mg of Dilaudid was pulled from the Pyxis Unit on 4/23/10 at 5:48 a.m. Review of the medical record of Patient #2 that was initially provided for review failed to contain documentation relating to the administration of the Zofran and/or Dilaudid on 4/23/10. When questioned if the medications (Zofran and Dilaudid) had been administered to Patient #2 after being pulled from the Pyxis Unit, S2 reviewed Patient #2's medical record and reported that she was unable to find any documentation to indicate that the medications (Zofran and Dilaudid) had been administered on 4/23/10 to Patient #2. S2 indicated that she would have someone look in the computerized medical record for more information relating to the administration of these medications.

On 9/14/10, S2 presented additional nursing documentation that included information relating to the administration of 1mg of Dilaudid to Patient #2 on 4/23/10 that was not included in the initial copy of Patient #2's medical record that was provided to this surveyor for review. S2 reported that she was unable to explain why this information was not included in the initial copy of Patient #2's medical record that was provided for review.

In an interview on 9/15/10 at 9:45 a.m., the HIM Director (S20) confirmed that the initial medical record of Patient #2 that was provided to this surveyor for review on 9/13/10 was not the complete medical record of Patient #2. S20 explained that the patient's medical record at Ochsner Medical Center is known as the Horizon Patient Folder. S20 indicated that the Horizon Patient Folder should contain all information relating to the care and services provided. S20 indicated that the Horizon Patient Folder consists of various pathways that cross over or interface to make up the complete medical record. S20 indicated that the HIS Pathway that contained the nursing documentation relating to the administration of the Dilaudid on 4/23/10 failed to cross over to the Horizon Patient Folder. S20 reported that she was unaware (prior to this survey) that this HIS Pathway was not crossing over to the Horizon Patient Folder. S20 confirmed that based on the information in this HIS Pathway not crossing over to the Horizon Patient Folder, some information may not be included in the copies of medical records provided to patients who request a complete copy of their medical record. S20 reported that she was not aware of any other pathways not crossing over to the Horizon Patient Folder.


2. Failing to identify that current and accurate records were not being kept regarding the disposition of controlled drugs following removal from the secured storage unit resulting in controlled drugs ( 4mg of Dilaudid and 4mg of Zofran) being unaccounted for in the hospital. Findings:

The Pyxis medication dispensing record that identified the medications pulled from the Pyxis Unit for administration to Patient #2 was reviewed. This dispensing record included the name and dose of the medications pulled, the time the medications were pulled, and the name of the person who pulled the medications from the unit. The timeframe reviewed was from the time of Patient #2's admission to the hospital on 4/21/10 till the time of the Code Blue being called on 4/23/10. The medications listed on the Pyxis medication dispensing record were reviewed with the medical record of Patient #2 to determine if the medications pulled from the Pyxis Unit matched the medications administered to Patient #2 as documented in the medical record of Patient #2. The following findings were identified in regards to medication administration discrepancies:

? 4/21/10 at 6:53 a.m.- Dilaudid 2mg pulled from the Pyxis Unit by S14 (RN) for administration to Patient #2. No documentation in Patient #2's medical record to indicate that this dose of Dilaudid was administered to Patient #2 after being pulled from the Pyxis Unit. In addition, there was no documentation to indicate that the Dilaudid was wasted. This Dilaudid 2mg was unaccounted for based on review of hospital records. In an interview on 9/15/10 at 1:20 p.m., the Director of Quality confirmed that there was no documentation to indicate that the 2mg of Dilaudid was administered to Patient #2 after being pulled from the Pyxis Unit. The Director confirmed that the 2mg of Dilaudid was unaccounted for.
? 4/23/10 at 5:46 a.m.- Zofran 4mg pulled from the Pyxis Unit by S14 (RN) for administration to Patient #2. No documentation in Patient #2's medical record to indicate that this 4mg dose of Zofran was administered to Patient #2 after being pulled from the Pyxis Unit. In addition, there was no documentation to indicate that the Zofran was wasted. This Zofran 4mg was unaccounted for based on review of hospital records. In an interview on 9/15/10 at 1:20 p.m., the Director of Quality confirmed that there was no documentation to indicate that the 4mg of Zofran was administered to Patient #2 after being pulled from the Pyxis Unit. The Director confirmed that the 4mg of Zofran was unaccounted for.
? 4/21/10 at 2:16 p.m.- Dilaudid 2mg pulled from the Pyxis Unit by S11 (LPN) for administration to Patient #2. Documentation in Patient #2's medical record revealed that 1mg of Dilaudid was administered to Patient #2 as ordered. There was no documentation to indicate what was done with the other 1mg of Dilaudid as there was no documentation to indicate that the 1mg of Dilaudid had been wasted by staff. This resulted in 1mg of Dilaudid being unaccounted for based on review of hospital records. In an interview on 9/15/10 at 1:20 p.m., the Director of Quality confirmed that there was no documentation to indicate what was done with the remaining 1mg of Dilaudid after 1mg was administered to Patient #2. The Director confirmed that the 1mg of Dilaudid was unaccounted for.
? 4/21/10 at 6:57 p.m.- Dilaudid 2mg pulled from the Pyxis Unit by S11 (LPN) for administration to Patient #2. Documentation in Patient #2's medical record revealed that 1mg of Dilaudid was administered to Patient #2 as ordered. There was no documentation to indicate what was done with the other 1mg of Dilaudid as there was no documentation to indicate that the 1mg of Dilaudid had been wasted by staff. This resulted in 1mg of Dilaudid being unaccounted for based on review of hospital records. In an interview on 9/15/10 at 1:20 p.m., the Director of Quality confirmed that there was no documentation to indicate what was done with the remaining 1mg of Dilaudid after 1mg was administered to Patient #2. The Director confirmed that the 1mg of Dilaudid was unaccounted for.

The Clinical Coordinator Pharmacist (S4) was interviewed on 9/15/10 at 2:40 p.m. S4 confirmed that there was no documentation to indicate what was done with the 4mg of Dilaudid or the 4mg of Zofran. S4 indicated that the disposition of these controlled drugs in unknown.

Interview with the Director of Quality on 9/16/10 between 10:30 a.m. and 12:30 p.m. revealed that the breakdown in medical records and the breakdown in pharmacy had not been previously identified and incorporated into the hospital's quality assurance performance improvement program.


3. Failing to identify the need to complete and review a CODE Blue Team Evaluation Competency Form following a Code Blue as outlined in the hospital approved policy/procedure titled "Code Blue". Findings:

Review of the medical record of Patient #2 revealed that a Code Blue was called on Patient #2 on 4/23/10 at 7:42 a.m.

The hospital approved policy/procedure titled "Code Blue" was reviewed. The policy/procedure documents "At completion of the code, complete the CODE Blue TEAM Evaluation Competency Form and turn this in to the Department Director" and "The Department Director shall review CODE Blue Team Evaluation Competency Form, then forward to Director of Critical Care for filing and trending purposes".

The Director of Critical Care (S7) was interviewed on 9/14/10 at 10:25 a.m. S7 reported that she is responsible for reviewing the effectiveness of all Code Blue's to determine the effectiveness of the Rapid Response Team and the effectiveness of the interventions implemented. S7 reported that she reviews and reports information relating to the information documented on the "CODE Blue Team Evaluation Competency Form" that is completed on all Code Blues. S7 reported that this did not happen in relation to the Code Blue called on Patient #2 because the "CODE Blue Team Evaluation Competency Form" was not filled out. S7 indicated that the form must have been overlooked.

Based on record review and interview, the registered nurse failed to supervise and evaluate the care provided to patients by failing to identify the need to increase the supervision of Patient #2's respiratory status following the administration of IV Dilaudid after Patient #2 was noted to have low oxygen saturations and shallow respirations following the administration of pain medications. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 was admitted to the hospital's med-surg unit on 4/21/10 at 1:00 a.m. after presenting to the hospital's Emergency Department. Review of the admission orders revealed that the patient's admitting diagnosis was Pancreatitis. Review of the record revealed a Code Blue was called on Patient #2 on 4/23/10 at 7:42 a.m. Review of the "Code Blue Flowsheet" revealed "(S17), RN entered room and found pt not breathing. Code blue called. (S9), RN initiated CPR at (7:42 a.m.) Pulse palpated. Placed pt on monitor. Narcan 0.4mg administered per (S5), RN. Pt bagged, sat 88%. 2nd IV started to LW. O2 sat 99%. Pt transferred to MICU bed 5". Documentation revealed that Patient #2 remained in MICU until her transfer to the Telemetry Unit on 4/24/10 at 10:00 a.m. where she remained until her discharge from the hospital on 4/26/10 at 12:30 p.m. Documentation revealed that Patient #2 was discharged from the hospital in stable condition.

Further review of Patient #2's medical record revealed the following documentation in relation to Patient #2's respiratory status: entry dated 4/21/10 at 7:30 a.m. that read " Pt's POX (pulse ox) 62% on Rm Air; Pt little sedated from earlier pain med; Sat pt up in bed, asked to breath thru nose out mouth; POX up to 64%; Put pt on 2L NC; Incr to 80%; Resp Ther came in Room, commented they had same issue earlier; Pt not increasing with 2L, increased O2 to 3L; Pt slowly incr to 99%" (of note- 4/21/10 at 6:53 a.m.- Dilaudid 2mg pulled from the Pyxis Unit by S14 (RN) for administration to Patient #2. No documentation in Patient #2's medical record to indicate that this dose of Dilaudid was administered to Patient #2 after being pulled from the Pyxis Unit. In addition, there was no documentation to indicate that the Dilaudid was wasted); entry dated 4/22/10 at 11:18 a.m. that indicated the patients O2 sat was 86. Documentation revealed "Pt. awakened sat on side of bed several deep breaths taken O2 turned up to 2l while sleeping, po=92%" (of note- 4/22/10 at 8:30 a.m.- Dilaudid 1mg documented as being administered to Patient #2); entry dated 4/23/10 at 7:35 a.m.- Documentation revealed "(name of S17), RN came out of patient's room stating that patient is not breathing good and to call a 'code'. Code team arrived with crash cart. Husband states she was 'gurgling in her sleep' and not breathing right. Narcan pulled from Pyxis and given by code team. Patient is transferred to ICU. Report given to ICU nurse by (name of S14)".

The Respiratory Therapist (S6) was interviewed on 9/14/10 at 10:05 a.m. S6 reviewed the medical record of Patient #6. S6 reported that she first met with Patient #2 on 4/21/10 sometime between 8:00 a.m. and 9:00 a.m. S6 reported that Patient #2 was on room air and that her O2 sats had dropped in the 70's. S6 reported that Patient #2 was placed on a nasal canula with O2 and her O2 sats returned to the 90's. S6 reviewed the nursing documentation dated 4/21/10 at 7:30 a.m. indicating "Pt's POX (pulse ox) 62% on Rm Air; Pt little sedated from earlier pain med; Sat pt up in bed, asked to breath thru nose out mouth; POX up to 64%; Put pt on 2L NC; Incr to 80%; Resp Ther came in Room, commented they had same issue earlier; Pt not increasing with 2L, increased O2 to 3L; Pt slowly incr to 99%". S6 reported that she had not met with Patient #2 prior to the time of this nursing entry (4/21/10 at 7:30 a.m.) and reported that she did not recall receiving any reports relating to Patient #2's respiratory status from the off-going night shift respiratory therapist (S19) who she relieved on the morning of 4/21/10.

The Respiratory Therapist (S19) was interviewed by telephone on 9/15/10 at 1:50 p.m. S19 reported that he did not recall seeing Patient #2 during the early a.m. on 4/21/10. There was no documentation from respiratory therapy services in Patient #2's medical record to indicate that Patient #2 was seen by a respiratory therapist on 4/21/10 prior to 7:30 a.m. which was the date and time of the above documented nursing entry that indicated "Resp Ther came in Room, commented they had same issue earlier".

The Director of Quality (S2) and the Director of Cardio-Pulmonary (S18) were interviewed on 9/15/10 at 1:55 p.m. S2 and S18 confirmed that there was no documentation from respiratory therapy services in Patient #2's medical record to indicate that Patient #2 was seen by a respiratory therapist on 4/21/10 prior to 7:30 a.m. as documented in the nursing documentation (dated 4/21/10 at 7:30 a.m.) which indicated "Resp Ther came in Room, commented they had same issue earlier" in reference to low O2 sats. S2 and S18 reported that they could offer no explanation as to why the nursing documentation indicated respiratory therapy had came in Patient #2's room prior to 7:30 a.m. on 4/21/10 when there was no respiratory therapy notes to indicate the findings documented in the nursing note.

The Licensed Practical Nurse (S8) was interviewed on 9/14/10 at 11:35 a.m. S8 reviewed the medical record of Patient #2. S8 reported that she was the primary nurse assigned to provide care to Patient #2 on the day shift on 4/22/10. S8 reported that she received report on Patient #2 at approximately 7:30 a.m. on 4/22/10. S8 reported that she conducted a full assessment on Patient #2 on 4/22/10 at 8:05 a.m. and reported that Patient #2 was in no distress at that time. S8 indicated that the following medications were administered to Patient #2 for pain on 4/22/10: 1mg of Dilaudid at 4:00 a.m., 8:30 a.m. and 10:40 p.m.; 650mg of Tylenol at 1:45 p.m.; and 15mg of Toradol at 4:50 p.m. S8 reported that Patient #2's O2 sats dropped to 86 on 4/22/10 at 11:18 a.m. S8 indicated that Patient #2's O2 sats returned to the 90's after she was awakened and encouraged to take deep breaths. S8 reported that she did not recall Patient #2 being in any distress on the day shift on 4/22/10.

The Licensed Practical Nurse (S11) was interviewed on 9/14/10 at 1:45 p.m. S11 reviewed the medical record of Patient #2. S11 reported that she was the primary nurse assigned to provide care to Patient #2 on the day shift (7:00 a.m. till 7:00 p.m.) on 4/21/10. S11 indicated Patient #2's O2 sat was 62 on 4/21/10 at 7:30 a.m. and that Patient #2 was a little sedated from an earlier pain medication. S11 reported that Patient #2 had received 1mg of Dilaudid on 4/21/10 at 3:45 a.m. S11 reported that she called "respiratory" and informed them of Patient #2's low O2 sat. S11 reported that "respiratory" told her that Patient #2 had had low sats during the night. S11 reported that she could not recall who she spoke with in respiratory and could not recall exactly what respiratory had told her other than the low sats. S11 reported that she coached Patient #2 on how to breathe deeply in through nose and out through mouth. S11 reported that she informed the physician and obtained an order for O2 to be administered by nasal canula at 2 or 3 liters per minute. S11 reported that Patient #2 presented with shallow mouth breathing with an O2 sat of 92 at 4:00 p.m. on 4/21/10. S11 reported that Patient #2 received 650mg of Tylenol at 2:05 p.m. on 4/21/10 and 1mg of Dilaudid and 4mg of Zofran at 2:15 p.m. on 4/21/10. When asked if she thought there was a correlation between Patient's respiratory status and the pain medication, S11 reported that she did not think about that while providing care to Patient #2.

The Registered Nurse (S14) was interviewed on 9/15/10 at 7:30 a.m. S14 reviewed the medical record of Patient #2. S14 reported that she admitted Patient #2 to the med-surg unit on 4/21/10 at 3:00 a.m. S14 reported that Patient #2's diagnosis was Pancreatitis. S14 reported that Patient #2 was alert and oriented at the time of her admission to the hospital. S14 reported that Patient #2's vital signs were BP-98/58, P-62, R-20, O2 sat-94, and her respirations were even and unlabored. S14 reported that she administered 20meq of KCl to Patient #2 at 3:05 a.m. on 4/21/10, 1mg of Dilaudid IV at 3:45 a.m. on 4/21/10, and 4mg of Zofran IV at 3:45 a.m. When asked about the IV administration time for Dilaudid, S14 reported that Dilaudid is to be pushed slowly over 2 minutes and a re-assessment must be done on the patient within 1 hour of administering the IV Dilaudid. S14 reported that she assessed Patient #2 on 4/21/10 at 4:00 a.m. and she (Patient #2) was in no distress at that time. S14 reported that she re-assessed Patient #2 at 5:00 a.m. and 6:00 a.m. and indicated that she (Patient #2) was in no distress at that time. S14 reported that she gave report at approximately 6:45 a.m. on 4/21/10 to S11 (LPN) who was the on-coming day shift nurse assuming care of Patient #2. S14 reviewed the documentation entered by S11 on 4/21/10 at 7:30 a.m. that indicated "Pt's POX (pulse ox) 62% on Rm Air; Pt little sedated from earlier pain med; Sat pt up in bed, asked to breath thru nose out mouth; POX up to 64%; Put pt on 2L NC; Incr to 80%; Resp Ther came in Room, commented they had same issue earlier; Pt not increasing with 2L, increased O2 to 3L; Pt slowly incr to 99%" and reported that she (S14) could not recall Patient #2 being in any respiratory distress or of respiratory therapy being in Patient #2's room prior to 7:30 a.m. on 4/21/10 which was the time of S11's entry. S14 indicated that her next shift with Patient #2 was the night shift that began at 6:45 p.m. on 4/21/10. S14 reported that 1mg of Dilaudid was administered to Patient #2 at 7:00 p.m. on 4/21/10. S14 reported that Patient #2 was on 2 liters of oxygen by nasal canula and was in no respiratory distress at 8:00 p.m. S14 indicated that Patient #2 had an uneventful night from 6:45 p.m. on 4/21/10 thru 6:45 a.m. on 4/22/10. S14 indicated that her next shift with Patient #2 was the night shift that began at 6:45 p.m. on 4/22/10. S14 reported that 1mg of Dilaudid, 4mg of Zofran, 1mg of Clonazepam, and 650mg of Tylenol were administered to Patient #2 at 10:40 p.m. on 4/22/10. S14 reported that 1mg of Dilaudid was given sometime between 6:00 a.m. and 6:45 a.m. on 4/23/10. (The administration of the 1mg of Dilaudid at 6:45 a.m. on 4/23/10 was not documented on the medication administration record. It was documented on the patient care notes and did not cross over to the medical record that was initially provided to this surveyor for review). S14 reported that she went to give report to the on-coming shift when she heard the Code Blue called. S14 reported that she ran to Patient #2's room and was told to get Narcan out of Pyxis. S14 reported that the Narcan was administered to Patient #2 during the Code Blue. S14 reported that Patient #2 was transferred to ICU following the Code Blue. S14 reported that she went to the ICU to check on Patient #2 and talked with Patient #2 while in the ICU. S14 reported that she did not recall Patient #2 questioning her about any medications that were administered during her shift. When asked what medications were administered to Patient #2 during the her shift (6:45 p.m. on 4/22/10 thru 6:45 a.m. on 4/23/10), S14 reported that 1mg of Dilaudid, 4mg of Zofran, 1mg of Clonazepam, 650mg of Tylenol, 40mg of Citalopram, and 112 mcg of Levothyroxine were administered to Patient #2 at 10:40 p.m. on 4/22/10 and 112 mcg of Levothyroxine was administered to Patient #2 at 6:45 a.m. on 4/23/10 and 1mg of Dilaudid was administered to Patient #2 sometime between 6:00 a.m. and 6:45 a.m. on 4/23/10. When asked why the a.m. administration of IV Dilaudid was not documented on the medication administration record, S14 reported that "everything happened so fast" and she must have forgot to document the administration of the IV Dilaudid. When asked to explain the process for the administration of the IV Dilaudid, S14 reported that she gave the Dilaudid IV push over 2 minutes.

Based on record review and interview, the registered nurse failed to ensure that drugs and biologicals were administered in accordance with Federal and State laws, the orders of the practitioner, and acceptable standards of practice. This was evidenced by:

1. Failing to ensure that current and accurate records were kept regarding the administration of medications and regarding the disposition of controlled drugs after the controlled drugs were removed from the secured storage unit resulting in controlled drugs ( 4mg of Dilaudid and 4mg of Zofran) being unaccounted for in the hospital. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 was admitted to the hospital's med-surg unit on 4/21/10 at 1:00 a.m. after presenting to the hospital's Emergency Department. Review of the admission orders revealed that the patient's admitting diagnosis was Pancreatitis. Review of the record revealed a Code Blue was called on Patient #2 on 4/23/10 at 7:42 a.m. Review of the "Code Blue Flowsheet" revealed "(S17), RN entered room and found pt not breathing. Code blue called. (S9), RN initiated CPR at (7:42 a.m.) Pulse palpated. Placed pt on monitor. Narcan 0.4mg administered per (S5), RN. Pt bagged, sat 88%. 2nd IV started to LW. O2 sat 99%. Pt transferred to MICU bed 5". Documentation revealed that Patient #2 remained in MICU until her transfer to the Telemetry Unit on 4/24/10 at 10:00 a.m. where she remained until her discharge from the hospital on 4/26/10 at 12:30 p.m. Documentation revealed that Patient #2 was discharged from the hospital in stable condition.

The following medications were ordered for Patient #2 while on the med-surg unit prior to the Code Blue being called:
? 4/21/10 at 1:00 a.m. - Dilaudid 1mg IV q 2 hours prn pain
? 4/21/10 at 1:00 a.m. - Acetaminophen 650mg q 6 hours by mouth as needed for pain or fever
? 4/21/10 at 1:00 a.m. - Ambien 10mg by mouth at bedtime as needed for insomnia
? 4/21/10 at 1:00 a.m. - Zofran 4mg IV push every 6 hours as needed for nausea
? 4/21/10 at 1:00 a.m. - Protonix 40mg by mouth q day
? 4/21/10 at 1:00 a.m. - KCl 40meq IV X 1
? 4/21/10 at 8:00 p.m. - Benadryl 25mg by mouth q 4 hours prn itching
? 4/22/10 at 4:40 p.m. - Toradol 15mg IV X 1 dose
? 4/22/10 at 6:25 p.m. - Clonazepam 1mg tab BID prn
? 4/22/10 at 6:25 p.m. - Citalopram 40mg tab q day
? 4/22/10 at 6:25 p.m. - Levothroxine 112mcg tab q day

The following medications were documented as being administered to Patient #2 while on the med-surg unit prior to the Code Blue being called:
? 4/21/10- Dilaudid 1mg administered at 3:45 a.m., 2:15 p.m., and 7:00 p.m.
? 4/21/10- Acetaminophen 650mg administered at 2:05 p.m.
? 4/21/10- Ambien (no documentation of Ambien being administered on 4/21/10)
? 4/21/10- Zofran 4mg administered at 3:45 a.m. and 2:15 p.m.
? 4/21/10- Protonix 40mg administered at 9:00 a.m.
? 4/21/10- KDur 40meq administered at 3:05 a.m.
? 4/21/10- Benadryl 25mg administered at 8:15 p.m.
? 4/22/10- Dilaudid 1mg administered at 4:00 a.m., 8:30 a.m., and 10:40 p.m.
? 4/22/10- Acetaminophen 650mg administered at 4:00 a.m., 1:40 p.m., and 10:40 p.m.
? 4/22/10- Ambien (no documentation of Ambien being administered on 4/22/10)
? 4/22/10- Zofran 4mg administered at 4:00 a.m. and 10:40 p.m.
? 4/22/10- Protonix 40mg administered at 9:00 a.m.
? 4/22/10- Toradol 15mg administered at 4:50 p.m.
? 4/22/10- Benadryl 25mg administered at 4:00 a.m. and 9:15 a.m.
? 4/22/10- Clonazepam 1mg administered at 10:40 p.m.
? 4/22/10- Citalopram 40mg administered at 10:40 p.m.
? 4/22/10- Levothyroxine 112mcg administered at 10:40 p.m.
? 4/23/10- Levothyroxine 112mcg administered at 6:45 a.m.
? 4/23/10- Dilaudid 1mg- Documentation at 6:00 a.m. on the "Nursing NTS" Pt. Notes indicates "Dilaudid 1mg given as ordered". The administration of this dose of Dilaudid was not documented on the medication administration record.
? 4/23/10- Zofran- 4mg- No documentation to indicate that Zofran was administered to Patient #2 on 4/23/10 prior to the Code Blue.

The Pyxis medication dispensing record that identified the medications pulled from the Pyxis Unit for administration to Patient #2 was reviewed. This dispensing record included the name and dose of the medications pulled, the time the medications were pulled, and the name of the person who pulled the medications from the unit. The timeframe reviewed was from the time of Patient #2's admission to the hospital on 4/21/10 till the time of the Code Blue being called on 4/23/10. The medications listed on the Pyxis medication dispensing record were reviewed with the medical record of Patient #2 to determine if the medications pulled from the Pyxis Unit matched the medications administered to Patient #2 as documented in the medical record of Patient #2. The following findings were identified in regards to medication administration discrepancies:
? 4/21/10 at 6:53 a.m.- Dilaudid 2mg pulled from the Pyxis Unit by S14 (RN) for administration to Patient #2. No documentation in Patient #2's medical record to indicate that this dose of Dilaudid was administered to Patient #2 after being pulled from the Pyxis Unit. In addition, there was no documentation to indicate that the Dilaudid was wasted. This Dilaudid 2mg was unaccounted for based on review of hospital records. In an interview on 9/15/10 at 1:20 p.m., the Director of Quality confirmed that there was no documentation to indicate that the 2mg of Dilaudid was administered to Patient #2 after being pulled from the Pyxis Unit. The Director confirmed that the 2mg of Dilaudid was unaccounted for.
? 4/23/10 at 5:46 a.m.- Zofran 4mg pulled from the Pyxis Unit by S14 (RN) for administration to Patient #2. No documentation in Patient #2's medical record to indicate that this dose of Zofran was administered to Patient #2 after being pulled from the Pyxis Unit. In addition, there was no documentation to indicate that the Zofran was wasted. This Zofran 4mg was unaccounted for based on review of hospital records. In an interview on 9/15/10 at 1:20 p.m., the Director of Quality confirmed that there was no documentation to indicate that the 4mg of Zofran was administered to Patient #2 after being pulled from the Pyxis Unit. The Director confirmed that the 4mg of Zofran was unaccounted for.
? 4/21/10 at 2:16 p.m.- Dilaudid 2mg pulled from the Pyxis Unit by S11 (LPN) for administration to Patient #2. Documentation in Patient #2's medical record revealed that 1mg of Dilaudid was administered as ordered to Patient #2 by S23 (RN). There was no documentation to indicate what was done with the other 1mg of Dilaudid as there was no documentation to indicate that the 1mg of Dilaudid had been wasted by staff. This resulted in 1mg of Dilaudid being unaccounted for based on review of hospital records. In an interview on 9/15/10 at 1:20 p.m., the Director of Quality confirmed that there was no documentation to indicate what was done with the remaining 1mg of Dilaudid after 1mg was administered to Patient #2. The Director confirmed that the 1mg of Dilaudid was unaccounted for.
? 4/21/10 at 6:57 p.m.- Dilaudid 2mg pulled from the Pyxis Unit by S11 (LPN) for administration to Patient #2. Documentation in Patient #2's medical record revealed that 1mg of Dilaudid was administered as ordered to Patient #2 by S14 (RN). There was no documentation to indicate what was done with the other 1mg of Dilaudid as there was no documentation to indicate that the 1mg of Dilaudid had been wasted by staff. This resulted in 1mg of Dilaudid being unaccounted for based on review of hospital records. In an interview on 9/15/10 at 1:20 p.m., the Director of Quality confirmed that there was no documentation to indicate what was done with the remaining 1mg of Dilaudid after 1mg was administered to Patient #2. The Director confirmed that the 1mg of Dilaudid was unaccounted for.

S14 (RN) was interviewed on 9/16/10 at 1:00 p.m. When asked about the 4mg of Zofran that was pulled from the Pyxis Unit on 4/23/10 at 5:46 a.m. for administration to Patient #2, S14 reported that she administered the 4mg of Zofran but forgot to chart the administration of this Zofran in Patient #2's medical record. When asked about the 2mg of Dilaudid that was pulled from the Pyxis Unit on 4/21/10 at 6:53 a.m. for administration to Patient #2, S14 reported that she must have forgot to chart the administration of this 1mg of Dilaudid to Patient #2 and forgot to chart the wasting of the other 1mg of Dilaudid. When asked about the 1mg of Dilaudid that was unaccounted for after 2mg of Dilaudid were pulled from the Pyxis Unit on 4/21/10 at 6:57 p.m. and only 1mg of Dilaudid was documented as being administered to Patient #2, S14 reported that she administered 1mg of Dilaudid to Patient #2 and must have forgot to chart the wasting of the other 1mg of Dilaudid.

S23 (RN) was interviewed on 9/16/10 at 1:20 p.m. When asked about the 1mg of Dilaudid that was unaccounted for after 2mg of Dilaudid were pulled from the Pyxis Unit on 4/21/10 at 2:16 p.m. and only 1mg of Dilaudid was documented as being administered to Patient #2, S23 reported that she could not recall what happened to the 1mg of Dilaudid that was unaccounted for.

The medical record of Patient #7 was reviewed. This review revealed an order indicating that 1mg of Dilaudid could be administered every 4 hours as needed for pain. Review of the medication administration record revealed that 1mg of Dilaudid was administered to Patient #7 on 9/07/10 at 10:00 a.m., 2:15 p.m., 6:50 p.m., and 11:05 p.m. Review of the Pyxis medication dispensing record revealed that a total of 10mg (5 - 2mg vials) of Dilaudid were pulled from the Pyxis Unit on 9/07/10 for administration to Patient #7. Review of the medical record of Patient #7 revealed that Patient #7 received a total of 4mg of Dilaudid in 4 different doses on 9/07/10. Review of hospital records revealed that a total of 5mg of Dilaudid was wasted after being pulled from the Pyxis Unit for administration to Patient #7 on 9/07/10. This resulted in 1mg of Dilaudid being unaccounted for in the hospital. In an interview on 9/15/10 at 1:20 p.m., the Director of Quality confirmed that there was 1mg of Dilaudid after unaccounted for relating to the Dilaudid that was pulled for Patient #7. The Director reported that this discrepancy occurred as a result of a broken vial of Dilaudid. The Director explained that the nurse pulled two 2mg vials of Dilaudid from the Pyxis Unit because she had dropped the first vial pulled and the vial broke so she pulled a second vial. The Director reported that two nurses documented the wasting of the broken vial as 1mg when in fact they had wasted 2mg of the Dilaudid because they did not administer any of the Dilaudid from the broken vial to Patient #7. The Director confirmed that there was a discrepancy in the documentation relating to the controlled drug as 1mg of Dilaudid was unaccounted for.

The hospital's policy/procedure (Policy Number OHS.HIM.030) titled "Hospital Medical Record Documentation" was reviewed. The policy/procedure documents to facilitate consistency and continuity in patient care, the medical record contains very specific data and information, including "every dose of medication administered (including the strength, dose, or rate of administration, administration devices used, access site or route, known drug allergies, and any adverse drug reaction) medications administered;".

The hospital's policy/procedure titled "Medication Administration, Timed Intervals For" was reviewed. The policy/procedure indicates that documentation on the MAR shall be completed at time of administration.


2. Failing to be certain that IV Dilaudid was administered to 1 of 7 sampled patients (Patient #2) in accordance with the guidelines for administration. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 was admitted to the hospital's med-surg unit on 4/21/10 at 1:00 a.m. after presenting to the hospital's Emergency Department. Review of the admission orders revealed that the patient's admitting diagnosis was Pancreatitis. Review of the record revealed a Code Blue was called on Patient #2 on 4/23/10 at 7:42 a.m. Review of the "Code Blue Flowsheet" revealed "(S17), RN entered room and found pt not breathing. Code blue called. (S9), RN initiated CPR at (7:42 a.m.) Pulse palpated. Placed pt on monitor. Narcan 0.4mg administered per (S5), RN. Pt bagged, sat 88%. 2nd IV started to LW. O2 sat 99%. Pt transferred to MICU bed 5". Documentation revealed that Patient #2 remained in MICU until her transfer to the Telemetry Unit on 4/24/10 at 10:00 a.m. where she remained until her discharge from the hospital on 4/26/10 at 12:30 p.m. Documentation revealed that Patient #2 was discharged from the hospital in stable condition.

Documentation in the nursing patient care notes revealed an entry dated 4/23/10 at 6:00 a.m. by S14 (RN) that read, "Dilaudid 1mg given as ordered". The administration of this dose of Dilaudid was not documented on the medication administration record.

Registered Nurse (S14) was interviewed on 9/15/10 at 7:30 a.m. S14 reviewed the medical record of Patient #2. S14 reported that she admitted Patient #2 to the med-surg unit on 4/21/10 at 3:00 a.m. S14 reported that Patient #2's diagnosis was Pancreatitis. S14 reported that she administered 20meq of KCl to Patient #2 at 3:05 a.m. on 4/21/10, 1mg of Dilaudid IV at 3:45 a.m. on 4/21/10, and 4mg of Zofran IV at 3:45 a.m. When asked about the IV administration time for Dilaudid, S14 reported that Dilaudid is to be pushed slowly over 2 minutes and a re-assessment must be done on the patient within 1 hour of administering the IV Dilaudid. S14 reported that she assessed Patient #2 on 4/21/10 at 4:00 a.m. and she (Patient #2) was in no distress at that time. S14 reported that she re-assessed Patient #2 at 5:00 a.m. and 6:00 a.m. and indicated that she (Patient #2) was in no distress at that time. S14 reported that she gave report at approximately 6:45 a.m. on 4/21/10 to S11 (LPN) who was the on-coming day shift nurse assuming care of Patient #2. S14 reviewed the documentation entered by S11 on 4/21/10 at 7:30 a.m. that indicated "Pt's POX (pulse ox) 62% on Rm Air; Pt little sedated from earlier pain med; Sat pt up in bed, asked to breath thru nose out mouth; POX up to 64%; Put pt on 2L NC; Incr to 80%; Resp Ther came in Room, commented they had same issue earlier; Pt not increasing with 2L, increased O2 to 3L; Pt slowly incr to 99%" and reported that she (S14) could not recall Patient #2 being in any respiratory distress or of respiratory therapy being in Patient #2's room prior to 7:30 a.m. on 4/21/10 which was the time of S11's entry. S14 indicated that her next shift with Patient #2 was the night shift that began at 6:45 p.m. on 4/21/10. S14 reported that 1mg of Dilaudid was administered to Patient #2 at 7:00 p.m. on 4/21/10. S14 reported that Patient #2 was on 2 liters of oxygen by nasal canula and was in no respiratory distress at 8:00 p.m. S14 indicated that Patient #2 had an uneventful night from 6:45 p.m. on 4/21/10 thru 6:45 a.m. on 4/22/10. S14 indicated that her next shift with Patient #2 was the night shift that began at 6:45 p.m. on 4/22/10. S14 reported that 1mg of Dilaudid, 4mg of Zofran, 1mg of Clonazepam, and 650mg of Tylenol were administered to Patient #2 at 10:40 p.m. on 4/22/10. S14 reported that 1mg of Dilaudid was given sometime between 6:00 a.m. and 6:45 a.m. on 4/23/10. (The administration of the 1mg of Dilaudid at 6:45 a.m. on 4/23/10 was not documented on the medication administration record. It was documented on the patient care notes and did not cross over to the medical record that was initially provided to this surveyor for review). S14 reported that she went to give report to the on-coming shift when she heard the Code Blue called. S14 reported that she ran to Patient #2's room and was told to get Narcan out of Pyxis. S14 reported that the Narcan was administered to Patient #2 during the Code Blue. S14 reported that Patient #2 was transferred to ICU following the Code Blue. When asked what medications were administered to Patient #2 during the her shift (6:45 p.m. on 4/22/10 thru 6:45 a.m. on 4/23/10), S14 reported that 1mg of Dilaudid, 4mg of Zofran, 1mg of Clonazepam, 650mg of Tylenol, 40mg of Citalopram, and 112 mcg of Levothyroxine were administered to Patient #2 at 10:40 p.m. on 4/22/10 and 112 mcg of Levothyroxine was administered to Patient #2 at 6:45 a.m. on 4/23/10 and 1mg of Dilaudid was administered to Patient #2 sometime between 6:00 a.m. and 6:45 a.m. on 4/23/10. When asked why the a.m. administration of IV Dilaudid was not documented on the medication administration record, S14 reported that "everything happened so fast" and she must have forgot to document the administration of the IV Dilaudid. When asked to explain the process for the administration of the IV Dilaudid, S14 reported that she gave the Dilaudid IV push over 2 minutes. When asked how did she determine that the IV Dilaudid was pushed over at least 2 minutes, S14 stated "it most likely was 2 minutes or longer". S14 explained that she sometimes uses a watch to ensure the two minute time frame is met and sometimes counts in her head. S14 reported that she could not recall the method (watch, clock, or counting) used when pushing the IV Dilaudid to Patient #2 between 6:00 a.m. and 6:45 a.m. on 4/23/10 to ensure that the IV Dilaudid was pushed slowly over at least 2 minutes.

Based on record review and interview, the hospital failed to ensure that all medical records are accurately written, promptly completed, properly filed and retained, and accessible. This was evidenced by the hospital's failure to identify that a clinical nursing documentation pathway was not interfacing with the "completed" or "discharged" medical record resulting in incomplete medical records. Findings:

On 9/13/10 at 1:50 p.m., the medical record of Patient #2 was requested for review. S2 (Director of Quality) presented a copy of Patient #2's medical record. Upon review of the medical record of Patient #2, this surveyor discovered that the complete medical record was not provided as there was missing nursing documentation. This discovery was found after discrepancies were identified while comparing documentation in the medical record of Patient #2 with the Pyxis medication dispensing record that identified the medications pulled from the Pyxis Unit for administration to Patient #2. Review of the Pyxis medication dispensing record revealed 4mg of Zofran was pulled from the Pyxis Unit on 4/23/10 at 5:46 a.m. and 2mg of Dilaudid was pulled from the Pyxis Unit on 4/23/10 at 5:48 a.m. Review of the medical record of Patient #2 that was initially provided for review failed to contain documentation relating to the administration of the Zofran and/or Dilaudid on 4/23/10. When questioned if the medications (Zofran and Dilaudid) had been administered to Patient #2 after being pulled from the Pyxis Unit, S2 reviewed Patient #2's medical record and reported that she was unable to find any documentation to indicate that the medications (Zofran and Dilaudid) had been administered on 4/23/10 to Patient #2. S2 indicated that she would have someone look in the computerized medical record for more information relating to the administration of these medications.

On 9/14/10, S2 presented additional nursing documentation that included information relating to the administration of 1mg of Dilaudid to Patient #2 on 4/23/10 that was not included in the initial copy of Patient #2's medical record that was provided to this surveyor for review. S2 reported that she was unable to explain why this information was not included in the initial copy of Patient #2's medical record that was provided for review.

In an interview on 9/15/10 at 9:45 a.m., the HIM Director (S20) confirmed that the initial medical record of Patient #2 that was provided to this surveyor for review on 9/13/10 was not the complete medical record of Patient #2. S20 explained that the patient's medical record at Ochsner Medical Center is known as the Horizon Patient Folder. S20 indicated that the Horizon Patient Folder should contain all information relating to the care and services provided. S20 indicated that the Horizon Patient Folder consists of various pathways that cross over or interface to make up the complete medical record. S20 indicated that the HIS Pathway that contained the nursing documentation relating to the administration of the Dilaudid on 4/23/10 failed to cross over to the Horizon Patient Folder. S20 reported that she was unaware (prior to this survey) that this HIS Pathway was not crossing over to the Horizon Patient Folder. S20 confirmed that based on the information in this HIS Pathway not crossing over to the Horizon Patient Folder, some information may not be included in the copies of medical records provided to patients who request a complete copy of their medical record. S20 reported that she was not aware of any other pathways not crossing over to the Horizon Patient Folder.

Based on record review and interview, the hospital failed to ensure that all information relating to the patient's progress and/or response to treatment and/or services was incorporated into the completed medical record. This was noted for 1 of 1 patients (Patient #2) reviewed for the completion of medical records out of a total sample of 7 patients. Findings:

On 9/13/10 at 1:50 p.m., the medical record of Patient #2 was requested for review. S2 (Director of Quality) presented a copy of Patient #2's medical record. Upon review of the medical record of Patient #2, this surveyor discovered that the complete medical record was not provided as there was missing nursing documentation. This discovery was found after discrepancies were identified while comparing documentation in the medical record of Patient #2 with the Pyxis medication dispensing record that identified the medications pulled from the Pyxis Unit for administration to Patient #2. Review of the Pyxis medication dispensing record revealed 4mg of Zofran was pulled from the Pyxis Unit on 4/23/10 at 5:46 a.m. and 2mg of Dilaudid was pulled from the Pyxis Unit on 4/23/10 at 5:48 a.m. Review of the medical record of Patient #2 that was initially provided for review failed to contain documentation relating to the administration of the Zofran and/or Dilaudid on 4/23/10. When questioned if the medications (Zofran and Dilaudid) had been administered to Patient #2 after being pulled from the Pyxis Unit, S2 reviewed Patient #2's medical record and reported that she was unable to find any documentation to indicate that the medications (Zofran and Dilaudid) had been administered on 4/23/10 to Patient #2. S2 indicated that she would have someone look in the computerized medical record for more information relating to the administration of these medications.

On 9/14/10, S2 presented additional nursing documentation that included information relating to the administration of 1mg of Dilaudid to Patient #2 on 4/23/10 that was not included in the initial copy of Patient #2's medical record that was provided to this surveyor for review. S2 reported that she was unable to explain why this information was not included in the initial copy of Patient #2's medical record that was provided for review.

In an interview on 9/15/10 at 9:45 a.m., the HIM Director (S20) confirmed that the initial medical record of Patient #2 that was provided to this surveyor for review on 9/13/10 was not the complete medical record of Patient #2. S20 explained that the patient's medical record at Ochsner Medical Center is known as the Horizon Patient Folder. S20 indicated that the Horizon Patient Folder should contain all information relating to the care and services provided. S20 indicated that the Horizon Patient Folder consists of various pathways that cross over or interface to make up the complete medical record. S20 indicated that the HIS Pathway that contained the nursing documentation relating to the administration of the Dilaudid on 4/23/10 failed to cross over to the Horizon Patient Folder. S20 reported that she was unaware (prior to this survey) that this HIS Pathway was not crossing over to the Horizon Patient Folder. S20 confirmed that based on the information in this HIS Pathway not crossing over to the Horizon Patient Folder, some information may not be included in the copies of medical records provided to patients who request a complete copy of their medical record. S20 reported that she was not aware of any other pathways not crossing over to the Horizon Patient Folder.

Based on record review and interview, the hospital failed to meet the Condition of Participation relative to Pharmaceutical Services by failing to ensure that the pharmacist provided oversight relating to the disposition of controlled drugs that are received in the hospital. This was evidenced by the hospital's failure to ensure that current and accurate records were kept regarding the disposition of controlled drugs after the controlled drugs were removed from the secured medication storage unit. The hospital administrative staff and the hospital's pharmacist were unaware, until it was brought to their attention during the survey, that narcotics were not being reconciled and coordinated with the computerized medication administration record in each patient's medical record to assure that when a narcotic was removed from the medication storage unit, the medication was accurately documented as given to the correct patient and the portion of the medication not used was appropriately and according to State and Federal Laws documented as "wasted". This failure was evident in 2 of 4 patients (#2 & #7) sampled for the administration of narcotics ordered by the physician out of a total sample of 7. (Cross reference to findings cited at A0494)

Based on record review and interview, the hospital failed to ensure that current and accurate records were kept regarding the disposition of controlled drugs after the controlled drugs were removed from the secured storage unit resulting in controlled drugs ( 4mg of Dilaudid and 4mg of Zofran) being unaccounted for in the hospital. This was noted based on the review of 2 of 4 patients (#2 & #7) sampled for the administration of controlled drugs out of a total sample of 7 patients. Findings:

The Pyxis medication dispensing record that identified the medications pulled from the Pyxis Unit for administration to Patient #2 was reviewed. This dispensing record included the name and dose of the medications pulled, the time the medications were pulled, the name of the person who pulled the medications from the unit, and the name of the patient who is to receive the medications that were pulled. The timeframe reviewed was from the time of Patient #2's admission to the hospital on 4/21/10 till the time of the Code Blue being called on 4/23/10. The medications listed on the Pyxis medication dispensing record were reviewed with the medical record of Patient #2 to determine if the medications pulled from the Pyxis Unit matched the medications administered to Patient #2 as documented in the medical record of Patient #2. The following findings were identified in regards to medication administration discrepancies:

? 4/21/10 at 6:53 a.m.- Dilaudid 2mg pulled from the Pyxis Unit by S14 (RN) for administration to Patient #2. No documentation in Patient #2's medical record to indicate that this dose of Dilaudid was administered to Patient #2 after being pulled from the Pyxis Unit. In addition, there was no documentation to indicate that the Dilaudid was wasted. This Dilaudid 2mg was unaccounted for based on review of hospital records. In an interview on 9/15/10 at 1:20 p.m., the Director of Quality confirmed that there was no documentation to indicate that the 2mg of Dilaudid was administered to Patient #2 after being pulled from the Pyxis Unit. The Director confirmed that the 2mg of Dilaudid was unaccounted for.
? 4/23/10 at 5:46 a.m.- Zofran 4mg pulled from the Pyxis Unit by S14 (RN) for administration to Patient #2. No documentation in Patient #2's medical record to indicate that this 4mg dose of Zofran was administered to Patient #2 after being pulled from the Pyxis Unit. In addition, there was no documentation to indicate that the Zofran was wasted. This Zofran 4mg was unaccounted for based on review of hospital records. In an interview on 9/15/10 at 1:20 p.m., the Director of Quality confirmed that there was no documentation to indicate that the 4mg of Zofran was administered to Patient #2 after being pulled from the Pyxis Unit. The Director confirmed that the 4mg of Zofran was unaccounted for.
? 4/21/10 at 2:16 p.m.- Dilaudid 2mg pulled from the Pyxis Unit by S11 (LPN) for administration to Patient #2. Documentation in Patient #2's medical record revealed that 1mg of Dilaudid was administered to Patient #2 as ordered by S23 (RN). There was no documentation to indicate what was done with the other 1mg of Dilaudid as there was no documentation to indicate that the 1mg of Dilaudid had been wasted by staff. This resulted in 1mg of Dilaudid being unaccounted for based on review of hospital records. In an interview on 9/15/10 at 1:20 p.m., the Director of Quality confirmed that there was no documentation to indicate what was done with the remaining 1mg of Dilaudid after 1mg was administered to Patient #2. The Director confirmed that the 1mg of Dilaudid was unaccounted for.
? 4/21/10 at 6:57 p.m.- Dilaudid 2mg pulled from the Pyxis Unit by S11 (LPN) for administration to Patient #2. Documentation in Patient #2's medical record revealed that 1mg of Dilaudid was administered to Patient #2 as ordered by S14 (RN). There was no documentation to indicate what was done with the other 1mg of Dilaudid as there was no documentation to indicate that the 1mg of Dilaudid had been wasted by staff. This resulted in 1mg of Dilaudid being unaccounted for based on review of hospital records. In an interview on 9/15/10 at 1:20 p.m., the Director of Quality confirmed that there was no documentation to indicate what was done with the remaining 1mg of Dilaudid after 1mg was administered to Patient #2. The Director confirmed that the 1mg of Dilaudid was unaccounted for.

S14 (RN) was interviewed on 9/16/10 at 1:00 p.m. When asked about the 4mg of Zofran that was pulled from the Pyxis Unit on 4/23/10 at 5:46 a.m. for administration to Patient #2, S14 reported that she administered the 4mg of Zofran but forgot to chart the administration of this Zofran in Patient #2's medical record. When asked about the 2mg of Dilaudid that was pulled from the Pyxis Unit on 4/21/10 at 6:53 a.m. for administration to Patient #2, S14 reported that she must have forgot to chart the administration of this 1mg of Dilaudid to Patient #2 and forgot to chart the wasting of the other 1mg of Dilaudid. When asked about the 1mg of Dilaudid that was unaccounted for after 2mg of Dilaudid were pulled from the Pyxis Unit on 4/21/10 at 6:57 p.m. and only 1mg of Dilaudid was documented as being administered to Patient #2, S14 reported that she administered 1mg of Dilaudid to Patient #2 and must have forgot to chart the wasting of the other 1mg of Dilaudid.

S23 (RN) was interviewed on 9/16/10 at 1:20 p.m. When asked about the 1mg of Dilaudid that was unaccounted for after 2mg of Dilaudid were pulled from the Pyxis Unit on 4/21/10 at 2:16 p.m. and only 1mg of Dilaudid was documented as being administered to Patient #2, S23 reported that she could not recall what happened to the 1mg of Dilaudid that was unaccounted for.

The medical record of Patient #7 was reviewed. This review revealed an order indicating that 1mg of Dilaudid could be administered every 4 hours as needed for pain. Review of the medication administration record revealed that 1mg of Dilaudid was administered to Patient #7 on 9/07/10 at 10:00 a.m., 2:15 p.m., 6:50 p.m., and 11:05 p.m. Review of the Pyxis medication dispensing record revealed that a total of 10mg (5 - 2mg vials) of Dilaudid were pulled from the Pyxis Unit on 9/07/10 for administration to Patient #7. Review of the medical record of Patient #7 revealed that Patient #7 received a total of 4mg of Dilaudid in 4 different doses on 9/07/10. Review of hospital records revealed that a total of 5mg of Dilaudid was wasted after being pulled from the Pyxis Unit for administration to Patient #7 on 9/07/10. This resulted in 1mg of Dilaudid being unaccounted for in the hospital. In an interview on 9/15/10 at 1:20 p.m., the Director of Quality confirmed that there was 1mg of Dilaudid after unaccounted for relating to the Dilaudid that was pulled for Patient #7. The Director reported that this discrepancy occurred as a result of a broken vial of Dilaudid. The Director explained that the nurse pulled two 2mg vials of Dilaudid from the Pyxis Unit because she had dropped the first vial pulled and the vial broke so she pulled a second vial. The Director reported that two nurses documented the wasting of the broken vial as 1mg when in fact they had wasted 2mg of the Dilaudid because they did not administer any of the Dilaudid from the broken vial to Patient #7. The Director confirmed that there was a discrepancy in the documentation relating to the controlled drug as 1mg of Dilaudid was unaccounted for.

The Clinical Coordinator Pharmacist (S4) was interviewed on 9/15/10 at 2:40 p.m. S4 reviewed the medical record of Patient #2. S4 reviewed the Pyxis reports and reported that she could not find any documentation to indicate the disposition of the 4mg of Zofran or the 4mg of Dilaudid that were unaccounted for. S4 indicated that the staff should have documented what was done with the medications after being pulled from the Pyxis unit. S4 indicated that there was a breakdown in regards to the documentation relating to the disposition of controlled drugs. S4 was unable to determine what happened to the unaccounted for Dilaudid and Zofran. S4 indicated that she was not aware of this breakdown prior to this survey. S4 indicated that she was unable to determine how many controlled drugs are unaccounted for due to this breakdown. S4 indicated that more work would need to be done to determine how many controlled drugs are unaccounted for.

Interview with the Director of Quality on 9/16/10 between 10:30 a.m. and 12:30 p.m. revealed that the breakdown in pharmacy relating to the hospital's inability to determine the disposition of controlled drugs that enter the hospital had not been previously identified. When asked if she was able to determine how many controlled drugs are unaccounted for in the hospital at this time due to this breakdown, the Director of Quality reported not without doing more research.