HospitalInspections.org

Based on record review and staff interview the hospital failed to:

a. ensure medications were administered safely. See Tag A-0405

b. ensure staff reported medications errors as outlined in hospital policy. See Tag A-0410

Based on record review and interview, the hospital failed to safely administer a high-risk medication to 1 (Patient #7) of 8 patients reviewed.

This failed practice resulted in adverse effects to the patient's health and the patient subsequently expired in the hospital.

Findings:

A document titled "Atoka County Medical Center Medication Record", which included the following:

Methotrexate 2.5mg tab "Pt own med" showed the medication was administered once on 02/16/22 (a Wednesday), twice a day from 02/17/22 through 02/23/22 (Thursday through Wednesday), and once on 02/24/22 prior to being discontinued.

A document titled "High Risk High Alert Medications" stated in part "Special safeguards are required to reduce the risk of errors when utilizing these medications... methotrexate"


On 3/16/2022 Staff C stated that Methotrexate is listed on the High Risk Medication list but no special precautions were taken as stated in High Risk Medication policy.

Based on record review and interview, the hospital failed to report a medication error for 1 (Patient #7) of 8 patients reviewed.

This failed practice had the potential to affect all patients in the facility due to a lack of corrective action for the error and subsequent possibility the error would recur.

Findings:

Policy:

The surveyors reviewed a policy titled "Medication Error Reporting" which read in part:

"Drugs administered in error...shall be reported and reviewed in accordance with this policy."

"A medication error is defined as any deviation from established policies and/or procedures during the prescribing, transcribing, dispensing, administering, and monitoring of a drug."

"Prescribing includes incorrect...rate of administration or instructions for use..."

"Transcribing includes incorrectly transferring information from the physician order sheet to either the MAR or the patient's profile."

"Monitoring includes a failure to review a prescribed regimen for appropriateness and detection of problems, or failure to use appropriate clinical or laboratory data for adequate assessment of patient response to prescribed therapy."

"The person who discovers the error...shall prepare a drug administration error report on the facility's approved form."

Records:

Patient #7

The surveyors reviewed a document titled "Atoka Manor Inc. Medication Review Report" (Atoka Manor, the LTC facility the patient resided in, provided this document when the patient was transferred). The document read in part:

"Methotrexate tablet 2.5mg (Methotrexate sodium) Give one tablet by mouth two times a day every Thur. related to psoriasis."

The surveyors reviewed a document titled "ChartLink Physician Entered Orders", which included the following:

1. An order dated 02/15/22 at 4:50 PM for Methotrexate 2.5mg tab with a dose/frequency of 2.5mg on Thursdays. The order included a start date/time of 02/16/22 (a Wednesday) at 4:44 PM. The order was changed by the pharmacist on 02/16/22 at 10:43 AM, changing the start date/time to 02/17/22 (a Thursday) at 9:00 AM.

2. An order dated 02/15/22 at 4:50 PM for Methotrexate 2.5mg tab with a dose/frequency of 2.5mg on Thursdays. The order included a start date/time of 02/15/22 (a Tuesday) at 4:48 PM. The order was changed by the pharmacist on 02/16/22 at 10:47 AM, changing the start date/time to 02/17/22 (a Thursday) at 9:00 PM.

3. An order dated 02/16/22 at 3:00 PM for Methotrexate 2.5mg tab with a dose/frequency of 2.5mg BID. The order included a start date/time of 02/16/22 (a Wednesday) at 9:00 PM.


The surveyors reviewed a document titled "Atoka County Medical Center Medication Reconciliation Report", which included the following:

1. An entry for Methotrexate 2.5mg tab "Existing Prescription" BID on Thursday was dated 02/15/22 at 5:10 PM and marked to continue.

The surveyors reviewed a document titled "Atoka County Medical Center Medication Record", which included the following:

1. An entry for Methotrexate 2.5mg tab "Pt own med" showed the medication was administered once on 02/16/22 (a Wednesday), twice a day from 02/17/22 through 02/23/22 (Thursday through Wednesday), and once on 02/24/22 prior to being discontinued.

On 03/15/22, the surveyors requested documentation of all incidents/variances in the facility for the past 12 months. There was no documentation to support a medication error report was completed and addressed.

During an interview on 03/16/22, Employee A stated the hospital thought the dosing error was the fault of the LTC facility and therefore a medication error report was not done.

During an interview on 03/17/22, Employee A stated a medication error report was done, but it was not investigated because the hospital thought it was an error made by the LTC facility.