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Based on observation, record review, and interview, the facility's governing body failed to carry out responsibilities in accordance with the facility's written policy and procedures to ensure specific patient rights and nursing services were protected and promoted.

Specifically, the governing body failed to ensure that the Condition of Patient Rights were met as follows:

1.) Patient rights were not protected and promoted by implementing their written policy and procedures for Patient #1, #2, and #3. Medical records reviewed with patient rights violation complaint regarding a medication error overdose and failure to ensure a safe environment for the storage of medications.

A.) The facility failed to ensure patients with an emergency medical condition which had not been stabilized were immediately transferred to another facility with the appropriate equipment and personnel by calling 911 in accordance with the facility's policy for patients who had acute changes in medical condition following a medication error overdose. The facility's Charge Registered Nurse (RN) initiated the transfer for Patient's #1, and #2 to a general hospital emergency room by calling the facility's contracted ambulance service and not calling 911.

B.) The facility nursing staff failed to ensure that drugs were left in a monitored and safe environment reducing access to medication from unauthorized individuals.

Refer to A144 for evidence of specific findings.



In addition, the governing body failed to ensure that the Condition of Nursing Services were met as follows:

1.) Nursing staff failed to ensure that drugs were administered in accordance with the treating physician's orders for Patient #1, #2, and #3; who were administered the incorrect physician ordered dosages of Clonidine on 04/20/16.

2.) Failed to ensure nursing notes, reports of treatment, timelines of interventions, and other information necessary to monitor the patient's condition were documented in the records; were complete and were accurate Patient #1, #2, and #3 who were administered the incorrect dosages of Clonidine on 04/20/16 and required transfer to another facility for emergency care treatment and monitoring.

3.) Nursing staff failed to ensure that drugs were left in a monitored and safe environment reducing access to medication by unauthorized individuals. Observations conducted on 04/27/16 revealed 2 incidences where 2 children simply accessed inside the nursing station where a medication cart was left unattended and unlocked.

4.) The Director of Nursing failed to ensure the implementation of monitoring and competency evaluations, and; the continuing education programs of the nursing care for 2 of 2 Licensed Vocational Nurses (LVN's) reviewed. The DON failed to ensure the implementation of the facility's approved training competencies and the 90-day evaluation were completed as per the facility's training policy and procedures.

Refer to A0395, A0397, A0405, A0502 for evidence of specific findings.



The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Governing Body.

Based on observation, record review, and interview, the facility failed to ensure specific patient rights were protected and promoted; and their written policy and procedures that protect and promote each patient's rights were implemented for 3 of 3 patients (Patient #1, #2, and #3) reviewed with a patient rights violation complaint regarding a medication error overdose and; failure to ensure a safe environment for the storage of medications.

Specifically,

1.) failed to ensure patients with an emergency medical condition which had not been stabilized were immediately transferred to another facility with the appropriate equipment and personnel by calling 911 in accordance with the facility's policy for 2 of 3 Patients (Patient #1 and #2); who had acute changes in medical condition following a medication error overdose. The facility's Charge Registered Nurse (RN) initiated the transfer for Patient's #1, and #2 to a general hospital emergency room by calling the facility's contracted ambulance service and not calling 911.

2.) failed to ensure nursing staff ensured that drugs were left in a monitored environment reducing access to medication by unauthorized individuals. Observations conducted on 04/27/16 revealed 2 incidences where 2 children simply accessed inside the nursing station where a medication cart was left unattended and unlocked.

Refer to A144 for evidence of specific findings.


The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Based on record review and interview, the facility failed to ensure a safe environment to include safety and security.


1) Facility failed to provide safe care to patients with documented medication overdose error who had acute changes in medical condition following a medication overdose error. Facility failed to provide safe care for patients with an emergency medical condition, and were not transferred to another facility with the appropriate equipment and personnel by calling 911 in accordance with the facility's policy. The facility's Charge Registered Nurse (RN) initiated transfer for Patients to a general hospital emergency room by calling the facility's contracted ambulance service and not calling 911.


2) Additionally, facility failed to have a secure environment to prevent access to medications by unauthorized personnel observation of 2 incidents.


Findings included:

1) Record review of the facility's Policy titled, Change in Medical Condition last reviewed June 2015 revealed in the area of procedures; if it is determined that the medical condition is critical or life-threatening, a Code Blue is called and an immediate transfer of the patient via a 911 call to the nearest general hospital or emergency room will be initiated. This transfer may be initiated by a physician, nurse, supervisor, physician assistant, advanced practice nurse or nurse practitioner. Criteria guidelines (but not limited to): "a. Acute changes in systolic blood pressure of 30+ points, j. Rapid decline in mental status."


Patient #1- a 6 year old female admitted 04/09/16.

Review of Patient #1's Nursing Progress Note dated 04/20/16 at 11:30 AM revealed Patient received wrong dose of medication at 08:05 AM on the morning of April 20th 2016. Patient was given 5 doses of Clonidine 0.1mg when order stated to give 0.5 of 0.1mg.

Review of the Physician Progress Note for Patient #1 dated 04/20/16 revealed Patient #1 "was given 10 x [times] normal dose of 0.05mg Clonidine this AM [morning]." The Patient was evaluated by staff on unit and was ordered to be evaluated at ER for possible toxic ingestion. The Patient was admitted to hospital by staff at emergency room.

Patient #1's Vital Sign documentation record dated 04/18/16 at 1500 documented Patient #1's Blood Pressure (BP) 115/48. Documentation of the BP on 04/20/16 at 09:08 AM; following the medication error overdose revealed BP was 74/41 (greater than 30 points variation from 04/18/16 to 04/20/16.)

Review of the Charge RN's nursing note dated 04/20/16 at 14:00 for Patient #1 revealed "Patient (Pt.) observed to be drowsy after breakfast and after taking her morning medications. LVN (LVN-A) reported to M.D (M.D.-A ) that she gave wrong dose of medication. Pt. was assessed by M.D. (M.D.-A) and ordered for Pt. to be transferred to local general hospital Emergency Room (ER) for evaluation and treatment. Pt. was transported via ambulance (contracted ambulance service). BP prior to leaving unit was 80/41. Pt. drowsy. Pt. admitted to the general hospital's Intensive Care Unit (ICU) for treatment."

Review of Patient #1's Ambulance Service Record report dated 04/20/16, revealed at 09:52 AM Patient was being carried by staff member. "Patient shows to be lethargic and non-compliant with any commands. Patient was give 5 doses of 0.1 milligrams (mg) of Clonidine when she was supposed to get 0.05mg for a total of 10 times prescribed dosage at 08:00 AM this morning. Patient care delayed by facility RN stating that she didn't want her to go per her M.D. I asked the M.D. on location why we could not take her when her systolic blood pressure was 80mmhg and Doctor stated, take her. I asked RN if that was okay, RN said she didn't know, that her M.D. said, No." "Patient transported emergent to the ER" .


Patient #2- a 12 year old female admitted 04/19/16.

Review of the Nursing Progress Note dated 04/20/16 at 11:30 AM revealed Patient #2 "received wrong dose of medication at 08:16 AM on the morning of April 20th 2016. Patient was given 5 doses of Clonidine 0.1mg order stated give 0.5 of 0.1mg."

Review of the Physician Psychiatric Evaluation for Patient #2 dated 04/20/16 at 09:00 AM revealed, "Pt [Patient] asleep. Hard to arouse. [Vital Signs] VS not stable. Judged to be medical emergency - due to medication dosing of Clonidine 0.5mg instead of 0.05mg [10 times the prescribed dosage] - will immediately transfer to [another facility] ER."

Review of the Charge RN's nursing note dated 04/20/16 at 14:30 for Patient #2 revealed "Pt. observed to be drowsy and eventually fell asleep in the chair shortly after breakfast and taking her mornings medications. Med nurse (LVN)-A reported to M.D-A that she gave wrong dose of medication. Pt. was assessed by (M.D.-A) and ordered for Pt. to be taken to (local general hospital) ER for evaluation and treatment." "Pt. looks drowsy and sluggish acadian notified. Taken to (ER) via ambulance."


Interview on 4/27/16 at approximately 10:45 a.m. with M.D.-A revealed he was concerned about Patient's #1, #2, and #3 after he was notified by LVN-A of the incorrect dosages administered of Clonidine. M.D.-A indicated "the patients were difficult to rouse" and he was concerned when he "couldn't feel a pulse" for Patient #1. M.D.-A stated youngest patient (#1) weighed about 50 to 60 pounds. M.D.-A stated he wasn't sure what the difference was between an "Ambulance Service" and "Emergency Medical Services (EMS)", he just wanted the patients to get to the emergency room quickly. M.D.-A revealed he does not make the determination on whether to call the Ambulance Service or EMS; that the facility makes that determination.

Interview on 04/28/16 at 1:15 PM with the Charge RN stated M.D. gave her orders to transfer Patient's #1, #2, and #3 to the general hospital ER for evaluation and treatment after they became symptomatic following administration of the incorrect dosage of Clonidine. Charge RN stated she called the facility's contracted Ambulance Service and not 911 Emergency Services because the patients were not a code blue ( May include but not limited to: respiratory arrest, cardiac arrest, and signs of stroke; according to policy). Charge RN stated she initially called the Ambulance Service for Patient #3 not aware that Patient's #1 and #2 needed immediate transfer. Charge RN stated when Ambulance Service showed up; they placed Patient's #1 and #2 to send immediately due to their symptoms and they were more emergent than Patient #3. Charge RN stated a second ambulance had to be called to transport Patient #3.


2)Observation during medication administration by LVN- C on 4/27/16 at 1058. Overseeing nurse exited nursing station to "social area of facility," the medication nurse was on opposite side of counter administering medications to a patient. Surveyor in nursing station observed patient (child) reach hand over the door and unlock door to come into nursing area. Child standing by unlocked medication cart, was unnoticed by staff.. LVN-C returned to medication cart and surveyor questioned if children were allowed in nursing station. LVN-C replied "no."

Observation at approx. 11:10 a second child was observed opening door and walking into nursing station to talk to nursing staff. Child unnoticed by staff, LVN-C back turned away from patient. Patient approaching unlocked medication cart. Child was eventually seen by staff and asked to exit the area. LVN-C speaking with Surveyor stated that children are not allowed in Nursing Area but just like the prior patient "force their way in."

Observation revealed medication unlocked and not monitored during both incidents of children entering nursing area. Nursing area easily assessable to children; small door allows children to reach arm over door and unlock from the inside as observed x2.

Review of Nurse training "Safe Steps to Medication Administration" - training to include: "understands that the medication cart is to be stored in the medication room when not administering medications."

Based on observation, record review, and interview, the facility's nursing services failed to provide nursing care in accordance for each patient's needs and physician orders which affected 3 of 3 Patients (Patient #1, #2, and #3) reviewed.

Specifically,

1.) Nursing staff failed to ensure that drugs were administered in accordance with the treating physician's orders for Patient #1, #2, and #3; who were administered the incorrect physician ordered dosages of Clonidine on 04/20/16.


2.) Failed to ensure nursing notes, reports of treatment, timelines of interventions, and other information necessary to monitor the patient's condition were documented in the records; were complete and were accurate Patient #1, #2, and #3 who were administered the incorrect dosages of Clonidine on 04/20/16 and required transfer to another facility for emergency care treatment and monitoring.


3.) Nursing staff failed to ensure that drugs were left in a monitored and safe environment; reducing access to medication from unauthorized individuals. Observations conducted on 04/27/16 revealed 2 incidences where 2 children simply accessed inside the nursing station where a medication cart was left unattended and unlocked.


4.) The Director of Nursing failed to ensure the implementation of monitoring and competency evaluations, and; the continuing education programs of the nursing care for 2 of 2 Licensed Vocational Nurses (LVN's) reviewed. The DON failed to ensure the implementation of the facility's approved training competencies and the 90-day evaluation were completed as per the facility's training policy and procedures.


Refer to A0395, A0397, A0405, A0502 for evidence of specific findings.


The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation of Nursing Services.

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Based on record review and interview, the facility's registered nurse (RN) failed to supervise the nursing care for each patient which affected 3 of 3 Patients (Patient #1, #2, and #3) reviewed as well as lack of oversight of patient care putting patients at risk.


Specifically,


1) the facility's RN failed to follow the physician admission orders to complete and monitor vital signs twice daily as ordered for Patient's #1, #2, and #3 and; failed to notify the physician for vital signs that were documented to be out of the designated range parameters.


2) The facility failed to ensure nursing notes, reports of treatment, timelines of interventions, and other information necessary to monitor the patient's condition were documented in the records complete and accurately for 3 of 3 patients reviewed (Patient #1, #2, and #3) who were administered the incorrect dosages of Clonidine on 04/20/16 and required transfer to another facility for emergency care treatment and monitoring.


3) nursing staff failed to ensure that drugs were left in a monitored environment reducing access to medication from unauthorized individuals. Observations conducted on 04/27/16 revealed 2 incidences where 2 children simply accessed inside the nursing station where a medication cart was left unattended and unlocked.


Findings included:

(1) Review of the facility's Patient Vital Sign (VS) Record revealed the form indicated the "RN must address out of range values." Vital Records included Blood Pressure, Pulse, Temperature (temps), Respirations, Pulse Oximetry (pO2) and Weight. The RN was to initial each recorded VS taken.

Patient #1- a 6 year old female admitted 04/09/16

Record review of Patient #1's Physician Admitting Orders dated 04/09/16 revealed Vital Signs Routine: Upon admission and twice per day.

Review of the daily VS record for Patient #1 revealed it was incomplete from admission of 4/9/16-4/20/16; as follows:

1.) There was no documentation of 19 out of 19 pO2 readings or weights since admission (04/09/16).

2.) The area for a RN initial had only one initialed review of VS on 4/11/16 18 of 19 left blank.

3.) Review of VS record shows Vitals were only taken once daily for 3 of 19 entries, dates of : 04/16/16, 04/17/16, and 04/19/16.

4.) Missing temp vitals on 4/18/16 and 4/19/16

5.) The documentation dated for the vitals taken on 4/10/16 were documented after 4/13/16 on vital sign treatment sheet.


Review of Patient #1's VS record revealed the RN was to address out of range values by notifying the MD for the following range values for 4-6 year olds: systolic blood pressure lower than 85 and higher than 110 and diastolic blood pressure lower than 50 and higher than 80, and Pulse rates lower than 70 and higher than 120.


VS documentation dated 04/18/16 at 1500 documented Patient #1's Blood Pressure (BP) 115/48 (systolic higher than range). Documentation of the next documented BP was 04/19/16 at 19:00 which indicated BP was 85/50 (greater than 30 points variation from 04/18/16 to 04/19/16.) There was no documentation of RN acknowledgment, intervention, or notification to the MD. Additional out of parameter vitals documented on 04/11/16 of BP 84/73, and 4/13/16 vitals of 80/46 were not addressed or acknowledged by the RN and no documentation of MD notified.


Patient #2- a 12 year old female admitted 04/19/16 and re-admitted 04/21/16.

Record review of Patient #2's Physician Admitting Orders dated 04/19/16 revealed Vital Signs Routine: Upon admission and twice per day.

Review of the daily VS record for Patient #2 revealed it was incomplete from re-admission of 4/21/16-4/25/16; as follows:

1.) There was no documentation of any pO2 readings or weights since admission (04/21/16) 8 of 8 .

2.) The area for a RN initials were blank and not reviewed 4/21/16 to 04/25/16 8 out of 8 times.

3.) Review of VS record shows Vitals were only taken once on 04/22/16.

4.) Missing respiration vital for 4/25/16.


Review of Patient #2's VS record revealed the RN was to address out of range values by notifying the MD for the following range values for 10-12 year olds: systolic blood pressure lower than 85 and higher than 120 and diastolic blood pressure lower than 50 and higher than 80, and Pulse rates lower than 70 and higher than 120.


VS documentation dated 04/23/16 at 1615 documented Patient #2's BP 126/63 (systolic higher than range). VS documentation dated 04/25/16 at 07:00 AM documented BP 141/69 (systolic higher than range). There was no documentation of a RN acknowledgment, intervention, or notification to the MD.


Patient #3- a 12 year old male admitted 04/14/16.

Record review of Patient #3's Physician Admitting Orders dated 04/14/16 revealed Vital Signs Routine: Upon admission and twice per day.

Review of the daily VS record for Patient #2 revealed it was incomplete from 4/15/16-4/19/16; as follows:

1.) There was no documentation of any pO2 readings or weights since admission (04/15/16) 7 out of 7 entries.

2.) The area for a RN initials were blank and not reviewed from 04/15/16 to 04/20/16 7 out of 7 times.

3.) Review of VS record shows Vitals were only taken once 3 out of 7times on 04/16/16, 04/17/16, and 04/19/16.

4.) Missing temperature for 3 out of 7 entries 4/15/16, 04/19/16, and 04/20/16.

During an interview with the Charge Registered Nurse- A on 04/27/16 at 13:16 during review of medical records for Patient #1, #2 and #3; surveyor questioned Charge Nurse regarding reportable vital signs to physicians. Charge Nurse stated that vital signs were put on "Daily Vital Sign Record" and the parameters used were located at top of the sheet. The Charge RN stated this process was how vitals were monitored and reported to physician if they were noted to be outside of the parameters designated.


(2) Review of facility Policy NPSG-16 titled, Rapid Response (Minor Medical Emergency) Code Blue (Major Medical Emergency), last reviewed April 2015 stated in the event of medical emergency #7 under procedures " the Rn shall document in the patient chart the situation that occurred, the interventions that were performed the patient responses and the disposition of the patient. Include timelines and contacts made throughout the event."

Review of facility Policy PC- 60 #5 regarding Change in Medical Condition, last reviewed June 2015 indicated: "Documentation in the patient's medical record will include the assessment of the patient and will include all interventions completed by the staff."


Patient #1- a 6 year old female admitted 04/09/16.

Interview on 4/26/16 at approximately 10:45 a.m. with M.D.-A revealed he was concerned about Patient's #1, #2, and #3 after he was notified by Licensed Vocational Nurse (LVN)-A that she had given Patient #1 5 tablets of the 0.1mg of Clonidine rather than .5 (half tablet) of the 0.1mg. M.D.-A indicated "the patients were difficult to rouse" and he was concerned when he "couldn't feel a pulse" for Patient #1. M.D.-A stated youngest patient (#1) weighed about 50 to 60 pounds. M.D.-A stated he told the nurses to "monitor vital signs";( blood pressure (BP), pulse, and respirations since Clonidine is known to lower BP and pulse).


Review of Patient #1's Vital Sign Record for 04/20/16 revealed the only documented BP, Pulse, and respiration following the medication error at 08:05 AM was at 09:08 AM which documented BP 74/41 which was below the designated parameters for a 4-6 year old (systolic below 85 and diastolic below 50).


During an interview with the LVN-A on 04/26/16 at 3:00 PM stated that vital signs were completed for Patient #1 following verbal orders received from M.D.-A. LVN-A confirmed the only documented vital sign for Patient #1 on 04/20/16 was for 09:08 AM. LVN-A indicated the nurses were documenting vital signs on "sticky notes" and may have not been transferred into the Patient #1's medical records.


Review of Patient #1's Nursing Progress Note dated 04/20/16 at 11:30 AM revealed the nursing note was not signed by a licensed nurse and the author unknown. The nursing note stated, "Patient received wrong dose of medication at 08:05 AM on the morning of April 20th 2016. Patient was given 5 doses of Clonidine 0.1mg when order stated to give 0.5 of 0.1mg. Once the medication error was noticed the medication nurse, [LVN-A] began to check vitals and immediately call prescribed physician. Patient had routine vitals checked every hour and monitored every (Q) 15 minutes" by Mental Health Worker and LVN. Transfer patient to Emergency Room (ER) due to med error and continue to watch patient and vitals. " Person who documented this note did not sign in the patient original record, a second copy signed by LVN-B was provided to state agency. Documentation fails to provide patient assessment or response to interventions provided.


Review of the Laurel Ridge Treatment Center Patient Observation Sheet dated 4/20/16 revealed that Pt #1 was on Suicide-Mod precautions on the 7-3 shift, with q15 minute line of sight observation. The documented observations were written over and illegible for the 15 minute intervals of 0900, 0915, 0930, and 0945. There was no means to determine the behavior of Pt #1 during the critical time after the medication error overdose and before Pt #2 was transferred to the hospital.


Review of the Charge RN's nursing note in medical record 24 hour nursing assessment dated 04/20/16 at 14:00 for shifts 7-3 stated, "Pt noted to be drowsy p [after] breakfast and p [after] taking AM med. Med. Nurse notified MD that pt received wrong dosage of medication. Pt was assessed. MD notified. Pt. transferred to[ ER] for evaluation and treatment. Patient was escorted by staff to the hospital. Pt was transported via ambulance. CPS caseworker was notified. BP prior to leaving the unit 80/[illegible and diastolic marked out]. Pt drowsy but responded when name was called. Pt presently adm to ICU @ [other facility] for treatment. (BP 80/41)." The box for "Oriented person, place time" had a check mark, next to the words, "person" and "place" and "time". The word "person" was circled, but not the words "place" and "time". "Sent to [ ER] for evaluation/treatment" was documented in the space for "Current Events, List any Medical Events".



Patient #2- a 12 year old female admitted to Laurel Ridge on 04/19/16 and re-admitted to Laurel Ridge 04/21/16.

Review of the Physician Psychiatric Evaluation for Patient #2 dated 04/20/16 at 09:00 AM revealed, "Pt [Patient] asleep. Hard to arouse. [Vital Signs] VS not stable. Judged to be medical emergency - due to medication dosing of Clonidine 0.5mg instead of 0.05mg [10 times the prescribed dosage] - will immediately transfer to [another facility] ER."

Review of the Nursing Progress Note dated 04/20/16 at 11:30 AM revealed the nursing note was not signed by a licensed nurse. The nursing note indicated "Patient received wrong dose of medication at 08:16 AM on the morning of April 20th 2016. Patient was given 5 doses of Clonidine 0.1mg order stated give 0.5 of 0.1mg. Once the medication order/error was noticed the medication nurse [LVN-A] began to check vitals and reported this mistake/error to prescribed physician. Patient had routine vitals ordered every hour. Patient alert after being woken up. Transfer Pt to ER due to med error and continue to watch pt. and vitals. " Review of nursing not in medical record reveals where the nurse failed to document vital signs obtained. Review of medical record reveals no order from physician for one hour vital signs on patients who received medication overdose error.


Review of Patient #2's VS Record for 04/20/16 revealed the only documented BP, Pulse, and respiration following the medication error at 08:16 AM was at 09:06 AM which documented BP 105/46 which was below the designated parameters for a 10-12 year old (diastolic below 50). Review of the Laurel Ridge Treatment Center Patient Observation Sheet dated 4/20/16 revealed that Pt #2 was on Suicide-Mod precautions on the 7-3 shift, with q15 minute line of sight observation. The documented observations for the 15 minute intervals of 0815, 0830 ,0845 ,0900, 0915 ,0930 ,0945 ,1000 and 1015 state patient as eating, in therapy, activities at 1030 are illegible and 1045 documented activity is " w/staff/MD " . Q15 for 1100 is documented " T: ER " Documented observations conflict with nursing notes documenting that patient was "observed to be drowsy and eventurally fell asleep in the chair shortly after break and after taking her morning meds." Observation additionally conflicts with physician prior statement "Pt [Patient] asleep. Hard to arouse." Conflicting documentation of patient behavior and status in medical records between health workers on site.


Review of the Charge RN's nursing note dated 04/20/16 at 14:30 for Patient #2 stated " Pt. observed to be drowsy and eventually fell asleep in the chair shortly after breakfast and taking her mornings medications. Med nurse ( LVN-A) reported to M.D (M.D-A )that she gave wrong dose of medication. Pt. was assessed by M.D.-A and ordered for Pt. to be taken to local general hospital ER for evaluation and treatment. BP taken - 99/53 p 71. Pt able to resond when called , although she looks drowsy and sluggish. Acadian notified. Taken to (local hospital) via ambulance. Pt still at ER (local hospital) at this time. The Charge RN's nursing note failed to ensure interventions performed, patient's responses, and timelines per facility's policy on rapid responses.

Review of Patient #2's Nurse to Nurse Report dated 04/21/16 at 09:25 for re-admission revealed the checklist had documented checks but was not signed or documented by the Nurse that the report was given by; the nurse reviewed by, and the nurse that received report. All areas for Nurse Signatures were blank. Facility failed to ensure completed documentation of nurse shift report.


Patient #3- a 12 year old male admitted on 04/14/16.

Review of Physician Order (PO) dated 04/20/16 at 09:20 AM revealed M.D.-A ordered "hold all further meds until patient is awake. Monitor VS q [every] 30 minutes."

Review of Patient #3's VS Record for 04/20/16 revealed the only documented BP, Pulse, and respiration following the medication error at 08:13 AM was at 08:47 AM which documented BP 114/51. Further review of Patient #3's medical records revealed no further VS documented following the above PO at 09:20 AM. Patient #3 was transferred from the facility to ER at 10:33 AM.

Review of the Charge RN's nursing note dated 04/20/16 at 13:30 for Patient #3 stated " Pt. became increasingly drowsy after he received his morning medications. Pt. fell asleep in the chair. Patient's VS was taken at 08:45; BP 107/89, P-88 (apical). LVN-A reported to M.D-A that she gave wrong dose of medication. Pt. was assessed by M.D.-A and ordered for Pt. to be taken to local general hospital ER for evaluation and treatment. Pt. agitated when ambulance arrived. Guardian and Child Protective Services (CPS) caseworker notified. Pt. transported to hospital ER via ambulance. Pt will be kept in the hospital for further observation.

The Food and Drug Administration document entitled, "Catapres®(clonidine hydrochloride, USP)", found at
stated, in part, "OVERDOSAGE
Hypertension may develop early and may be followed by hypotension, bradycardia, respiratory depression, hypothermia, drowsiness, decreased or absent reflexes, weakness, irritability and miosis. The frequency of CNS depression may be higher in children than adults. Large overdoses may result in reversible cardiac conduction defects or dysrhythmias, apnea, coma and seizures. Signs and symptoms of overdose generally occur within 30 minutes to two hours after exposure. As little as 0.1 mg of clonidine has produced signs of toxicity in children."


The Charge RN's nursing note failed to ensure interventions performed, patient's responses, and timelines per facility's policy on rapid responses. There was no documented evidence of an RN assessment, to include neurological checks, pulse, respirations, or oxygen saturation in a patient that was transferred to a higher level of care due to a medication error overdose of clonidine. There was no documented evidence in the medical record of a neurologic assessment, despite the risk for decreased or absent reflexes, weakness or other central nervous system affects possible with an overdose of 0.5 mg of Clonidine, as overdose of Clonidine can result in decreased or absent reflexes, apnea, hypotension, bradycardia, respiratory depression, weakness or seizures. There is no documented evidence of the time of the events in the narrative note, including the time of the medication error, the time the patient was "noted to be drowsy," the time the MD was notified. There is no documentation of the patient assessment for an overdose, including pulse, respiration, or neurological assessment, There was no documented evidence in the record that Patients #1,#2, and #3 were monitored continuously for potential overdose symptoms after the RN became aware of the medication error overdose. There was no documentation of the time the ambulance was called or arrived, or when the patient departed to the hospital. There was no documentation of the patient's #2 and #3 vital signs prior to leaving the facility.



(3) Based on observation during medication administration of the children's unit by Licensed Vocational Nurse (LVN) - C on 4/27/16 at 10:58 AM revealed a medication cart located in the nursing station area. Charge Registered Nurse (RN)- A exited the nursing station to the " social area of facility " and, LVN-C exited the nursing station to the opposite side of the counter; administering medications to a patient. Surveyor in nursing station observed a non sampled patient (child) reached his hand over the door to the nursing station, and unlock the door to enter into the nursing area. The non-sampled patient- Child stood by the unlocked medication cart, and was unnoticed by staff. LVN-C returned to medication cart and surveyor asked if children were allowed in the nursing station, and he replied, "No".

Further observation at 11:10AM, a second non sampled child was observed reaching over the door with his hand opening the door to the nursing station and walked into the nursing station to talk to nursing staff. Child was unnoticed by staff, and LVN-C's back was turned away from patient. Patient approached the unlocked medication cart. Child was eventually seen by staff and asked to exit the area. LVN-C speaking with Surveyor stated that children are not allowed in Nursing Area and stated; just like the prior patient, they "force their way in".

Review of the facility's Nurse training, " Safe Steps to Medication Administration " dated 04/20/16- and the Medication Administration Competency Checklist revealed training did not include; ensuring a secure area where drugs were stored in a manner to prevent access by unauthorized individuals or to ensure drugs where locked when left unattended.


Review of the Texas Nurse Practice Act 217.11, Standards of Nursing Practice, states, in part,

" (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: ...

(B) Implement measures to promote a safe environment for clients and others;

(C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same;

(D) Accurately and completely report and document:

(i) the client's status including signs and symptoms;

(ii) nursing care rendered;

(iii) physician, dentist or podiatrist orders;

(iv) administration of medications and treatments;

(v) client response(s); and

(vi) contacts with other health care team members concerning significant events regarding client's status; "

Based on record review and interview, the facility's Director of Nursing failed to ensure the implementation of monitoring and competency evaluations, and; the continuing education programs of the nursing care for 2 of 2 Licensed Vocational Nurses (LVN's) reviewed. The DON failed to ensure the implementation of the facility's approved training competencies and the 90-day evaluation were completed as per the facility's training policy and procedures.

Findings included:

Review of the facility's Policy Titled Training Requirements (MANDATORY) last reviewed January 2015 revealed all Direct Care Staff; which included mental health workers, LVN's, Registered Nurses, and Therapists, were to have a 90-Day "Departmental/Observation Checklist (assessing competency & skills)" Within Initial Training Period (90-days). Further review revealed, "Any training assessment or skills competency that an employee does not pass (Test score must be 80% or above) employee must receive additional training in the specific area and re-assessed again, all training will be documented in training record and noted on assessment and/or skills competency forms.

Review of the LVN Skills & Age Competency Checklist, revised 07/2015 revealed the employee must complete a self-assessment checklist prior to or during orientation to his/her position and at his/her 90-day and annual review dates. The checklist is a self-assessment of current level of knowledge and skill. Once the employee has completed the self-assessment portion of the Competency Assessment Skills Checklist and Evaluation, the supervisor will rate the employee's competence in each area using the ratings provided.

Review of LVN A's employee record file revealed she was hired 01/11/16. Further review on 04/27/16 (over 90 days since date of hire) revealed she had not been assessed for her competency & skills using the LVN Competency Checklist.

Review of LVN's employee record revealed a Medication Error Review report dated 04/20/16 which described Patient's #1, #2, and #3 were given the incorrect doses of Clonidine. The patients were given 5 tablets of 0.1 milligrams (mg) of Clonidine due to a misread of the Medication Administration Records. Patient's #1, #2, and #3 were supposed to receive .5 each (1/2 tablet) of the 0.1mg tablets provided.
Factor that contributed to this medication error included; "Lack of knowledge about child population" medications and read the MARS too fast.

Review of LVN B's employee record file revealed she was hired 03/2014 and completed the following 4 tests:

1.) Psychiatric Disorders on 03/12/14,

2.) Environment of care Program Quiz on 03/10/14,

3.) Annual Infection Control Test on 03/11/14, and

4.) Patient Rights on 03/10/14.

None of the 4 tests completed by LVN B had been scored to determine if she passed with an 80% or above.

Further review of LVN B's employee file revealed she had not been assessed for her competency & skills using the LVN Competency Checklist within 90-days of initial training.

During an interview on 04/27/16 at 03:40 PM with LVN A stated she completed a week of in-class orientation following her date of hire, 01/11/16, and a second week of "shadowing" on the adolescent unit. LVN A stated she had not been assessed for skills and competency since her date of hire; which had been more than 90-days.

During an interview on 04/28/16 at 03:00 PM with the DON stated that the unit "Nurse Manager" was to complete the employee's 90-Day Staff Performance Evaluation. The DON provided an example of the Staff Performance Appraisal evaluation which only summarized the job performance and expectations. The Performance Appraisal did not include an assessment of skills and competency of the job specific duties of the employee to include age differentiations from Adults, Adolescents, and Children. The DON stated the LVN Skills & Age Competency Checklist, revised 07/2015 was only used during an employee's annual evaluation of assessment and was not used during an employee's initial or 90-day reviews.

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Based on interview and record review, the facility's nursing staff failed to ensure that drugs were administered in accordance with the treating physician's orders for 3 of 3 patients reviewed (Patient #1, #2, and #3); who were administered the incorrect physician ordered dosages of Clonidine on 04/20/16.

As result, Patient's #1, #2, and #3 required transfer to another facility for emergency care treatment and monitoring.


Findings included:

Patient #1- a 6 year old female admitted 04/09/16.

Review of Patient #1's Physician Orders (PO) dated 04/09/16 at 1415 revealed Clonidine 0.05 milligrams (mg) by mouth (PO) twice daily (BID) for Attention Deficit Hyperactivity Disorder (ADHD).

Review of Patient #1's Medication Administration Record (MAR) dated 04/20/16 revealed Clonidine 0.05mg Oral Twice a day. "To give 0.05mg use 0.5 ea [each] of 0.1mg for ADHD." Further review of the MAR for 04/20/16 revealed Clonidine administered at 08:05 by Licensed Vocational Nurse (LVN)-A.

Review of the Risk Management Incident Report for event dated 04/20/16 revealed Patient #1 "was given wrong dose of medication. It (Medication error overdose) was immediately identified. Medical Doctor (MD) was notified. Patient was assessed and monitored. Orders were given to have Patient transferred to Emergency Room (ER)."

Review of the Physician Progress Note for Patient #1 dated 04/20/16 revealed Patient #1 "was given 10 x [times] normal dose of 0.05mg Clonidine this AM [morning]." The Patient was evaluated by staff on unit and was ordered to be evaluated at ER for possible toxic ingestion. The Patient was admitted to hospital by staff at emergency room.

Review of Patient #1's Nursing Progress Note dated 04/20/16 at 11:30 AM revealed Patient received wrong dose of medication at 08:05 AM on the morning of April 20th 2016. Patient was given 5 doses of Clonidine 0.1mg when order stated to give 0.5 of 0.1mg.


Patient #2- a 12 year old female admitted 04/19/16.

Review of Patient #2's PO dated 04/19/16 at 14:02 revealed Clonidine 0.05mg PO BID for Impulsivity.

Review of Patient #2's MAR dated 04/20/16 revealed Clonidine 0.05mg Oral Twice a day. "To give 0.05mg use 0.5 ea [each] of 0.1mg for Impulsivity." Further review of the MAR for 04/20/16 revealed administration of Clonidine administered at 08:16 by LVN - A.

Review of the Risk Management Incident Report for event dated 04/20/16 revealed Patient #2 " was given wrong dose of medication. It was immediately identified. MD was notified. Patient was assessed and monitored. Orders were given to have Patient transferred to ER. "

Review of the Physician Psychiatric Evaluation for Patient #2 dated 04/20/16 at 09:00 AM revealed, "Pt [Patient] asleep. Hard to arouse. [Vital Signs] VS not stable. Judged to be medical emergency - due to medication dosing of Clonidine 0.5mg instead of 0.05mg [10 times the prescribed dosage] - will immediately transfer to [another facility] ER."

Review of the Nursing Progress Note dated 04/20/16 at 11:30 AM revealed Patient #2 received wrong dose of medication at 08:16 AM on the morning of April 20th 2016. Patient was given 5 doses of Clonidine 0.1mg order stated give 0.5 of 0.1mg.


Patient #3- a 12 year old male admitted 04/14/16.

Review of the PO for Patient #3 dated 04/15/16 at 12:30 revealed Clonidine changed to 0.1mg, take ½ tab at 08:00 AM, ½ tab at noon, ½ tab at 4:00 PM, and 1 tablet at hour of sleep (HS). Prescribed for Impulsivity.

Review of Patient #3's MAR dated 04/20/16 revealed Clonidine 0.05mg Oral Three Times Daily. "To give 0.05mg use 0.5 ea [each] of 0.1mg for Impulsivity." Further review of the MAR for 04/20/16 revealed administration of Clonidine administered at 08:13 by LVN- A.

Review of the Risk Management Incident Report for event dated 04/20/16 revealed Patient #3 " was given wrong dose of medication. It was immediately identified. MD was notified. Patient was assessed and monitored. Orders were given to have Patient transferred to ER. "

Review of Patient #3's Physician Progress Note dated 04/20/16 at 13:00 revealed Patient " (Pt.) transferred to another facility for observation and monitoring due to mistaken Clonidine dosing of 0.5mg instead of 0.05mg (10 times the amount of prescribed dosing). Pt was lethargic at time of transfer. "

Review of the Nursing Progress Note dated 04/20/16 at 11:30 AM revealed Patient #3 received wrong dose of medication at 08:13 AM on the morning of April 20th 2016. Patient was given 5 doses of Clonidine 0.1mg order stated give 0.5 of 0.1mg.

During an interview with LVN-A on 04/26/16 at 03:00 PM confirmed she administered the incorrect prescribed dosages to Patient #1, Patient #2, and Patient #3 on 04/20/16 during the 08:00 AM medication administration pass. LVN-A stated she administered 5 tablets of 0.1mg to equal 0.5mg to each Patient #1, #2, and #3 instead of 0.05mg as ordered for Patient's #1, #2, and #3; which should have been only one half a tablet of the 0.1mg (0.05mg). LVN-A stated she "misread" the instructions on the MAR which indicated, "To give 0.05mg use 0.5 ea [each] of 0.1mg." LVN-A indicated once she saw "the children sleeping" that triggered her thoughts to review the MAR for Patient's #1, #2, and #3. LVN- A stated she then immediately realized she gave the wrong doses to Patient's #1, #2, and #3 and notified M.D.-A who was on the unit at that time. LVN-A stated the M.D.-A ordered for Patient's #1, #2, and #3 to be transferred to another facility's ER for assessment and monitoring.

Review of the facility's Policy titled Medication Administration and Documentation last reviewed March 2015 indicated in the area of Administration, in part, "Prior to administration, the nurse will compare the medication with the MAR and verify that the medication, dosage, route and times are correct."


Review of the Texas Nurse Practice Act 217.11, Standards of Nursing Practice, states, in part,

" (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: ...

(B) Implement measures to promote a safe environment for clients and others;

(C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same;

(D) Accurately and completely report and document:

(i) the client's status including signs and symptoms;

(ii) nursing care rendered;

(iii) physician, dentist or podiatrist orders;

(iv) administration of medications and treatments;

(v) client response(s); and

(vi) contacts with other health care team members concerning significant events regarding client's status; "

Based on observation and interview the facility nursing staff failed to ensure that drugs were left in a monitored and safe environment; reducing access to medication from unauthorized individuals. Observations conducted on 04/27/16 revealed 2 incidences where 2 children simply accessed inside the nursing station where a medication cart was left unattended and unlocked.

Findings included:

Based on observation during medication administration of the children's unit by Licensed Vocational Nurse (LVN) - C on 4/27/16 at 10:58 AM revealed a medication cart located in the nursing station area. Charge Registered Nurse (RN)- A exited the nursing station to the " social area of facility " and, LVN-C exited the nursing station to the opposite side of the counter; administering medications to a patient. Surveyor in nursing station observed a non sampled patient (child) reached his hand over the door to the nursing station, and unlock the door to enter into the nursing area. The non-sampled patient- Child stood by the unlocked medication cart, and was unnoticed by staff. LVN-C returned to medication cart and surveyor asked if children were allowed in the nursing station, and he replied, "No".

Further observation at 11:10AM, a second non sampled child was observed reaching over the door with his hand opening the door to the nursing station and walked into the nursing station to talk to nursing staff. Child was unnoticed by staff, and LVN-C's back was turned away from patient. Patient approached the unlocked medication cart. Child was eventually seen by staff and asked to exit the area. LVN-C speaking with Surveyor stated that children are not allowed in Nursing Area and stated; just like the prior patient, they " force their way in " .

Review of the facility's Nurse training, " Safe Steps to Medication Administration " dated 04/20/16- and the Medication Administration Competency Checklist revealed training did not include; ensuring a secure area where drugs were stored in a manner to prevent access by unauthorized individuals or to ensure drugs where locked when left unattended.