HospitalInspections.org

Based on observation, record review and interview, the facility failed to:


A. 1.) insure that staff recognized a patient's family concerns as a grievance in 1 of 21 (#1)
patient reviewed.

2.) follow its policy for grievance resolution.

Refer to Tag 0118, 42 CFR 482.13(a)(2)



B. 1.) insure nurses followed the physician's orders as written in 3 (#1-#3) of 21
patient reviewed.

2.) insure the nursing staff did not disregard the family's warning about drug
sensitivity in 1(#1) of 21 patients reviewed,

3.) insure the nurse fully assessed the patient after administering narcotic pain
medication for #1 of patients (#1 -#21) reviewed.

Refer to Tag 0144, 42 CFR 482.13(c)(2)

Based on interview and document review the facility failed to insure staff recognized a patient's family concerns as a grievance in 1 of 21 (#1) patients reviewed, and follow its policy for grievance resolution.

On 9/17/2014, in the Administrative conference room, at 10:20 AM, the Nursing Administration was made aware that a formal complaint had been received against the hospital. A request to review the facility compliant log, revealed no complaint was documented as received from the complainant.

On 9/18/2014, in the nursing conference room, at 11:00 AM, a request was made to review the facilities log of persons who had requested copies of Medical Records (MR). Staff #3 left the conference room to retrieve the log. Upon return to the conference room, staff #3 presented a one page typed letter of complaint from Pt #1's family. Staff #3 explained that the MR/Billing Department had received the letter, directed to the attention of the "MR/Billing Department". The Billing Department felt they had satisfied the complainant. The letter of complaint had never been shared with the Compliance officer or any member of the Administration. The complaint allegations were never made known to the Nursing Department and had never been investigated. The Nursing Administration which included staff #1- #5 confirmed no one in the room had seen the complaint letter until that moment. A formal response to the family concerning the allegations never occurred. All Nursing Administrative staff present ( staff #1- #5) confirmed that the MR/Billing Department failed to follow the Hospital's process for complaint/grievance resolution.

On 9/18/2014, at 9:30 AM, in the nursing conference room, an interview with Physicians #8 and #9 confirmed patient #1's daughter complained to them regarding how "rough" the Radiology Technicians (Techs) had been with her father during the night. When asked how had they addressed this family concern they both indicated they mentioned it to the Radiology Department supervisor. No direct follow-up by either physician was done with the family and neither physician made the Compliance Officer nor Administration aware of the complaint.

On 9/17/2014, at 11:00 AM, in the Administrative conference room, an interview with Staff #15, the Radiology Department Supervisor, revealed the following: "We have something called track events to record anything out of the ordinary, so in case this happens no one has to recall events by their memory". Request was made of staff #15 to provide any track event notes made during the last week of February 2014 through the first 10 days of March 2014. None were provided. Further interview with the Radiology Department Supervisor indicated he had not had any complaints about his staff. He indicated both his night radiology staff were men who had worked years for him in the hospital. Subsequent interview of both Radiology Techs, #13 - #14, confirmed they had both worked the night shift for years and both had worked during pt #1's hospitalization. Neither staff could recall anything about pt #1. Neither staff recalled being spoken to about handling pt #1 roughly. Review of the employee files of staff #13 and #14 identified no education or corrective action for patient handling, outside their annual employee training.

On 10/3/2014, a telephone interview with pt #1's daughter, who at the time was his primary care giver, stated "two (2) male staff from radiology jerked my father up in bed to place a radiology flat plate behind his back. Dad yelled out in pain. I told them don't you know he has a fractured neck?" (Pt #1's MR revealed pt was admitted with cervical fractures and a fractured left hip. He was 10 days post surgical repair of fractured thoracic vertebrae.)

Review of the facility's "Complaint/Grievance Policy" revealed the following:

"Policy:
Patients have the right to prompt attention to any concerns that they may have.

Procedure:
1. Any time a patient complaint is received, the person receiving the compliant should act quickly to resolve the issue to the patient's satisfaction.

2. If the compliant or problem falls within the general duties of the person receiving the complaint, then resolving the complaint should be prioritized appropriately to ensure patient satisfaction. Most patient concerns that can be resolved quickly are not to be considered a grievance.

3. If the complaint cannot be handled with the duties of the person receiving the complaint, then the compliant should be communicated to the appropriate supervisor responsible for the patient and/or for the patients' service so the compliant can be resolved quickly. While sometimes it might appear convenient to give the patient another number to call or to refer the patient to someone else, nothing can be better that helping the patient yourself.

4. If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation , and/or requires further action for resolution, then the complaint is a grievance.

5. A written complaint is considered a grievance...

6. Whenever the patient or the patient's representative request that his or her complaint be handled as a formal complaint or grievance or when the patient request a response from the hospital, the complaint is considered a grievance.

7. Formal complaint or grievance will be documented on a complaint form. A follow-up letter or email to the patient or the patient's representative regarding the resolution should be sent in an average of seven days, a copy of the follow-up correspondence should be attached to the complaint form.

8. The Complaint form and copy of the letter will be forwarded to Administration and kept in the complaint log book.

9. Billing issues are usually not considered grievances. However, a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489 is considered a grievance."

Physician staff as well as Radiology staff failed to follow the facility policy identifying a complaint as a grievance when it is not immediately resolved and passed to another person for resolution, or when the complaint is never resolved.

Based on interview and document review the facility failed to :

1.) insure nurses followed the physician's orders as written in 3 (#1-#3) of 21
patients reviewed.

2.) insure the nursing staff did not disregard the family's warning about drug
sensitivity in 1(#1) of 21 patients reviewed,

3.) insure the nurse fully assessed the patient after administering narcotic pain
medication for #1 of patients (#1 -#21) reviewed.



In the afternoon of 9/17/2014, in the Administrative Conference room, Pt #1's MR review of the ED physician's orders dated 2/24/2014 revealed an incomplete physician's order for "Demerol 12.5 mg (milligrams) IV (Intravenous) and Zofran 4 mg IV" The ED physician's order indicated both drugs to be given together and was implied one (1) time. This was confirmed by staff #5 and the staff #19, however the physician's order did not include the frequency the combination of drugs was to be given.

Medical Record (MR) revealed Staff #11's signature indicated she was the receiving nurse who provided triage for pt #1 upon ambulance arrival to the ED. She remained with him as the primary RN providing care while in the ED. ED physician documentation indicated Pt #1's listed allergies were Ibuprofen, Influenza vaccine, NSAIDS (non steroidal anti-inflammatory drugs) Feldene and Tetanus Toxoid. At the time staff RN #11 began giving physician ordered Demerol for pain, pt #1's family told RN #11 "Please stop, he (pt #1) is allergic to Demerol". The family further reported that staff #11 stated to them, "I just gave a smidgeon". However, staff RN #11 documented a full dose of 12.5 mg was administered IV. This initial dose of Demerol was documented as given on 2/24/2014 at 1336 (1:36 PM).

On 9/17/2014, at 11:30 AM, in the Administrative conference room, an interview with staff #11 confirmed she worked in the Emergency Department (ED) as a Registered Nurse (RN). She also confirmed she used the word "smidgeon".

The response to the IV Meperedine was documented on 2/24/2014 at 1426 by staff #11 as "No adverse reaction", a time span of 50 minutes. There was no assessment of pt #1 for adverse reactions documented. Vitals signs were incomplete. documenting only the Blood pressure and pulse. There was no documentation of the family reporting pt #1's Demerol allergy.

On 2/24/2014, at 1455, staff #11 documented that report was called to the Intermediate Care unit (IMC). At 1457, two (2) minutes after report had been called and prior to actually transporting pt #1 to the IMC, Staff #11 documented a second dose of Meperedine 12.5 mg IV was administered. There was no physician's order for the second dose of Demerol IV. Staff #11 never documented the physician's ordered Zofran 4 mg IV as given.

On 10/1/2014, the MR for Pt #2 was reviewed and revealed the following: Pt #2 came to the ED via ambulance on 1/28/2014 at 8:12 AM. The chief complaint was bilateral thigh with muscle spasms. She was a patient at rehab for a fractured hip. ED Physician's orders for "Dilaudid 1 mg/Zofran 4 mg IV" were identified on the ED "Physician's Order Sheet". Further review identified the following in the nurses "ED Treatment Given" The first dose of "Dilaudid 1 mg /Zofran 4 MG given IV 1/28/2014 at 08:44. The second dose of Dilaudid 1 mg/Zofran 4mg IV was given on 1/28/2014 at 11:12. The third dose of Dilaudid 1 mg/Zofran 4 mg IV was given 1/28/2014 at 15:35.

RN staff #s 22, 23, 24 each gave Dilaudid 1 mg with Zofran 4 mg IV, for a total of three doses of IV medication . Only one (1) incomplete physician's order was identified in the pt MR for 1 dose of Dilaudid 1 mg and Zofran 4 mg.

The morning of 10/1/2014, in the nursing conference room, the MR for Pt #3 was reviewed and revealed Pt #3 was treated in the ED on 3/24/2014 at 16:17. Her chief compliant was abdominal pain and vomiting. Identified in the "ED Physician's Order Sheet" were the following orders: "Normal Saline 500 cc (cubic centimeters) Bolus, Zofran 4 mg (Drug commonly used in hospitals for nausea and vomiting) IV, Protonix 40 mg (drug commonly used in hospitals for Gastric irritation and stomach pain) IV, Demerol 25 mg IV". Review of the form titled "ED Treatment Given" Nursing staff #25 gave Zofran 4 mg 3/24/2014 at 16:18. Staff RN #11 gave Protonix 40 mg IV 3/24/2014 at 16:18. Staff RN #25 gave a second dose of Zofran 4 mg on 3/24/2014 at 20:22 and a second dose of Protonix 40 mg IV was given 3/24/2014 at 20:10. Staff RN #25 gave two (2) doses of IV Zofran 4 mg and IV Protonix 40 mg with one incomplete physician's order for "Zofran 4 mg IV and Protonix 40 mg IV".

Staff RN #11 began giving physician ordered Demerol for pain pt #1's family told RN #11 "Please stop, he (pt #1) is allergic to Demerol" The family further reported staff #11 stated to them, "I just gave a smidgeon". However, staff RN #11 documented a full dose of 12.5 mg was administered IV. This initial dose of Demerol was documented as given on 2/24/2014 at 1336 (1:36 PM)

A review on-line of "Physician's Medication Facts" revealed the following: "Demerol is considered an Opioid pain medication used to treat mild to moderate pain. Warnings include the following: Take this medication exactly as prescribed. Misuse of this narcotic can cause addiction, overdose or death. DO NOT TAKE with any type of breathing problem or lung disease. Demerol is more likely to cause breathing problems in older adults, severely ill patients, or otherwise debilitated patients. Precaution is advised with use when the patient has heart problems, B/P issues or COPD (Chronic Obstructive Pulmonary Disease)".

MR indicated that pt #1 was transferred to the IMC unit. Review of the Medication Administration History Detail revealed the following pharmacy note: 2/24/2014 1536 hours. "IS PT ALLERGIC TO DEMEROL? ITS ON ONE TIME DOSE UNSCHEDULED. In patient's Allergy list, but given in ER (Emergency Room). Please check thanks". Review of the MR for pt #1 identified no nursing or physician documentation pt #1 was allergic to Demerol. Two (2) IV doses of Demerol were administered.

Staff RN #11 disregarded the family's warning of pt #1's Demerol allergy and administered a second dose of Demerol IV after being made aware of the allergy. Also pt #1's diagnosis included hypertension, arterial stenosis, and COPD (Chronic Obstructive Pulmonary Disease)


On the morning of 9/18/2014, in the nursing conference room, review of the MR for Pt #1 revealed the Pharmacy Medication Administration history on 2/24/2014, at 2018 hours, Dilaudid 2 mg/ml (millimeter) is entered with the following instructions for use: Give IV 0.25 mg-0.5 mg every 2 hours for severe pain. Review of the physician orders dated 2/24/2014 revealed the following "Dilaudid 0.25 mg-0.5 mg IV every 2 hours for severe pain". Review of the complainants written statement of complaint indicated the Dilaudid was a new drug for pt #1.

An interview on 9/18/2014, at 8:00 AM, with staff RN #12 confirmed that she gave the initial dose of 0.5 mg Dilaudid for pt #1's complaint of severe pain. During this interview, staff RN #12 confirmed, "as a nurse, this was the first time to give Dilaudid". Review of pt #1 MR revealed the initial dose of Dilaudid was documented as given at 2330 (11:30 PM) Vital signs (V/S) documented at that time were recorded as follows: (temperature) 97.2- (pulse) 88- (respirations) 21- (B/P) 94/60 Oxygen saturation at 98%.

Staff #12 indicated both the patient and his wife were asleep during most of the night shift. "I checked on them through the window and both were asleep. Both had their eyes closed with regular breathing".

Review of the hospital policy for obtaining routine vital signs for the IMC unit is every 2 hours. Review of the policy for assessment and V/S after unscheduled, PRN (As needed) medications are given is within 1 hour after dosing. This was confirmed by staff #5.

Further interview with staff #12 revealed, near the end of the shift pt #1's wife came to the nurse station saying "something just isn't right". Staff #12 indicated she entered the patient room to assess the patient at that time and could not elicit a pain response. She called for the ICU charge nurse to come assess the patient and she called the pt's attending physician, #7. When she did not reach physician"#7, she called Physician #18 who suggested Narcan but was unsure of the dose and told her to call Physician #7 again. Staff #12 called again to physician #7 but got no response. Per staff #12, both physician's #7 and #18 arrived at the ICU at the same time, shortly after the phone conversation with physician #18. Physician #7 wrote a now order for Narcan to be given. Review of the physician's order reads as follows: "IV Narcan 0.4 mg Now, given" The order was not timed.

Pt #1's MR revealed the next V/S were documented 2/25/2014 at 0630 (6:30 AM) as follows: 98-107-14-73/55. Seven (7) hours after the initial dose of 0.5 mg Dilaudid was given. The MR revealed pt #1 was on a heart monitor. The heart monitor tracings found in the MR indicated a tracing was recorded on 2/24/2014 at 15:27 (3:27 PM). The tracing indicated Pt #1's heart rate was 94 with Normal Sinus Rhythm (NSR). On 2/242014 at 23:10 (11:10 PM). Pt #1's heart rate was 83 with NSR and first degree heart block. The next heart monitor tracing was recorded at 2/25/2014 at 6:16 AM. The hand written note on the tracing reads "Transfer strip to ICU (Intensive Care Unit). There was no interpretation documented.

Staff #12 failed to follow the hospitals policy for obtaining vitals signs. Staff #12 failed to assess Pt #1 or obtain vital V/S and document the assessment for pt #1 after giving the initial dose of Dilaudid.

Based on interview, and document review the failed to:



1.) follow written physician's orders and failed to recognize the risk of administering Narcotic pain medication to geriatric adults without assessment of the patients both before and after administering pain medication for 3 of 21 patients identified (Pt #1, #2 ,#3 of #1-#21). Refer to Tag A-395, 42 CFR 483.23(b)(3)




2.) insure nursing staff clarified incomplete physician's orders per policy and 2.) identify medication errors and report them in #1, #2, #3 of #1-#21 patients reviewed. Refer to Tag A405, 42 CFR 483.23(c)(1),(c)(1)(i) & (c)(2)

Based on interview and document review, the facility failed to follow written physician's orders and failed to recognize the risk of administering narcotic pain medication to geriatric patients without assessments before and after administering pain medication for 3 of 21 patients identified (Pt #1, #2 ,#3 of #1-#21).

On 9/17/2014, at 2:00 PM, in the conference room review of pt #1"s MR revealed the ED physician's orders dated 2/24/2014 12:10 contained the following order "Demerol 12.5 mg IV and Zofran 4 mg IV". Staff #5 and staff #19 confirmed the ED physician order was incomplete and indicated both drugs were to be given together and implied to be given only one (1) time.

Further review of staff #11's ED treatment notes indicated the following: Staff #11 administered Meperedine (generic Demerol) 12.5 mg (miligrams) IV (intravenous) without administering Zofran 4 mg IV on 2/24/2014 at 1336 hours. The response to the IV Meperedine was documented on 2/24/2014 at 1426 by staff #11 as "No adverse reaction", a time span of 50 minutes.

On 2/24/2014, at 1457, prior to transporting pt #1 to the IMC (Intermediate Care) unit, Staff #11 documented a second dose of Meperedine 12.5 mg IV was administered and recorded the response on 2/24/2014 at 1458 as "No adverse reaction" (One minute after administration) Pt #1's Blood Pressure (B/P) had dropped from 133/93 to 106/68 prior to the administration of the second dose of Demerol. Complete vital signs were not documented after administering the unauthorized dose of Demerol 12.5 mg IV and no patient assessment was identified in the ED record.

Review of the reference "The Internet Drug Index" revealed the following: "Demerol is an Opiod agonist and a schedule II controlled substance and an abuse liability similar to Morphine, and should be used with extreme caution with Chronic Obstructive Pulmonary Disease (COPD). In such patient's even usual therapeutic doses of narcotic may decrease respiratory drive while simultaneously increasing airway resistance to the point of apnea".

Review of the reference, "US National Library of Medication, National Institute of Health", "The half life of Demerol is 2-5 hours, however the metabolites may be 15-30 hours excreted through the kidney in adults. In renal impaired patients it may increase 35-40 hours with multiple doses"

On 917/2014, in the conference room a review of Pt #1 MR revealed the following History and Physical dated 2/24/2014, documentation found in the "History of Present Illness: Long-standing COPD, hypertension, rectal bleeding, Congestive Heart Failure (CHF) He does use oxygen at home and a walker to get around".

On the morning of 9/18/2014, in the nursing conference room, review of the MR for Pt #1 revealed the Pharmacy Medication Administration history on 2/24/2014, at 2018 hours, Dilaudid 2 mg/ml (millimeter) is entered with the following instructions for use: Give IV 0.25 mg-0.5 mg every 2 hours for severe pain. Review of the physician orders dated 2/24/2014 revealed the following "Dilaudid 0.25 mg-0.5 mg IV every 2 hours for severe pain". Pt #1 had never taken Dilaudid prior to this date.

An interview on 9/18/2014, at 8:00 AM, with staff RN #12 confirmed she gave the initial dose of 0.5 mg Dilaudid for pt #1's complaint of severe pain. During this interview staff RN #12 confirmed, "as a nurse, this was the first time to give Dilaudid". Review of pt #1 MR revealed the initial dose of Deluded was documented as given at 2330 (11:30 PM) Vital signs (V/S) documented at that time were recorded as follows: (temperature) 97.2- (pulse) 88- (respirations) 21- (B/P) 94/60 Oxygen saturation at 98%..

Review of reference titled, "Patient Safety Authority.org/Advisory Library, September 4, 2010," revealed the following: "Hydromorphone (Dilaudid) is a semisynthetic Opiod agonist. A derivative of Morphine. The estimated potency of IV Hydromorphone compared to IV Morphine is 7.5:1 The equivalent dose of Dilaudid would be 0.3 mg-0.67 mg (2.5 mg to 5 mg of Morphine). The primary expected effect is depressed or decreased respirations even in non-elderly patients."

Staff #12 indicated both the patient and his wife were asleep during most of the night shift. "I checked on them through the window and both were asleep. Both had their eyes closed with regular breathing".

Review of the hospital policy for obtaining routine vital signs for the IMC unit is every 2 hours. Review of the policy for assessment and V/S after unscheduled, PRN (As needed) medications are given was within 1 hour after dosing. This was confirmed by staff #5.

Further interview with staff #12 revealed, near the end of the shift pt #1's wife came to the nurse station saying "something just isn't right". Staff #12 indicated she entered the patient room to assess the patient at that time and could not elicit a pain response. She called for the ICU charge nurse to come assess the patient and she called the pt's attending physician, #7. When she did not reach physician #7, she called Physician #10, the patient's surgeon, who suggested Narcan but was unsure of the dose and told her to call Physician #7 again. Staff #12 indicated she tried to reach physician #7 again by phone, but got no response. Per staff #12, both physician's #7 and #10 arrived at the ICU at the same time, shortly after the phone conversation ended with physician #10. Physician #7 wrote a now order for Narcan to be given. Review of the physician's order reads as follows: "IV Narcan 0.4 mg Now, given". The order was not timed.

Pt #1's MR revealed the next V/S were documented 2/25/2014 at 0630 (6:30 AM) as follows: 98-107-14-73/55. Seven (7) hours after the initial dose of 0.5 mg Dilaudid was given. The MR revealed pt #1 was on a heart monitor. The heart monitor tracings found in the MR indicated a tracing was recorded on 2/24/2014 at 15:27 (3:27 PM). The tracing indicated Pt #1's heart rate was 94 with Normal Sinus Rhythm (NSR). On 2/242014 at 23:10 (11:10 PM), Pt #1's heart rate was 83 with NSR and first degree heart block. The next heart monitor tracing was recorded at 2/25/2014 at 6:16 Am. The hand written note on the tracing reads "Transfer strip to ICU (Intensive Care Unit). There was no interpretation documented.


On 10/1/2014, the MR for Pt #2 was reviewed and revealed the following: Pt #2 came to the ED via ambulance on 1/28/2014 at 8:12 AM. His chief compliant was bilateral thighs with muscle spasms. Pt #2 came from rehab for recent fractured hip. ED Physician's orders for "Dilaudid 1 mg and Zofran 4 mg IV" were identified on the ED "Physician's Order Sheet". Further review identified the following in the nurses "ED Treatment Given" documenation. The first dose of "Dilaudid 1 mg and Zofran 4 MG was given IV 1/28/2014 at 08:44. The second dose of Dilaudid 1 mg and Zofran 4 mg IV was given on 1/28/2014 at 11:12. The third dose of Dilaudid 1 mg and Zofran 4 mg IV was given 1/28/2014 at 15:35.

RN staff #'s 22, 23, 24 each gave Dilaudid 1 mg with Zofran 4 mg IV for a total of three (3) doses of Dilaudid and Zofran. One (1) incomplete physician's order was identified in the pt MR for 1 dose of Dilaudid 1 mg and Zofran 4 mg. After each doses of IV pain medication, the nurse conducted an interview with the patient and documented the patient's complaint of pain was unchanged or decreased. No assessment was identified in the ED nurses record.

On 10/2/2014 at 11:00 AM, during an interview with the hospital's Registered Pharmacist who was shown RN documentation of the above findings, revealing he was unaware RN staff in the ED were giving physician ordered medication (narcotics) more frequently than the order allowed.

The morning of 10/1/2014, in the nursing conference room, the MR for Pt #3 was reviewed and revealed Pt #3 was treated in the ED on 3/24/2014 at 16:17. Her chief complaint was abdominal pain and vomiting. Identified in the "ED Physician's Order Sheet" were the following orders: "Normal Saline 500 cc (cubic centimeters) Bolus, Zofran 4 mg (Drug commonly used in hospitals for nausea and vomiting) IV, Protonix 40 mg (drug commonly used in hospitals for Gastric irritation and stomach pain) IV, Demerol 25 mg IV". Review of the form titled "ED Treatment Given" Nursing staff #25 gave Zofran 4 mg 3/24/2014 at 16:18. Staff RN #11 gave Protonix 40 mg IV 3/24/2014 at 16:18. Demerol 25 mg IV was given by staff RN #22 at 20:15. Review of expected possible outcomes from use of IV Demerol, found in manufactures literature, is Nausea. Pt #3 came to the ED for abdominal pain and vomiting.

Staff RN #25 gave a second dose of Zofran 4 mg on 3/24/2014, at 20:22, and a second dose of Protonix 40 mg IV was given 3/24/2014 at 20:10. Each time an IV dose of medication was given the RN documented "Patient reports no change in pain".

Based on interview and document review the facility failed to 1.) insure nursing staff clarified incomplete physician's orders per policy and 2.) identify medication errors and report them in 3 (#1, #2, #3) of 21 (#1-#21) patients reviewed.

On 10/2/2014, in the conference room, the hospitals "Prescribing/Ordering - General Practices for Patient Care Services" was reviewed and revealed the following:

Procedure:

The prescribing practitioner will be contacted by pharmacy or nursing personnel for clarification of any order staff members feel are not legible.

The physician must date and time his or her signature. All verbal and or telephone orders for medication shall include the following. The generic and the brand name of the drug, drug dosage (Strength or concentration), Quantity and or duration, route drug is to be administered, frequency of administration, age and weight of the patient if this is not known or in clinical circumstances where this is appropriate, known allergies, reason the drug is ordered, specific indication for use as appropriate.

On the morning of 9/17/2014, in the Administrative Conference room, Pt #1's MR (Medical Record) review of the ED physician's orders dated 2/24/2014 revealed the physician's order for as follows: "Demerol 12.5 mg (milligrams) IV (Intravenous) and Zofran 4 mg IV". The physician's order did not include the generic equivalent, frequency for use, or season for use.

Further review of pt #1's MR revealed Staff #11 did not clarify the physician's order. Documentation indicated she administered this initial dose of Demerol and documented it as given on 2/24/2014 at 1336 (1:36 PM). On 2/24/2014 at 1457, prior to transporting pt #1 to the IMC (Intermediate Care) unit, Staff #11 documented a second dose of Meperedine 12.5 mg IV was administered. Without a written physician's order, the second dose of Demerol 12.5 mg IV administered was a medication error. No Medication error report was identified.

On 10/1/2014, the MR for Pt #2 was reviewed and revealed the following: Pt #2 came to the ED via ambulance on 1/28/2014 at 8:12 AM. The chief complaint was bilateral thighs with muscle spasms. At rehab facility for fractured hip. ED Physician's orders for "Dilaudid 1 mg and Zofran 4 mg IV" were identified on the ED "Physician's Order Sheet". The physician's order failed to include why the drug was ordered, frequency the drug was to be given, and no generic equivalence. Further review identified the following in the nurses "ED Treatment Given". The first dose of "Dilaudid 1 mg and Zofran 4 MG given IV 1/28/2014 at 08:44. The second dose of Dilaudid 1 mg and Zofran 4 mg IV was given 1/28/2014 at 11:12. The third dose of Dilaudid 1 mg and Zofran 4 mg IV was given 1/28/2014 at 15:35.

The morning of 10/1/2014, in the nursing conference room, the MR for Pt #3 was reviewed and revealed that Pt #3 was treated in the ED on 3/24/2014 at 16:17. Her chief complaint was abdominal pain and vomiting. Identified in the "ED Physician's Order Sheet" were the following orders: "Normal Saline 500 cc (cubic centimeters) Bolus, Zofran 4 mg (Drug commonly uses in hospitals for nausea and vomiting) IV, Protonix 40 mg (drug commonly used in hospitals for Gastric irritation and stomach pain) IV, Demerol 25 mg IV". No nursing documentation for clarification of the multiple incomplete physician's orders were identified in the MR.

Review of the form titled "ED Treatment Given" Nursing staff #25 gave Zofran 4 mg 3/24/2014 at 16:18. Staff RN #11 gave Protonix 40 mg IV 3/24/2014 at 16:18.
Demerol 25 mg IV was given by staff RN #22 at 20:15.

On 10/2/2014, interview with the hospital Registered Pharmacist revealed an expected possible outcomes from use of IV Demerol, is nausea. Review of the chief complaint from Pt #3 was abdominal pain and vomiting.

Staff RN #25 gave a second dose of Zofran 4 mg on 3/24/2014 at 20:22 and a second dose of Protonix 40 mg IV on 3/24/2014 at 20:10.

The staff RN failed to recognize the adverse effects of Demerol and when the second dose of Zofran and Protonix were given without a physician's order it constituted a medication error. No medication error report was located for Zofran 4 mg and Protonix 40 mg, given without the physician's order

Based on document review and interview the facility failed to insure that the hospital pharmacy provided medication in a safe manner for 3 (#1-#3) of 21(#1-#21) patients identified.


On 9/17/2014, in the Administrative Conference room, the MR (Medical Record) for 21 patients were reviewed and 3 records revealed the following incomplete physician's orders:

1. Review of Pt #1's record revealed in the ED (Emergency Department) physician's orders dated 2/24/2014 12:10, "Demerol 12.5 mg (milligrams) IV (intravenous) and Zofran 4 mg IV" The physician failed to include the frequency for use in his written order. Staff #5 and staff #19 confirmed their interpretation of the ED physician order would indicate both drugs to be given together one (1) time. However, MR documentation revealed the staff RN gave only the Demerol and gave it twice. The pharmacy provided Demerol and Zofran for administration to patient #1 without clear instructions from the prescribing physician.

On 9/17/2014, at 2:00 PM, in the conference room, review of physician's orders dated 2/24/2014 12:10 contained the following order "Demerol 12.5 mg IV and Zofran 4 mg IV". Staff #5 and staff #19 confirmed the ED physician order was incomplete and indicated both drugs were to be given together and implied to be given only one (1) time.


2. Review of Pt #2's record revealed ED physician's orders dated 1/28/2014 "Dilaudid 1 mg, Zofran 4 mg IV". Found in the Nurses notes, ED Treatment given: Dilaudid 1 mg; IV time 1/28/2014 08:44 and Zofran 4 mg IVP (Intra Venous Push). 1/28/2014 at 11:12 Hydromorphone (generic Dilaudid) 1 mg IVP and Zofran 4 mg. IVP were given. On 1/28/2014 at 15:35 Dilaudid 1 mg IVP and Zofran 4 mg IVP were given. A one time order for Dilaudid and Zofran was given 3 times by the ED nursing staff.


3.) Pt #3, found in the ED physician's orders dated 3/24/2014, the following orders: "Normal Saline 500 CC (Cubic Centimeter) Bolus, Zofran 4 mg IV, Protonix 40 mg IV, NPO (Nothing By Mouth) Demerol 25 mg IV". Found in the Nurses notes dated and timed 3/24/2014 16:18, Zofran 4 mg IVP. 3/24/2014 at 20:15 Demerol 25 mg IVP was given, Zofran 4 mg IVP was given again at 20:22. Pt #3 received two (2) doses of IV Zofran when it was ordered one (1) time only with Demerol 25 mg.

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State Administrative Code (TAC) Title:22, Part: 15, Chapter: 291, Subchapter: A Rule 291.29 (a) Pharmacist shall exercise sound professional judgment with respect to the accuracy and authenticity of any prescription drug order dispensed. If the pharmacist questions the accuracy or authenticity of a prescription drug order, the pharmacist shall verify the order with the practitioner prior to dispensing.

On 10/2/2014 in the pharmacists office, staff # 19 acknowledged difficulty with physician's writing incomplete orders in the past but voiced hope that a new automated order entry system was correcting the problem of incomplete orders by physician staff. However, there remained one or two physicians' who continued to hand write verbal orders.