HospitalInspections.org

Based on medical record reviews, review of facility policies, and staff interviews, nursing staff failed to administer medications in accordance with the orders of the practitioner responsible for the patient for one patient (P) (P#1) of three sampled patients for the care and accepted standards of practice.

Findings include:

A review of the policy titled, "Assessment and Reassessment", revised 10.2021, revealed that a History and Physical would be completed within the first 24 hours of admission and would include an examination, medical history, and medications.

A review of the policy titled, "Change in Condition", NO: CTS-032" dated 4/202 with review date of 12/2/2022, revealed the nurse would contact the physician if there were any concerns regarding the patient's medical condition where nursing staff believed a delay may have caused a negative outcome.

A review of the policy titled, "Medication Reconciliation" NO: MM-014" revised 03/11, revealed the facility provided a process for accurate reconciliation of medications to prevent medication errors related to failed communication. The process included obtaining the most accurate list possible of the patient's current medications at the time of admission. The physician would review the list to determine which medications would be prescribed for continued use, and the nurse would transcribe the orders per facility procedures.

A review of the policy titled, "Medication Administration: General Guidelines" NO: MM-010. Revised: 03/11, revealed that patient profiles would include current medications. All medications would be documented on the Medication Administration Record (MAR) immediately after they were given.
A review of the policy titled, "Use of Patient's Own Medications," NO: MM-022, revised 03/11, revealed that it was the policy of the facility that a patient's own medications could be used if there was a physician's order saying the patient may take their own medications and the medications had been appropriately identified. The nurse would notify the physician of any medications brought to the facility and obtain orders from the physician for use if indicated. If a patient required medications that were not available to the hospital, the family may have been asked to bring those medications to the facility.

Medical record review revealed that Patient P#1 was voluntarily admitted to the facility on 6/13/23 at 1:00 p.m. due to suicidal ideation (the act of thinking about or a state of preoccupation with taking one's own life).

A review of the Intake Assessment by Registered Nurse (RN) EE dated 6/13/23 at 1:00 p.m. revealed that P#1 had severe depression stemming from a diagnosis of lupus (an inflammatory disease caused by the immune system attacking itself) in 2019.

A review of a History and Physical examination by Nurse Practitioner (NP) AA dated 6/14/23 at 2:30 p.m. revealed that P#1 was diagnosed with lupus and high blood pressure. Medications included Norvasc (high blood pressure), prednisone (steroid), and folic acid (supplement). The plan of care was for P#1 to resume home medications.

A review of the Medication Reconciliation Orders form revealed that P#1's medications (the medications for P#1) were verified with the pharmacy by RN GG on 6/14/23 2023 at 4:00 p.m. and included the following:
1. Clomid (medication to treat lupus).
2. amlodipine (blood pressure).
3. folic acid.
4. lisinopril (blood pressure).
5. azathioprine (lupus).
6. Hydralazine (blood pressure).

The psychiatrist (MD) II opted to continue all listed medications and signed the form on 6/14/23 2023 at 4:03 p.m.
A review of the Medication Administration Records (MAR) revealed no MAR on the admission date 6/13/23. The pharmacy had printed the MAR on 6/14/23 at midnight with as-needed medications only and failed to include a list of routine medications transcribed by the nurse. The MAR dated on 6/15/23 2023 at midnight included Clomid every other day, Norvasc daily, folic acid daily, lisinopril twice daily, and azathioprine twice daily. Routine medications, including lupus medications, were first documented as being administered on 6/15/23 2023 at 9:00 a.m.

A review of a nursing reassessment dated 6/15/23 at 8:00 a.m. by RN HH revealed that P#1 was complaining of chest pain related to a lupus flare-up. The medical provider was aware, and P#1 would follow up with the medical provider.

An order by the Nurse Practitioner (NP) AA dated 6/15/23 at 8:30 p.m. revealed that P#1 would be transferred to the hospital due to a lupus flare.

A Discharge Summary by the NP JJ dated 6/15/23 revealed that P#1 was transferred to the hospital and did not return to the facility

An interview was conducted with NP AA on 8/22/23 at 1:15 p.m. in the Conference Room. NP AA revealed medications would be prescribed to patients after being seen by the provider. A nurse would call the provider if a medication needed to be started before the patient could be seen. NP AA said every patient was different, and a couple of missed doses of lupus medication may or may not have caused a flare-up.

An interview was conducted with the RN CC on 8/22/23 2023 at 2:28 p.m. in the Conference Room. RN CC revealed the medication nurse would call the pharmacy to verify a patient's medication history as quickly as possible after arrival at the unit. The nurse would complete a medication reconciliation form with the medications the patient was taking. The medical provider would decide whether or not to continue the medications during the initial evaluation, which would be completed within 24 hours of admission. If the nurse did not feel a medication could wait until the evaluation, the nurse would call the medical provider for an order. After the medical provider signed the medication reconciliation form, the form would be faxed to the pharmacy and given to the medication nurse for review. RN CC said medications should have been written on the MAR for P#1 on 6/14/23 after signing the medication reconciliation form. RN CC verified that there was no hand-written MAR for P#1 on 6/14/23.