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Based on medical record review, review of policy and procedure and interviews the hospital failed to maintain Patient Identifier (PI ) # 1's NPO (nothing by mouth) status as ordered by the physician. As a result, PI # 1 received oral medications even though it was not clear if medication administration was indicated. There is no policy and procedure that describes whether or not medication is to be given when a patient is NPO. The physician failed to specify indications for medication in the NPO order and nursing staff failed to clarify the physician's intent regarding medication administration while PI # 1 was in a NPO status. This deficient practice affected PI # 1, one of ten sampled patients.

Findings Include:

1. Medical Record Review

PI # 1 was brought to the Emergency Department and subsequently admitted to the hospital on 3/16/15 after passing out at home.

A review of the Physician Orders dated 3/16/15 through 3/18/15 at 9:53AM revealed PI # 1's status was NPO.

According to the Nursing Admission History dated 3/17/15, PI # 1 was assessed to have chewing and swallowing problems. Cough. Chokes with liquids.

A Barium Swallow test on 3/17/15 revealed PI # 1 needed nectar thick liquids.

A review of the medication administration record (3/16/15-3/18/15) revealed PI # 1 was given the following medications orally by staff when the NPO order, written by the physician(s),was in effect:
- Coreg 3.125 po (by mouth) every day: 3/16, 3/17, 3/18.
- Celexa 20 milligrams (mg.) po every day: 3/17, 3/18.
- Synthroid: 75 micrograms 1 po every morning: 3/17, 3/18.
- Namenda 10 mg every day: 3/16, 3/17, 3/18.
- Potassium Chloride 20 milliequivalents: 3/18.
- Liquid Potassium 40 milliequivalents: 3/17.
- Pravastatin 10 mg 1 po at bedtime: 3/16, 3/17.

A review of the Physician Orders for PI # 1 revealed:
- 3/16/15: NPO
- 3/16/15 at 6:12 PM: Cardiac Heath Healthy Diet
- 3//16/15 at 6:49 PM: Cardiac diet discontinued. NPO.
- 3/18/15: NPO status discontinued on 3/18/15 at 09:53. A new order was written for a Regular diet with nectar thickened liquids.
- 3/19/15 at 11:30 AM: Regular diet discontinued. NPO


During an interview on 8/19/15 at 2:40 PM, the Quality Director/Risk Manager Employee Identifier (EI # 1) confirmed PI # 1 received the medications listed above even though physician orders dated 3/16/15 - 3/18/15 documented PI # 1 was NPO.

During an interview on 8/19/15 at 2:40 PM, the Quality Director, EI # 1 was asked if PI # 1 received oral medications when the physician orders documented the patient was NPO. EI # 1 verified the medications listed above were given by nursing staff to PI # 1 when PI # 1 was NPO per physician order dated 3/16/15.

On 8/20/15 at 9:03AM, the Quality Director, EI # 1, verified there is no policy and procedure that addresses NPO and medication administration. EI # 1 confirmed the definition of NPO means no medications, no food and no liquids.

During an interview on 8/20/15 at 11:30AM, the Cardiology Unit Manager, EI # 2, was asked if medications should have been given to PI # 1 even though PI # 1 was NPO per physician order. EI # 2 stated she would have called the physician for clarification as to whether or not oral medications were to be administered to PI # 1.

A review of hospital Policy and Procedure, Medication Administration Practice Guidelines - Preparation, Dispensing, Ordering, Revised 1/15, revealed no indications regarding medication administration when a physician has ordered NPO (nothing by mouth) for a patient.

As a result, PI # 1 received 14 doses of medication when the physician order was NPO (nothing by mouth).