HospitalInspections.org

Based on interview, clinical record, and facility policy review, it was determined the facility failed to ensure an appropriate plan of care, assessment and treatment free of medication errors, in 1 of 10 Patients (Patient #1), as evidenced by a medication, Keppra, being administered to Patient #1 when there is evidence in the clinical record that Patient #1 has an allergy to Keppra.

The findings include:

Review of the electronic clinical record of Patient # 1 indicates he was admitted to this acute care Medical Center on 7/25/12 through the 10/25/12, at which date he was discharged to a skilled nursing facility (SNF). Patient #1 is a 75 year old male with an admission diagnosis of Cardiac Arrest.
Patient #1 was living in an assistant living facility (ALF) were he was found un-responsive in cardiac arrest. He was transported to this Medical Center by emergency medical services (EMS) to the emergency room.
The emergency department (ED) Physician examination dated 7/25/12 at 10:16 AM revealed that a previous record acquired from another Medical Center indicates allergies in the past to: Keppra, Erythromycin, Macrolide, Zithromycin, Lovenox, and Aspirin.

During the interview on 12/3/12 at1:18 PM with the quality assurance manager, she was given a copy of the patient ' s record. This record review reveals Patient #1 was admitted to the Intensive care unit (ICU) on 7/25/12. Patient #1 has a previous medical history of; cardiac arrest prior to arrival, cardiac arrhythmia, hypertension, seizures, mild renal insufficiency, urinary tract infections (UTI), and dyslipidemia.

Review of the Physician's admission orders dated 7/25/12 at 1:02 PM revealed a medication to prevent seizures; Keppra 500 mg intravenous (IV) every 12 hours, was ordered. The medication administration record (MAR) indicates Keppra was given on 7/25/12 at 4:26 PM once, and discontinued on 7/25/12 at 6:49 PM.
The further electronic clinical record indicates no adverse effect was incurred from this one dose of Keppra, and a Physician order to discontinue Keppra was acquired in a timely manner.

The Vice President of Regulatory compliance (VPRC) was interviewed on 12/4/12 at 11:45 AM, she was given and electronic record of the emergency department (ED) Physician ' s history and physical (H&P) of Patient #1. This document indicates Patient #1 has past history of allergies to the medication Keppra. The VPRC acknowledged that the Pharmacy tracking system did not automatically communicate this allergy noted in the ED H&P to the Pharmacy admission scanning document system. She stated she did not know why the allergy for Keppra was not listed when the Keppra was administered to Patient #1 on 7/25/12 at 4:26 PM, even though this medication Keppra was scanned by the administration nurse before given the Keppra and no allergies to Keppra were identified by the pharmacy scanning computer records.
The VPRC further stated she believed the Pharmacy electronic system should have forwarded the allergy from the ED H&P to the current allergy listing and does not know why it did not. The VPRC upon inquiry states the facility is currently investigating why the documented allergy noted in the ED H&P did not flow to the admission records pharmacy medication allergies section, and that information technology is presently investigating this lack of communication of Patient #1 ' s allergies.

Review of the facility policy and procedures (P&P) entitled " Medication administration and documentation " indicates on page 2, section 4, line a: To administer medication appropriately, the administrating person must know the patient ' s diagnosis and the disease involved, and any allergies the patient has should be clearly marked on the chart, on the MAR and on an allergy band applied to patient ' s wrist. The VPRC and the Quality assurance Manager stated after review of the clinical record that this communication of allergies must have not been present due to the nurse administration of the medication, after scanning the medication Keppra and the Patient ' s wrist ID band.