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25892

Based on observation, interview, and record review the hospital failed to ensure a Registered Nurse supervised and evaluated the care of each patient by failing:
1. to ensure that line of sight observations delegated to Mental Health Technicians (MHT) were completed as ordered, resulting in a patient with ordered line of sight observations being discovered sleeping on the floor in her room by the surveyor for 1 of 2 patient records reviewed for line of sight observations out of a total sample of 8 patients (#6);
2. to obtain clarification for monitoring frequency for patients who had physician's orders to maintain line of sight observations while awake for 2 of 2 patients with orders for line of sight observations while awake out of a total sample of 8 patients (#5, #6).
3. to ensure hospital policy was developed and implemented regarding the hospital's practice of placing patients on mattresses on the floor which included assessment of the patient to ensure the intervention would not result in deterioration of the patients' mobility or act as a restraint and triggers for placing a patient's mattress on the floor for 1 of 8 sampled patients (#3)
4. to ensure nursing staff contact the dietician when a patient triggered the need for a dietary consult for 1 of 8 sampled patients (#1).
Findings:

1.
Observations on 2/02/2011 at 3:10 p.m. revealed Patient #6 to be barefoot ,lying on the floor next to her bed, covered with a sheet and blanket with no pillow. Further observations revealed a puddle of fluid on the floor approximately 4 feet from where Patient #6 was lying, as well as, a pair of panties lying on the floor near the puddle. The mattress on the bed was ajar. Patient #6 indicated she had fallen and was cold and hurting all over. Staff responded by evaluating the patient's neuro status, range of motion, vital signs, capillary blood glucose, and calling the Advance Practice Nurse to the patient's bedside. Patient #6 was moved to a wheelchair. The Advanced Practice Nurse arrived and examined the patient.

Review of Patient #6's Psychiatric Nursing Notes dated 02/02/11 at 3:05pm, revealed, in part, "found on floor at foot of bed, covered with blanket, curled up Right side, sleeping. Awakened with shaking of shoulder and calling into her ear. Vital signs taken- blood pressure 110/61 Right arm, Pulse 76 to 88, respirations 20 easy, Temperature 98.1, oxygen saturation 97%, skull, neck, spine, hips, legs, palpated without pain response. Alert to name, able to move all extremities, pupils positive reactive, able to grimace, touch fingers to nose, grip with both hands, raise both knees against downward pressure, Administrator and MHT lifted her from floor, placed in wheelchair. Capillary blood glucose= 82. Patient able to converse with staff, stating she was cold and wheelchair uncomfortable. Assessed by Physician's Assistant, started on neurochecks every four hours times 12 hours. Patient taken to shower to cleanup and dress in warm clothes".

Review of Patient #6's Physician's order dated 01/31/11 at 2350 (11:50pm) revealed "line of sight while awake".

Review of Patient #6's Observation Check Sheet dated 02/02/11 revealed, that S17, MHT, was assigned to perform line of sight observations for Patient #6. Further review of the observation check sheet revealed the following observations documented:
2:45pm- patient sleeping in patient room documented by S17, MHT;
3:00pm- patient sleeping in patient room documented by S17, MHT,
3:15pm- in patient room with nurse documented by S17, MHT.

In interview on 02/03/11 at 10:55am, S17, MHT, indicated that orders for line of sight observation while awake required the patient to be in her view at all times while awake, but monitored every 15 minutes while sleeping. S17 indicated that the last time she observed the patient was at 2:45pm on 02/02/11. S17 indicated the patient was sleeping in her bed at 2:45pm. S17 indicated that she then went to conduct a group "A" session. S17 indicated that she was conducting group "A" at 3:00pm. S17 further indicated that she signed off on the observation check sheet as having observed the patient at 3:00pm, even though she did not make the observation, and was conducting group "A" at the time. S17 stated that she had reported to S12, MHT who had assumed responsibility for observing Patient #6 at 3:00pm. S17 indicated that S12, MHT, had reported to her that the patient was sleeping in bed at 3:00pm, and this was the reason that she documented the observation on the observation check sheet. S17 indicated that she was notified at 3:10pm that Patient #6 was found on the floor sleeping in her room.

In a telephone interview on 02/03/11 at 12:15pm, S12, MHT, indicated that the last time she observed Patient #6 was around 2:35pm on 02/02/11. S12 indicated that she left the building to take her assigned break after 2:35pm and did not return to the hospital till 3:00pm. S12 stated that she did not observe Patient #6 at 3:00pm, and further indicated that she did not report any observations of the patient to S17, MHT, at 3:00pm. S1, Administrator and S3, Vice President of Operations were present during the interview, and both confirmed that the hospital staff failed to make the ordered observation of Patient #6 at 3:00pm on 02/02/11.

2.
Review of Patient #5's Physician's orders dated 01/31/11 at 2350 (11:50pm) revealed "line of sight while awake". Further review of the entire medical record revealed no documented evidence of any clarification regarding observations that should be made while the patient was asleep.

Review of Patient #6's Physician's orders dated 01/31/11 at 2350 (11:50pm) revealed "line of sight while awake". Further review of the entire medical record revealed no documented evidence of any clarification regarding observations that should be made while the patient was asleep.

In interview on 02/03/11 at 11:45am, S10, Registered Nurse, confirmed the physician's orders did not specify the observations that should be made while the patient is asleep. S10 indicated that all hospital staff are aware that observations should be made every 15 minutes while the patient is asleep. S1, Administrator, and S3, Vice President of Operations were present, and confirmed that the physician's order should clearly list the observation frequency for the patient while asleep. S1 and S3 further indicted the hospital's current observation policy did not address the monitoring frequency for the patient while asleep.

Review of the hospital policy titled "TX-SPEC. 05 Suicidal Precautions/Close Observations, Date Revised: 2008" revealed, in part, "Procedure: Assigned Nursing Staff- Maintains 1:1 and line of sight during all groups, meals, and break times. For patients on close observation, carefully and consistently documents on the Observation Check Sheet every 15 minutes on each shift while the patient is on close observation. Charge Nurse- oversees close observation sheets, assumes responsibility for close observation and may delegate task to appropriate staff members. Reassesses patient each shift for continued need for 1:1, line of sight and close observation. If suicidal, the suicidal assessment will be documented in the Progress Notes and reported to the attending physician."

3.
Patient #3 (87 year old male):
Patient #3 was admitted to the hospital (Oceans Behavioral Hospital of Baton Rouge) on 1/18/2011 with diagnoses that included Dementia (serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging) with behavioral disturbances, General Anxiety Disorder by history, Macular Degeneration (loss of vision in the center of the visual field), Benign Prostatic Hypertrophy (enlargement of the prostate), Osteoporosis (Disease of the bone that leads to increased risk of fracture), Hypercholesterolemia (high levels of cholesterol in the blood), Atrial Fibrillation (heart arrhythmia), Hypertension (high blood pressure), Degenerative Joint Disease (group of mechanical abnormalities involving degradation of joints), Hypokalemia (low potassium), and Gastroesophageal Reflux Disease (chronic symptoms or mucosal damage caused by stomach acid coming up from the stomach into the esophagus).. Patient #3 was transferred to Hospital " A " on 1/23/2011.

Review of Patient #3's Medical Record revealed a "(ARF) At Risk for Falls Score Sheet" dated 1/18/2011 (no documented time) and 1/23/2011 (no documented time) with a total score of 34 on both dates. Scoring was a result of "1" point for being "over 65" , "7" points for having "fallen just prior to admit or during hospital stay", "2" points for being "on hypnotic, neuroleptic, antianxiety or antidepressant" , "5" points for being "confused, disoriented", "7" points for "poor balance" , "3" points for "uses cane, walker, or wheelchair", "4" points for "sight deficit" , and "5" points for "poor motor function". Further review revealed a score of 0-5 indicated the patient was a low risk for falls, 6-12 indicated the patient was a moderate risk (initiate fall precautions), and 13 - 35 indicated a high risk (initiate fall precautions). Review of "Fall Precautions" as listed on the ARF revealed, " Place falling star precaution sign on patient chart, Falling star precaution sticker is placed on the Kardex, Place falling star sticker on patient bed and on patient door, fall risk identified on treatment plan, teach fall prevention/precautions to patient, falling star precaution sticker is placed on close observation sheet, patient is not left unattended during activities that place him/her at increased risk of falling, place yellow (falling star) arm band on patient."

Review of Patient #3's Multidisciplinary Integrated Treatment Plan revealed the Problem of "High Risk for falls related to confusion or disorientation, Cognitive Deficit, and Motor Deficit" were identified "as evidenced by at risk for fall score of 34, incidence of falling prior to admit, (and) poor balance or motor function" with a short term goal of the patient requesting assistance with ambulation and remaining free from falls for 14 days. Review of interventions revealed in part, Identify fall risks on treatment plan by Registered Nurse, Patient observation every 15 minutes by Mental Health Tech, Assist patient with bathing and ADLs (Activities of Daily Living) daily and prn (as needed) by Mental Health Tech, Provide safe environment by identifying fall inducing hazards and keeping patient's environment clear of these hazards daily by all staff, Call bell, Mattress placed on floor for added protection against falls, assess patient frequently and assist patient with transfer.

Review of Patient #3's entire medical record revealed no documented evidence of an assessment of the 87 year old patient to determine if placing his mattress on the floor would result in decline in the patient's mobility or act as a restraint.

Review of the hospital policy titled, "Fall Assessment/Re-Assessment and Precautions, AS-12, Date: November 2009" presented by the hospital as their current policy revealed in part, "Guidelines for Patient Safety (individualized according to patient needs): Keep bed in low position. Keep bed in locked position. Use bed alarms as appropriate. Provide bell at bedside. Leave bathroom light on. Use manufacturer low bed whenever possible. Ambulation Safety Measures: Eliminate environmental hazards (remove wastebaskets, other items from the path between patient's bed and doorways), Instruct patient to wear shoes with non-skid soles, Instruct patient to ask for assistance if feeling weak, dizzy, or lightheaded, Instruct patient to notify staff of any spills, Offer frequent toileting, Attempt to relocate patient near nurses' station as appropriate (for fall or repeat fall), Keep ambulatory devices (walker, cane) within reach, Provide appropriate ROM (range of motion) exercises to include balancing and strengthening, 1:1 staffing may be needed in special cases for fall prevention."

Review of the entire policy revealed no documented evidence regarding the hospital's practice of placing patients' mattresses on the floor as an intervention for prevention of falls to include what would trigger the need to place the patient's mattress on the floor or how the patient would be assessed to determine if placing the mattress on the floor would; in effect, benefit the patient by preventing falls, restrain the patient that would otherwise be mobile, or contribute to a decline in the patient's mobility.

4.
Review of the hospital policy titled, "AS-05: Nutritional Screening. November 2009" presented by the hospital as their current policy revealed in part, "Purpose: to provide guidelines and establish criteria for utilization/consultation of dietary therapeutic services in meeting the patient's nutritional needs. . . Identified triggers may include: Determining if patient was on a therapeutic diet at home before admission. Patient's appropriate weight for height and frame, as established from American Dietary Association norms for sex and age. Evaluation of appetite and food tolerance. Significant abnormal lab findings. Review of history of eating disorders and medical diagnoses that could establish the need for review by registered dietitian. Geriatric patients are considered at risk for nutritional difficulties. Physician: Orders need for dietitian consult based on nutritional screen, previous special diet and other patient needs. . ."

Review of Patient #1's "Nutritional Screening Form" completed by Registered Dietician S9 on 1/19/2011 revealed in part, "Indications for a Nutritional Assessment: Risk Criteria of 2 or more indicated need for assessment:" Further review revealed a check mark placed by the following triggers, "Loss of Appetite, Albumin <3.5" and the patients intake of meals from the dates of 1/12/2011 through 1/18/2011 was less than 50% for 14 of the 19 meals served. Patient #1's Albumen was documented as 3.3 on 12/22/2010 and 3.0 on 1/02/2011. Review of Registered Dietician S9's recommendations included, "spoke (with) PA (Physician's assistant) per possible protein supplement and consider appetite stimulant. Pro stat 30 ml (milliliters) bid (two times per day), reassess and later (decrease) to qd (every day)."

Review of Patient #1's Physician's orders dated 1/19/2011 at 1330 (1:30 p.m.) revealed an order for Megace (appetite stimulant) 400 milligrams by mouth daily and Prostat (supplement) 30 milliliters two times per day.

During a face to face interview on 2/01/2011 at 9:55 a.m., Registered Dietician S9 indicated, after reviewing the medical record for Patient #1, that Patient #1 would have triggered for a dietary consult on 1/13/2011. S9 indicated Patient #1's Albumin had dropped to 3.0 on 1/02/2011 and the patient's intake at meal time had decreased by 1/13/2011. S9 further indicated the Dietary Manager had been out during that time and the oversight may have been a result of her absence.

Based on record review and interview the hospital failed to ensure nursing staff updated the nursing plan of care by:
1. failing to update the nursing care plan when a patient's ordered observation status was changed from 1 to 1 observation to line of sight observation while awake for 1 of 3 patients records reviewed for updated nursing care plans out of a total sample of 8 patients (#5);
2. failing to update the nursing care plan when a patient's ordered observation status was changed from every 15 minutes to line of sight observation while awake for 1 of 3 patient records reviewed for updated nursing care plans out of a total sample of 8 patients (#6).
Findings:

Patient #5

Review of Patient #5's Physician's Orders dated 01/26/11 at 1645 (4:45pm) revealed a order for "1 to 1 observation". Further review of the Physician's Orders dated 01/31/11 at 2350 (11:50pm) revealed "DC (discontinue) 1 to 1 observation and change to line of sight while awake".

Review of Patient #5's Multidisciplinary Integrated Treatment Plan revealed, in part, "Clinical Interventions- Implement 1:1 staffing as situation requires per MD order (RN), initiated on 01/26/11. Further review of the treatment plan revealed no documented evidence that the treatment plan was updated when the patient's ordered observation status was changed from 1 to 1 observation to line of sight observation while awake.

Patient #6

Review of Patient #6's Physician's Orders dated 01/25/11 revealed a order for "every 15 minutes observation". Further review of the Physician's Orders dated 01/31/11 at 2350 (11:50pm) revealed "line of sight while awake".

Review of Patient #6's Multidisciplinary Integrated Treatment Plan revealed, in part, "Clinical Interventions- Patient observation every 15 minutes Mental Health Tech". Further review of the treatment plan revealed no documented evidence that the treatment plan was updated when the patient's ordered observation status was changed from every 15 minutes observation to line of sight observation while awake.

In interview on 02/03/11 at 11:55am, S1, Administrator, and S3, Vice President of Operations confirmed that the Multidisciplinary Integrated Treatment Plan should have been updated by the Registered Nurse for any change in the patient's ordered observation status.

Review of the hospital policy titled "TX-Gen-02: Treatment Planning; Integrated/Multidisciplinary, dated: November 2009" revealed, in part, "Procedure: Nurse- Revises and develops nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths and limitations, and physician's orders. Includes all physician orders in the Treatment Plan. Revises plan based on changes in condition and physician's orders received. All physician orders will be added to the Treatment Plan".

25892

Based on record review (personnel files) and interview the hospital failed to ensure nursing staff and other nursing personnel were deemed competent, through documented return demonstrations, for the appropriate techniques for lifting and transferring patients for 3 of 3 personnel files reviewed for lifting and transferring competencies (S10, RN, S12, mental health tech (MHT), S17, MHT).
Findings:

The personnel file for S10, RN, S12, MHT, S17, MHT were reviewed. Review of the files revealed a document titled "Employee Safety Rules" signed by S10 on 04/12/10, S12 on 05/04/10, and S17 on 01/18/11. Further review of the document revealed, in part, "2. All patient lifting and transfer will be done by two employees who have demonstrated the knowledge and ability of lifting techniques to the Director of Nurses or Charge Nurse". Review of the entire personnel file for S10, S12, and S17, revealed no documented evidence of a return demonstration, documenting competence for lifting and transferring techniques.

In interview on 02/03/11 at 2:00pm, S2, Director of Nursing, indicated that all staff were required to demonstrate knowledge and competency for proper techniques for lifting and transferring patients during orientation. S2 further indicated that the hospital did not currently document return demonstrations and competencies for lifting and transferring patients.

Based on record review and interview the hospital failed to ensure medications were administered according to physician's orders and/or accepted standards of practice as evidenced by failing to ensure nursing staff monitored patient's heart rate prior to the administration of Inderal, Metoprolol, or Atenelol as indicated by the Supervising Pharmacist through documentation on the Patients' Medication Administration Record for 3 of 3 patients (#1, #3, #5) prescribed one of the drugs requiring monitoring out of 8 sampled patients. Findings:

Patient #1:
Review of Patient #1's Physician's orders dated 12/23/2010 at 10:30 p.m. revealed an order for Inderal LA 60 milligrams by mouth two times per day. Review of Patient #1's medication Administration Record (MAR) revealed typed documentation regarding administration of "Inderal/Propranolol" indicating " Record Apical Pulse on MAR, Hold if < (less than)/= (equal) 60 and call MD (Medical Doctor). " Review of Patient #1's medical record revealed no documented evidence that Patient #1's apical pulse had been taken prior to the administration of Inderal on 1/08, 1/09, 1/11, 1/12, 1/13, 1/16, 1/18, 1/19, or 1/21/2011. Review of Patient #1's Graphic documentation indicated on the morning of 1/12/2011 (no documented time) patient #1's pulse was 58. Review of Patient #1's Physician's Progress notes dated 1/18/2011 at 11:45 revealed the patient's pulse to be 51.

Review of the hospital's drug reference book titled, "Nursing 2011 Drug Handbook, page 316" revealed in part, "Check blood pressure and apical pulse before giving drug. If hypotension or extremes in pulse rate occur, withhold drug and notify prescriber."

Patient #3:
Review of Patient #3's Physician's orders dated 1/18/2011 at 2145 (9:45 p.m.) revealed an order to continue Atenelol 50 milligrams by mouth every day ("Active Medications at time of Admission" order form). Review of Patient #3's Medication Administration Record (MAR) revealed typed documentation regarding administration of "Tenormin/Atenelol" indicating " Record Apical Pulse on MAR, Hold if < (less than)/= (equal) 60 and call MD (Medical Doctor)". Review of Patient #3's entire medical record revealed no documented evidence that Patient #3's apical pulse had been taken prior to the administration of Atenelol on 1/20/2011 at 9:00 a.m., 1/21/2011 at 9:00 a.m., 1/22/2011 at 9:00 a.m. or 1/23/2011 at 9:00 a.m.

Review of the Ocean Behavioral Hospital of Baton Rouge's Drug Reference Book titled, "Nursing 2009 Drug Handbook" page 359 revealed in part, "(Atenelol) Check apical pulse before giving drug; if slower than 60 beats/minute, withhold drug and call prescriber.

Patient #5:
Review of Patient #5's physician's orders dated 1/15/2011 at 6:45 a.m. revealed an order for Metoprolol 50 milligrams by mouth every day. Review of Patient #5's Medication Administration Record (MAR) revealed typed documentation regarding administration of "Metoprolol/Toprol XL" indicating "Record Apical Pulse on MAR, Hold if < (less than)/= (equal) 60 and call MD (Medical Doctor)". Review of Patient #5's entire medical record revealed no documented evidence that Patient #5's apical pulse had been taken prior to the administration of Metoprolol on 1/16/2011 or 1/17/2011. Patient #5 was transferred to Hospital A on 1/18/2011 at 7:55 a.m. for an apical heart rate of 34. Patient #5 returned to the hospital on 1/18/2011 with physician's orders at 1615 (4:15 p.m.) to discontinue Metoprolol.

Review of the hospital's Drug Reference Book titled, "Nursing 2008 Drug Reference" page 312 regarding the Medication Metoprolol revealed in part, "Nursing considerations: Always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/minute, withhold drug and call prescriber immediately. .. Monitor blood pressure frequently; drug masks common signs and symptoms of shock."

The following employees were interviewed: Registered Nurse (RN) S8 on 2/01/2011 at 9:00 a.m., RN S5 on 2/01/2011 at 12:50 p.m., Licensed Practical Nurse (LPN) S13 on 2/02/2011 at 8:30 a.m., Administrator S1 on 2/04/2011 at 9:40 a.m., and Vice President of Operations S3 on 2/04/2011 at 9:40 a.m. S1, S3, S5, S8, and S13, all confirmed the above findings regarding no documented evidence of taking an apical pulse prior to the administration of Atenelol, Inderal, and Metoprolol. S1, S3, S5, S8, and S13, all indicated nursing staff should have taken an apical pulse prior to the administration of these medications (Atenelol, Inderal, Metoprolol), documented it on the patients' Medication Administration Record, and notified the patients' physician prior to administering the medication if the pulse had been 60 or below.

Based on record review and interview the hospital failed to ensure all medical record entries were accurately written by failing to document patient observation levels as ordered by the physician on observation check sheets as required by hospital policy for 2 of 3 medical records reviewed for accurate observation levels documented (#5, #8).
Findings:

Patient #5
Review of Patient #5's Physician's Orders dated 01/26/11 at 1645 (4:45pm) revealed the following order "1 to 1 observation". Further review revealed a Physician's order dated 01/31/11 at 2350 (11:50pm) to "Discontinue 1:1 observation and change to line of sight while awake".

Review of Patient #5's Observation Check Sheets revealed the following:
Check sheet dated 01/26/11- Observation level checked for every 15 minutes (ordered 1:1);
Check sheet dated 01/27/11- Observation level checked for every 15 minutes (ordered 1:1);
Check sheet dated 01/28/11- Observation level checked for every 15 minutes (ordered 1:1);
Check sheet dated 01/29/11- Observation level checked for every 15 minutes (ordered 1:1);
Check sheet dated 01/30/11- Observation level checked for every 15 minutes (ordered 1:1);
Check sheet dated 01/31/11- Observation level not specified on this form (ordered 1:1, changed to line of sight at 11:50pm);
Check sheet dated 02/01/11- Observation level checked for every 15 minutes (ordered line of sight).

Patient #8
Review of Patient #8's Physician's Orders dated 01/24/11 at 2:30pm revealed the following order, "8)Observation: 1:1". Further review revealed a Physician's order dated 01/29/11 at 0800 (8:00am) to "Discontinue 1:1 observation and begin line of sight observation".

Review of Patient #8's Observation Check Sheets revealed the following:
Check sheet dated 01/26/11- Observation level checked for every 15 minutes (ordered 1:1);
Check sheet dated 01/28/11- Observation level checked for every 15 minutes (ordered 1:1);
Check sheet dated 01/29/11- Observation level checked for every 15 minutes (ordered 1:1, changed to line of sight at 8:00am);
Check sheet dated 01/30/11- Observation level checked for every 15 minutes (ordered line of sight);
Check sheet dated 01/31/11- Observation level checked for every 15 minutes (ordered line of sight);
Check sheet dated 02/01/11- Observation level checked for every 15 minutes (ordered line of sight);
Check sheet dated 02/02/11- Observation level not specified on this form (ordered line of sight).

In interview on 02/03/11 at 2:45pm, S1, Administrator, and S3, Vice President of Operations, confirmed that the patient observation check sheets were not accurately completed. S1 and S3 further confirmed that the inaccurate documentation should have been identified with the nursing 24 hour chart checks.

Review of the hospital policy titled: "TX-SPEC. 05 Suicidal Precautions/Close Observations, Date revised: June 2008" revealed, in part, "Charge Nurse- Oversees close observation sheets, assumes responsibility for close observation and may delegate task to appropriate staff members".

Based on record review and interview the hospital failed to ensure the pharmacist supervised all activities of pharmacy services by failing to notify hospital staff of a possible drug interaction between Haldol (Haloperidol) and Inderal (Propranolol) that could have resulted in Cardiac Arrest for 1 of 1 patients prescribed Haldol and Inderal out of a total sample of 8 (Patient # 1). Findings:

Review of the hospital's Nursing 2011 Drug Handbook, Page 316, revealed in part, "(Propranolol Hydrochloride/Inderal) Drug Interaction: Haloperidol: May cause cardiac arrest. Avoid using together."

Review of the hospital's contracted pharmacy's "Drug/Drug Monograph" regarding the concurrent use of Haloperidol and Propranolol revealed in part, "Concurrent use of Haloperidol and Propranolol may result in an increased risk of hypotension and cardiac arrest. Onset: Rapid. Severity: Major"

Review of the hospital's contracted pharmacy policy titled, "Drug Therapy Monitoring, 10-14.13.0" revealed in part, "Drug therapy monitoring shall be an ongoing, prospective or concurrent quality improvement process to assure effective, appropriate, and safe drug therapy. . . The pharmacy shall inform the prescriber and nurse of any irregularities identified in monitoring drug therapy."

Review of Patient #1's Physician's orders revealed an order dated 12/23/2011 at 10:30 p.m. for Inderal LA 60 milligrams by mouth twice per day. Further review revealed a physician's order dated 1/08/2011 at 1:30 a.m. for Haldol 2.5 milligrams by mouth every 8 hours as needed for anxiety or increased psychosis or Haldol 2.5 milligrams intramuscular every 8 hours as needed for severe anxiety or increased psychosis.

During a telephone interview on 2/01/2011 at 2:15 p.m., Pharmacist S6 and Pharmacist S7 indicated there had been no notification of the nursing or medical staff regarding the possible drug/drug interaction between Haldol and Inderal for Patient #1. S7 indicated it had been an oversight on the part of pharmacy and should never have happened. S7 indicated the hospital should have been notified to determine if the physician wished to proceed with the order.

During a face to face interview on 2/02/2011 at 11:50 a.m., Advanced Practice Nurse S15 confirmed that she had ordered Haldol prn (as needed) for Patient #1 on 1/08/2011 when the patient was receiving Inderal as a routine medication. S15 indicated she had not been aware that concurrent use of the medications could result in cardiac arrest. S15 indicated she had never received a call from pharmacy informing her of the possible drug/drug interaction.