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Based on interviews and clinical record review, it was determined the facility failed to ensure (1) nursing followed prescribed physician orders; (2) nursing administered intravenous pain medications accurately according to accepted standards of nursing practice and hospital policy; and (3) nursing supervised, assessed and evaluated the nursing care and care plan for patient #3.

Professional Standard of Care is defined in Chapter 766.102 as, "The prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers."


The findings include:

During record review on 12/13/10 for a Patient #3 receiving intravenous (IV) PCA (Patient Controlled Analgesia) pain medications in the Spine Unit, it was revealed this patient had the following diagnoses including but not limited to: past history of emphysema, coronary artery disease with s/p CABG (Coronary Artery By-Pass Graft) with stents, high blood pressure, chronic back pain with use of oral narcotic analgesics and questionable obstructive sleep apnea. Home medications for chronic back pain included: Percocet 2 tabs every 4-6 hours and Vicodin every 6 hours for breakthrough pain. Weight: 194 lbs. The patient was admitted to the facility on 10/14/10.

1. Timeline of documented events for Patient #3:
A. At 8:26 a.m., patient went directly to the operating room from outpatient department.
B. At 1:45 p.m., patient arrived post-op to spine unit alert and oriented with incision pain of "10" on a scale of "0-10" PCA (patient controlled analgesia) of Dilaudid started at 0.1 mg every 6 minutes for a total of 1 mg Dilaudid every hour. A 0.2 mg bolus was given at that time. Lortab 5/500 (Norco used in place of Lortab at hospital) 2 tabs every 4 hrs prn (as needed) as additional pain medications for breakthrough pain
C. At 2:51 p.m., patient had some apneic respirations with physician in to see patient. The patient is drowsy but awakened with name called. No orders given.
D. At 6:45 p.m., patient remains very drowsy. Heart rate 119 and O2 sat 94% at 3L/NC. Patient using incentive spirometer up to 1500. Dr. notified of patient's heart rate and drowsiness with orders to give 250 ml normal saline bolus and hold oral pain meds except PCA until more awake.
E. From 9:00 p.m. (10/13/10) to 5:00 a.m. (10/14/10) patient continued to complain of incision pain. At 10:00 p.m., breakthrough pain meds were given. At 11:45 p.m., 1 mg Dilaudid was given as bolus without benefit of a physician's order. At 12:56 a.m., documentation in the Medication Discharge Summary record reported the nurse gave Percocet 1 tablet by mouth without a prescribed physician's order (order written on 10/14/10 at 11:10 a.m.). At 2:00 a.m., another pain pills (drug not documented) were given. At 4:30 a.m., pain pills (Norco 2 tabs) repeated with patient reported to be anxious/restless. At 4:45 a.m., lorazepam (Ativan) 1 tab given (Lorazepam 0.5 mg po [by mouth] q4hr prn). Vitals stable. Encouraged more PCA use.
F. On 10/14 at 9:10 a.m., physician ordered a basal rate of 0.1 mg to be added to PCA pump.
G. On 10/14 at 9:35 a.m., the nurse gave Norco 2 tabs po for pain "10" pain scale "0-10" with incision pain listed as "Severe" and "Throbbing" and increased with movement. Level of sedation listed as "Awake and alert."
H. On 10/14 at 11:10 a.m., physician discontinued Norco and ordered Percocet 5/325 mg po q4 hrs prn pain. At the same time nursing increased the PCA from 0.1 mg every 6 minutes to 0.2 mg every 6 minutes for an increased total of 2 mg every hour. (Twice the Dilaudid amount not including basal rate) as per protocol without notifying the physician.
I. On 10/14 at 12:34 a.m., the nurse gave Percocet (5/325 mg) 1 tab po for pain "8" pain scale "0-10" with incision pain "moderately severe" and "Aching" and increased with movement. Level of sedation listed as "Awake and alert."
J. On 10/14 at 12:45 p.m., consulting pain mgmt. physician discontinued the Percocet and ordered oxycodone 15 mg (Roxicodone used at hospital) po q4 hrs prn "Moderate" pain and oxycodone 30 mg po q4 hrs prn for "Severe" pain.
K. On 10/14 at 5:24 p.m., the nurse gave oxycodone 30 mg. (maximum dose ordered) for complaints of pain "9" on pain scale "0-10" with incision pain "Severe" and aching and increased with movement. Level of sedation listed as "Awake and alert."
L. On 10/14 at 8:17 p.m., received patient in bed sleeping. Respiration normal. Patient is not easily aroused with calling and shaking. Patient opened eyes slightly. Pain mgmt. physician arrived and was unable to arouse patient. PCA Dilaudid discontinued per order.
M. On 10/14 at 8:56 p.m., patient still unable to wake up. O2 sat 88% on 3L/NC. Reported to charge nurse. Narcan (opiate antagonist) 0.4 mg IV now was administered per physician order. Patient is awake but still very lethargic. Respirations remain at 18 and patient has periods of apnea while sleeping at 25-30 sec (normal 16-20). Non-rebreathing mask is in place and patient sat 97% at this time. Charge nurse notified pain mgmt. physician.
N. On 10/14 at 9:30 p.m., the nurse documented condition improved, awake and alert, but disoriented and vital signs remain WNL (Within Normal Limits).
O. On 10/14 at 11:12 p.m., the nurse documented patient is easier to arouse but remains very lethargic. Patient on "BIPAP" machine but O2 sat remains very unstable. Periods of apnea are now between 30-45 seconds. Blood gases were ordered with the following results posted at 11:18 p.m.: CO2 level 61 (high) with normal values 35-45 mmHg, pH level 7.26 (acidotic) with normal values 7.35-7.45, HCO3 (sodium bicarb) level 26.7 (high) normal values 22-26 mEq/L and PO2 adequate at 127 with normal values >80 mmHg.
P. On 10/14 at 11:44 p.m., physician ordered patient transferred to ICU.
Q. On 10/15, in ICU the patient had a run of ventricular tachycardia (potential lethal arrhythmia) with Cardiology consult ordered. Cardiac enzymes negative x 2. Echocardiogram results: "Technically adequate."

Throughout the above timeline, nursing failed to follow physicians orders and administered medications without physicians orders.

During various administrative interviews (CNO, Pharmacy, QA Director, Director Spine Unit) throughout the survey process (12/13/10 to 12/14/10), it was confirmed nursing failed to ensure prescribed physician orders were followed including nursing failure to administer intravenous medications according to hospital policy; and nursing failure to supervise, update, assess and evaluate the nursing care and care plan for this patient with regard to narcotic administration.

Based on record reviews and interviews, the facility failed to ensure the nurses administered medications as physician prescribed and with accepted standards of practice.

Professional Standard of Care is defined in Chapter 766.102 as, "The prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers."

The findings include:

During record review on 12/13/10 for a Patient #3 receiving intravenous (IV) PCA (Patient Controlled Analgesia) pain medications in the Spine Unit, it was revealed this patient had the following diagnoses including but not limited to: past history of emphysema, coronary artery disease with s/p CABG (Coronary Artery By-Pass Graft) with stents, high blood pressure, chronic back pain with use of oral narcotic analgesics and questionable obstructive sleep apnea. Home medications for chronic back pain included: Percocet 2 tabs every 4-6 hours and Vicodin every 6 hours for breakthrough pain. Weight: 194 lbs. The patient was admitted to the facility on 10/14/10.

At 11:45 p.m. on 10/13/10, 1 mg Dilaudid was given as bolus without benefit of a physician's order.
At 12:56 a.m. on 10/13/10, documentation in the Medication Discharge Summary record reported the nurse gave Percocet 1 tablet by mouth without a prescribed physician's order (order written on 10/14/10 at 11:10 a.m.)

During various administrative interviews (CNO, Pharmacy, QA Director, Director Spine Unit) throughout the survey process (12/13/10 to 12/14/10), it was confirmed nursing failure to ensure prescribed physician orders were followed for this patient with regard to narcotic administration.