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Based on medical record reviews, policy review and staff interviews, the facility failed to ensure nursing staff administered the correct medication, failed to ensure medications administered were documented according to the facility's policy and failed to ensure medications were administered timely.(A405) The cumulative effect of this systemic practice resulted in the inability to ensure patient safety.

Based on medical record review, policy review and interviews, the facility failed to ensure a nurse administered the right medication to one patient (Patient #10) and failed to ensure nurses documented medications administered to one patient (Patient #10) of 10 medical records reviewed according to the facility's policy. The facility failed to nursing staff administered medications according to the facility's policy time requirements for three patients (Patient #1, #5, and #8) of 10 medical records reviewed. This had the potential to affect all of the facility's active 225 patients.

Findings include:

1. The medical record review for Patient #10 was completed on 10/15/14. Patient #10 was admitted to the facility on 9/21/14 with a diagnosis of Urinary Tract Infection and Left Flank Pain. A physician ordered Patient #10 to receive Zosyn (an antibiotic) intravenously on 9/21/14.

During an interview with Staff H on 10/15/14 at 7:47 AM, Staff H stated he/she administered a bottle of Diprivan labeled by pharmacy with a Zosyn label to Patient #10 on 9/21/14. Staff H reported he/she questioned the appearance of the intravenous medication to co-workers. Staff H stated the co-workers reported the intravenous medication could appear different due to generic brands. Staff H reported he/she did not question a pharmacist regarding the appearance of the medication.

The facility's Medications, Administration/Documentation policy stated drug manufacturer's package insert and the Medical Center pharmacist are available as resources for the administration of medications. Utilizing best safe practices, medication will be removed from the unit dose cart as needed, utilizing the EMAR (Electronic Medication Administration Record) to check "The Five Rights" which include the correct medication.

2. The medical record review for Patient #10 contained a Medication Administration Record that revealed Staff C electronically signed for the administration of Zosyn to Patient #10 on 9/21/14 at 7:46 PM.

Staff C stated in interview on 10/15/14 at 10:14 AM, he/she did not administer Zosyn to Patient #10 on 10/15/14 at 10:14 AM. Staff C reported Staff H administered a Diprivan bottle labeled as Zosyn to Patient #10 on 9/21/14 at 7:46 PM. Staff C reported he/she was learning the process of the Electronic Medication Administration and only observed Staff H administer the medication.

The facility's Medications, Administration/Documentation policy read the barcode attached to the ID (identification) badge of the nurse administering the medication is to be used.

3. On 10/15/14, Patient #1's medical record was reviewed in the presence of Staff F. According to this review, the patient was admitted on 09/25/14 with a diagnosis of altered mental status. On 10/01/14, the patient's physician was notified of the patient's elevated temperature of 101.2 degrees Fahrenheit (F). The physician prescribed an antipyretic (anti-fever) medication for the fever at 7:25 PM on 10/01/14. The order was for Acetaminophen 650 mg/20 ml liquid per tube every 4-5 hours as needed. Per the record review, and interview with Staff F (at 3:00 PM on 10/15/14), this order was entered electronically into the patient's medical record at 7:30 PM on 10/01/14.

On 10/01/14 at 9:10 PM, a medication request form was sent to the pharmacy by a staff nurse on 7 Main for this liquid medication. The form contained a circle around instruction five. Instruction five listed a fax to pharmacy-use STAT fax number only if needed stat. A handwritten note which documented patient has fever was observed near the word Stat on the form. This was confirmed with Staff F on 10/15/14 at 3:00 PM.

Staff F also confirmed even though the medication was received on the floor at 9:30 PM on 10/01/14, it was not administered to Patient #1 until 10:21 PM (forty-one minutes later) for the elevated fever.

According to the medical record, on 10/01/14, Patient 1's body temperature was elevated to 102.1 degrees F. at 7:05 PM. The patient's medical record lacked documentation of the reason for the delay in receiving the antipyretic medication on 10/01/14.

During an interview on 10/14/14 at 3:02 PM, Staff E confirmed the facility considered this a medication error due to a three hour delay in getting the medication after it was ordered by the physician.

On 10/16/14, additional information was received from Staff G (Director of Pharmacy) in regard to dispensing times of medications prescribed by physicians. This documentation stated the facility's turn around time benchmark is defined as two hours for dispensing medications from the pharmacy. This documentation also included a Management Performance Improvement Monitoring and Reporting Mechanism which documented dispensing in a timely manner was two hours for routine medications (not listed as stat medications).

On 10/15/14, a review of facility policy 8,10, titled Medications, Administration/Documentation, approved September 2014, listed the following: In the event that a medication cannot be given within the scheduled medication time, the nurse must document the reason in the chart.

4. On 10/15/14, a medical record review of Patient #8 was conducted with Staff F. Patient #8 was admitted to the facility on 10/14/14 with a diagnosis of gastrointestinal bleeding. Nurse Practitioner's orders for an antibacterial medication (Flagyl) to be administered intravenously every six hours were received on 10/15/14 at 9:09 AM.

Documentation in the medication record, confirmed with Staff F, during the record review, revealed the medication administration times listed were 5:00 AM, 11:00 AM, 5:00 PM, and 11:00 PM.

The first dose of the medication was not administered by nursing staff until 1:05 PM on 10/15/14. Staff F confirmed the delay in administering the medication by staff, stating the medication should have been given at 11:00 AM on 10/15/14.


5. On 10/15/14 at 9:58 AM, a medical record review of Patient #5 was conducted with Staff F. Patient #5 was admitted on 10/07/14 with diagnoses of a right ankle fracture with infection, cellulitis, and abscess. On 10/08/14 at 6:00 PM, a physician order for intravenous antibiotic (Vancomycin) every twelve hours was reviewed. The medical record listed the administration times as 7:00 AM and 7:00 PM. According to the medical record review, the medication was not administered until 11:23 PM on 10/08/14. The medical record lacked evidence of the delay in administration of this medication. Staff F confirmed the medication was not given in a timely manner, and also confirmed the medical record lacked evidence of the reason for the delay.








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Based on review of facility documentation for medication dispensing times , medical record reviews, and staff interview, the facility failed to follow their set pharmacy benchmarks to dispense medications in a timely manner (within two hours) for two of ten patients reviewed. (Patient #8 and Patient #10). The total census during the survey was 225 patients.

Findings include:

1. On 10/15/14, a medical record review of Patient #8 was conducted with Staff F. Patient #8 was admitted to the facility on 10/14/14 with a diagnosis of gastrointestinal bleeding. Physician's orders for an antibacterial medication (Zosyn) were received on 10/14/14 at 6:17 PM for the medication to be administered intravenously every eight hours. According to documentation in the medication record, confirmed with Staff F during the record review, the medication was ordered by the physician on 10/14/14 at 6:13 PM, edited and dispensed by the pharmacy on 10/14/14 at 8:23 PM with administration times listed at 3:00 AM, 11:00 AM, and 7:00 PM. The medication was not administered by nursing staff at 9:36 PM on 10/14/14. Staff F confirmed the delay in dispensing of the medication by pharmacy.



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2. The medical record for Patient #10 contained an order for 3.372 milligrams of Zosyn (an antibiotic) in 50 milliliters of 0.9% Sodium Chloride to be administered at a rate of 12.5 milliliters per hour every eight hours on 9/21/14 at 3:47 PM. Review of the electronic medication administration record revealed Staff C administered Zosyn at 7:46 PM on 9/21/14.



On 10/16/14, additional information was received from Staff G (Director of Pharmacy) in regard to dispensing times of medications prescribed by physicians. This documentation stated the facility's turn around time benchmark is defined as two hours for dispensing medications from the pharmacy. This documentation also included a Management Performance Improvement Monitoring and Reporting Mechanism which documented dispensing in a timely manner was two hours for routine medications.