HospitalInspections.org

Based on medical record review, facility policy review, review of the Medication Error Listing, review of the facility incident logs, and staff interview, the facility failed to ensure nursing staff administered medications as ordered to the correct patient (A0405) and the facility failed to follow their policy to ensure medication errors were investigated and evaluated for the cause to prevent further errors. This affected Patient #10 and one unidentified patient and had the potential to affect all patients admitted to the hospital. (A0411). The cumulative effects of these systemic practices resulted in the agency's inability to ensure patient care needs would be met.

Based on medical record review, facility policy review, review of the Medication Error Listing, and staff interview, the facility failed to ensure nursing staff administered medications as ordered to the correct patient. This affected Patient #10 and one unidentified patient and had the potential to affect all patients admitted to the hospital.

Findings include:

1.Review of the Medication Error Listing provided by the pharmacy revealed on 05/16/24 a patient was administered medications ordered for another patient. The physician was contacted and the patient was monitored every two hours.

Interview with Registered Nurse Staff D via phone on 07/03/24 at 11:54 AM revealed a few months ago she had mistakenly administered medication belonging to Patient #1 to Patient #10. She stated Patient #10 wasn't wearing a band and there were no pictures on the screen of the patient. Patient #10 answered when she called the name of Patient #1. Staff D stated she administered the medication to Patient #10. She later went in the room of Patient #1 to administer the medication and knew immediately she had made an error. She called the attending physician for Patient #10. The physician ordered staff to monitor the patient, including vital signs. Staff D stated she wrote a progress note in Patient #10's record every time she monitored the patient. Staff D also stated she completed an incident report and gave it to the Director of Nursing (DON) as required by facility policy. Staff D denied any corrective action or communication from management occurred related to this event.

Review of the medical record of Patient #10 revealed an admission to the facility on 05/14/24 at 5:57 PM and a discharge on home at 12:30 PM on 05/17/24.

Review of the medication administration record (MAR) revealed Patient #10 was medicated with the antipsychotic Risperdal 0.5 milligrams (mg) on 05/16/24 at 8:28 PM.

Review of the progress note on 05/16/24 at 8:56 PM stated the patient was alert and oriented, lying in bed. She stated she felt fine. She drank a cup of water then laid down in bed. Staff will continue to monitor. The patient's vital signs were within normal limits.

Review of a progress note on 05/16/24 at 10:00 PM stated Patient #10 remained alert and oriented with no acute distress. The patient's gait was noted to be steady when she got up to go to the bathroom. The vital signs were within normal limits.

Review of a progress note on 05/17/24 at 2:00 AM revealed Patient #10 was sleeping in bed but was easily aroused. The patient remained alert and oriented. Her vitals signs remained stable. At 4:00 AM the progress note revealed the patient continued to rest in bed, was easily aroused, and denied any ill feelings.

Review of medication administration record (MAR) of Patient #1 revealed on 05/16/24 between 8:07 PM and 8:09 PM , medications to be administered included Cogentin (medication used to treat involuntary muscle movements caused by certain psychiatric drugs including antipsychotics) 1 milligram (mg), Atarax (medication used to help control anxiety and tension caused by nervous and emotional conditions) 25 mg, and propranolol (for treat high blood pressure) 40 mg.

Review of the medical record of Patient #1 and Patient #10 revealed neither patient had a picture for identification.

Interview with the Administrator, Staff A, on 07/03/24 at 12:45 PM revealed she was unaware of this medication error. She stated the former DON was terminated in June due to realizing there were too many instances without follow through. Staff A also confirmed that she discovered the the scanner for medication administration was malfunctioning shortly after the DON was terminated. She stated the problem with the scanner was a server issue and should be repaired soon. Staff A stated nurses should be asking patients to state their name and looking at the picture of the patient taken on admission and scanned into the medical record. Staff A verified neither Patient #10 or Patient #1 had a picture scanned into the medical record to use for patient identification. Staff A stated the nurses should not state the name of the patient but have the patient state their name and date of birth as patients could have the identical name or a name that sounds like another patient.

Review of the facility policy titled "Medication Administration," (Policy Number: MM.52), effective 01/2023, revealed staff nurses (licensed practical and registered) are instructed on the procedure to safely administer medication. The medication administration procedure instructed nurses to positively identify the patient before administering the medication. Scan the patient's wristband barcode. In the case the patient refused to wear the wrist band check the patients identification with two hospital approved identifiers and when possible ask the patient to state his/her name. Nurses are instructed to report medication administration errors, adverse drug events, and incompatibilities to the attending physician immediately.

Review of the policy titled "Incident Reporting and Investigation," (Policy Number: RM.06), effective 01/2023, revealed the purpose of the incident report was to collect information and document facts concerning the incident, provide a means of evaluating why the incident occurred to avoid similar, future occurrences, and to assist in an investigation to provide adequate information should there be any legal action relative to the incident. The incident report is to be completed as soon as possible after an adverse event and turned into the department director/supervisor before the end of the shift in which the incident occurred. This can include but not limited to a medication error.

2. Review of Medication Error Listing, provided by Staff A on 07/03/24 at 1:55 PM, revealed an entry dated 04/01/24 which identified an unknown patient received Haldol (antipsychotic) 150 mg intramuscular (IM) instead of the ordered 50 mg.

Based on medical record review, facility policy review, review of the Medication Error Listing, review of the facility incident logs, and staff interview, the facility failed to follow their policy to ensure medication errors were investigated and evaluated for the cause to prevent further errors. This affected Patient #10 and one unidentified patient and had the potential to affect all patients admitted to the hospital.

Findings include:

1.Review of the Medication Error Listing provided by the pharmacy revealed on 05/16/24 a patient was administered medications ordered for another patient. The physician was contacted and the patient was monitored every two hours.

Interview with Registered Nurse Staff D via phone on 07/03/24 at 11:54 AM revealed a few months ago she had mistakenly administered medication belonging to Patient #1 to Patient #10. She stated Patient #10 wasn't wearing a band and there were no pictures on the screen of the patient. Patient #10 answered when she called the name of Patient #1. Staff D stated she administered the medication to Patient #10. She later went in the room of Patient #1 to administer the medication and knew immediately she had made an error. She called the attending physician for Patient #10. The physician ordered staff to monitor the patient, including vital signs. Staff D stated she wrote a progress note in Patient #10's record every time she monitored the patient. Staff D also stated she completed an incident report and gave it to the Director of Nursing (DON) as required by facility policy. Staff D denied any corrective action or communication from management occurred related to this event.

Review of the medical record of Patient #10 revealed an admission to the facility on 05/14/24 at 5:57 PM and a discharge on home at 12:30 PM on 05/17/24.

Review of the medication administration record (MAR) revealed Patient #10 was medicated with the antipsychotic Risperdal 0.5 milligrams (mg) on 05/16/24 at 8:28 PM.

Review of the progress note on 05/16/24 at 8:56 PM stated the patient was alert and oriented, lying in bed. She stated she felt fine. She drank a cup of water then laid down in bed. Staff will continue to monitor. The patient's vital signs were within normal limits.

Review of a progress note on 05/16/24 at 10:00 PM stated Patient #10 remained alert and oriented with no acute distress. The patient's gait was noted to be steady when she got up to go to the bathroom. The vital signs were within normal limits.

Review of a progress note on 05/17/24 at 2:00 AM revealed Patient #10 was sleeping in bed but was easily aroused. The patient remained alert and oriented. Her vitals signs remained stable. At 4:00 AM the progress note revealed the patient continued to rest in bed, was easily aroused, and denied any ill feelings.

Review of medication administration record (MAR) of Patient #1 revealed on 05/16/24 between 8:07 PM and 8:09 PM , medications to be administered included Cogentin (medication used to treat involuntary muscle movements caused by certain psychiatric drugs including antipsychotics) 1 milligram (mg), Atarax (medication used to help control anxiety and tension caused by nervous and emotional conditions) 25 mg, and propranolol (for treat high blood pressure) 40 mg.

Review of the medical record of Patient #1 and Patient #10 revealed neither patient had a picture for identification.

Interview with the Administrator, Staff A, on 07/03/24 at 12:45 PM revealed she was unaware of this medication error. She stated the former DON was terminated in June due to realizing there were too many instances without follow through. Staff A also confirmed that she discovered the the scanner for medication administration was malfunctioning shortly after the DON was terminated. She stated the problem with the scanner was a server issue and should be repaired soon. Staff A stated nurses should be asking patients to state their name and looking at the picture of the patient taken on admission and scanned into the medical record. Staff A verified neither Patient #10 or Patient #1 had a picture scanned into the medical record to use for patient identification. Staff A stated the nurses should not state the name of the patient but have the patient state their name and date of birth as patients could have the identical name or a name that sounds like another patient.

Review of the facility policy titled "Medication Administration," (Policy Number: MM.52), effective 01/2023, revealed staff nurses (licensed practical and registered) are instructed on the procedure to safely administer medication. The medication administration procedure instructed nurses to positively identify the patient before administering the medication. Scan the patient's wristband barcode. In the case the patient refused to wear the wrist band check the patients identification with two hospital approved identifiers and when possible ask the patient to state his/her name. Nurses are instructed to report medication administration errors, adverse drug events, and incompatibilities to the attending physician immediately.

Review of the policy titled "Incident Reporting and Investigation," (Policy Number: RM.06), effective 01/2023, revealed the purpose of the incident report was to collect information and document facts concerning the incident, provide a means of evaluating why the incident occurred to avoid similar, future occurrences, and to assist in an investigation to provide adequate information should there be any legal action relative to the incident. The incident report is to be completed as soon as possible after an adverse event and turned into the department director/supervisor before the end of the shift in which the incident occurred. This can include but not limited to a medication error.

Review of the facility Incident Log from 05/01/24 through 07/02/24 revealed no medication errors or incidents involving Patient #1 or Patient #10 identified on the log.

Interview with Staff A on 07/03/24 at 1:55 PM revealed she was not aware of the incident or it would have been listed on the incident log and would have been investigated. Staff A confirmed that the medication error should have been investigated.

2. Review of Medication Error Listing, provided by Staff A on 07/03/24 at 1:55 PM, revealed an entry dated 04/01/24 which identified an unknown patient received Haldol (antipsychotic) 150 mg intramuscular (IM) instead of the ordered 50 mg.

The facility did not provide any evidence of this being investigated.