HospitalInspections.org

Based on medical record review, staff interviews, and review of policy and procedures, the facility failed to ensure medications administered for 5 of 23 sample patients (#1, #6, #8, #15, #22), were administered according to the physicians' orders and in accordance with facility policies for medication administration. The findings were:

1. Review of the medical record for patient #15 showed the patient received treatment in the emergency department (ED) on 7/1/11 for a fever and low white blood cell count. This review also showed the ED physician's orders, timed 10:18 PM, included an order for one gram of vancomycin to be given intravenously (IV) every twelve hours and one gram of meropenem to be given IV every eight hours (both medications are antibiotics).

Review of the documentation of the care the patient received in the ED and review of the medication administration record showed the vancomycin and meropenem were not administered prior to transferring the patient at 10:51 PM from the ED to the inpatient medical surgical unit. Review of the medication administration record completed by the nurses on the medical surgical unit showed meropenem was not administered until 9:10 AM on 7/2/11 (over eleven hours after it was ordered) and vancomycin was administered on 7/2/11 at 10:32 AM (over twelve hours after it was ordered).

Interview with the risk manager on 9/13/11 at 4:15 PM revealed the following information: The medication error for patient #15 was brought to the facility's attention by the patient's family member, and unless a staff person would have completed an occurrence report, the error would not have been otherwise noted. The risk manager's root cause analysis revealed patient #15 did not receive the medication as ordered and an action plan was developed to address this problem and prevent future reoccurrence's. However, the action plan had only been partially successful because similar incidents continued to occur.

2. Review of the medical record for patient #1, who was an inpatient on the medical surgical unit, revealed a 3/25/11 physician's order for ativan one mg IV every six hours when needed. Review of the medication administration record showed one mg of Ativan was given at 5:49 AM on 3/26/11. Review of the physician order form revealed the physician wrote a "now" order for an IV injection of two milligrams (mg) of Ativan on 3/26/11 at 10 AM, and the word "done" (the writer was not identified) had been written beside the physician's written order. Review of the medication administration record showed one mg of ativan was administered at 11:45 AM for nausea, vomiting and violent tremors. Review of the medical record did not revealed why the medication was not administered according to the "now" order, nor was there information regarding attempts to clarify the order.

During an interview on 9/8/11 at 10:10 AM, the chief of clinical operations stated her expectations of the response to a "now" order for patient #1 would have been a more immediate response than one hour and forty-five minutes later. She further stated "stat" and "now" orders had not been defined in the policy and procedures, but it needed to be.

3. Review of the medical record for patient #8 showed s/he was transported to the ED on 6/25/11 due to a collapsed lung and chest wound. Further review showed the ED physician ordered IV doses of five mg of morphine (pain medication) and two hundred mg of propofol (sedation medication) at 11:40 AM. Review of the medication administration record showed one hundred mg of propofol was administered; furthermore, there was no documentation to show the patient received the morphine. The explanation for the discrepancies was not found during the medical record review.

4. Review of the ED medical record for patient #6 showed the physician ordered Lortab 7.5/325 mg and Vicodin 5/325 mg (pain medications) on 7/3/11 at 11:22 PM for pain due to a fractured foot. The physician's order form further showed the patient was to be given four Vicodin pills to take home with him/her. Review of the medical record showed no documentation of the medication being administered or nor was a pain assessment completed by the nursing staff.

During the interview on 9/8/11 at 10:20 AM, the ED nurse manager stated she did not know whether patients #6 and #8 failed to receive the ordered medications or if it was a documentation error.

5. Review of the physician's order form for patient #22, an inpatient on the medical surgical unit, showed nitro cr 2.5 mg (medication used for regulating the supply of oxygen and blood to the heart) was ordered on 9/3/11 to be given daily. According to the medication administration record, the patient received the first dose at 8:25 PM the day it was ordered. Further review revealed the medication was not documented as being administered at any time on 9/4/11, but it was administered on 9/5/11 at 10:42 AM (thirty-two hours after the last dose). The corresponding documentation in the nurse's notes showed the medication was administered late on 9/5/11 because the nurse thought it had been given during the previous evening. The review failed to show an explanation for the missed dose on 9/4/11.

Interview with the risk manager on 9/14/11 at 2:25 PM revealed staff were not aware of the above medication error involving patient #22.

6. Review of the policy and procedures for medication administration/EMAR, revised 6/2011, showed the following policy requirements were included:
a. ..." Medication administration the ED will be as follows: when a medication order is received from an independent licensed practitioner, all administered medications will be documented on the appropriate medication from, including dose, route, time and site (if applicable). This form will be scanned into the electronic health record with all other emergency room records."
b. ..." Document the effectiveness of as needed medication on the RX note of the EMAR. For IV medications, this documentation must be done within 30 minutes of administration. For IM or PO medications, documentation must be done within 1 hour."
c. ..." If a medication is not administered and/or administered late, a reason is documented on the EMAR. Notify the physician of any medication not given and reason as appropriate."
d. ..."Medications should be given as soon as possible after admission and/or receiving the order."

Based on medical record review, staff interviews, and review of policy and procedures, the pharmacy services failed to develop and implement an effective system for ensuring medication orders were accurate and that medications were administered as ordered for 5 of 23 sample patients (#1, #6, #8, #15, #22). The findings were:

Interview with the pharmacy director on 9/8/11 at 10:10 AM revealed the following information: The ED medication administration system was not automated, therefore, pharmacy services did not have a system for determining whether problems with administering medication in the ED according to the pyhsician's order was lack of documentation or staff failed to administer the medications. For the inpatient units, the pharmacy staff reconciled the number of medications in the patient drawers of the electronic medication dispensing machine. This was effective for instances when the discrepancy showed less or more than the prescribed amount had been removed from the drawer, but failed to identify other types of errors and irregularities. A system for verifying medication administration through periodic audits and surveillance had not been implemented. The following concerns were identified:

1. Review of the medical record for patient #15 showed the patient received treatment in the emergency department (ED) on 7/1/11 for a fever and low white blood cell count. This review also showed the ED physician's orders, timed 10:18 PM, included an order for one gram of vancomycin to be given intravenously (IV) every twelve hours and one gram of meropenem to be given IV every eight hours (both medications are antibiotics).

Review of the documentation of the care the patient received in the ED and review of the medication administration record showed the vancomycin and meropenem were not administered prior to transferring the patient at 10:51 PM from the ED to the inpatient medical surgical unit. Review of the medication administration record completed by the nurses on the medical surgical unit showed meropenem was not administered until 9:10 AM on 7/2/11 (over eleven hours after it was ordered) and vancomycin was administered on 7/2/11 at 10:32 AM (over twelve hours after it was ordered).

Interview with the risk manager on 9/13/11 at 4:15 PM revealed the following information: The medication error for patient #15 was brought to the facility's attention by the patient's family member, and unless a staff person would have completed an occurrence report, the error would not have been otherwise noted. The risk manager's root cause analysis revealed patient #15 did not receive the medication as ordered and an action plan was developed to address this problem and prevent future reoccurrence's. However, the action plan had only been partially successful because similar incidents continued to occur.

2. Review of the medical record for patient #1, who was an inpatient on the medical surgical unit, revealed a 3/25/11 physician's order for ativan one mg IV every six hours when needed. Review of the medication administration record showed one mg of Ativan was given at 5:49 AM on 3/26/11. Review of the physician order form revealed the physician wrote a "now" order for an IV injection of two milligrams (mg) of Ativan on 3/26/11 at 10 AM, and the word "done" (the writer was not identified) had been written beside the physician's written order. Review of the medication administration record showed one mg of ativan was administered at 11:45 AM for nausea, vomiting and violent tremors. Review of the medical record did not revealed why the medication was not administered according to the "now" order, nor was there information regarding attempts to clarify the order.

During an interview on 9/8/11 at 10:10 AM, the chief of clinical operations stated her expectations of the response to a "now" order for patient #1 would have been a more immediate response than one hour and forty-five minutes later. She further stated "stat" and "now" orders had not been defined in the policy and procedures, but it needed to be.

3. Review of the medical record for patient #8 showed s/he was transported to the ED on 6/25/11 due to a collapsed lung and chest wound. Further review showed the ED physician ordered IV doses of five mg of morphine (pain medication) and two hundred mg of propofol (sedation medication) at 11:40 AM. Review of the medication administration record showed one hundred mg of propofol was administered; furthermore, there was no documentation to show the patient received the morphine. The explanation for the discrepancies was not found during the medical record review.

4. Review of the ED medical record for patient #6 showed the physician ordered Lortab 7.5/325 mg and Vicodin 5/325 mg (pain medications) on 7/3/11 at 11:22 PM for pain due to a fractured foot. The physician's order form further showed the patient was to be given four Vicodin pills to take home with him/her. Review of the medical record showed no documentation of the medication being administered or nor was a pain assessment completed by the nursing staff.

During the interview on 9/8/11 at 10:20 AM, the ED nurse manager stated she did not know whether patients #6 and #8 failed to receive the ordered medications or if it was a documentation error.

5. Review of the physician's order form for patient #22, an inpatient on the medical surgical unit, showed nitro cr 2.5 mg (medication used for regulating the supply of oxygen and blood to the heart) was ordered on 9/3/11 to be given daily. According to the medication administration record, the patient received the first dose at 8:25 PM the day it was ordered. Further review revealed the medication was not documented as being administered at any time on 9/4/11, but it was administered on 9/5/11 at 10:42 AM (thirty-two hours after the last dose). The corresponding documentation in the nurses notes showed the medication was administered late on 9/5/11 because the nurse thought it had been given during the previous evening. The review failed to show an explanation for the missed dose on 9/4/11.

Interview with the risk manager on 9/14/11 at 2:25 PM revealed staff were not aware of the above medication error involving patient #22.