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Based on interview, record review, and facility policy review it was determined the facility failed to ensure one (#1) patient in the selected sample of eleven (11) patients received care in a safe setting. Patient #1 presented to the Emergency Department (ED) on 01/22/13 and was diagnosed with Pneumonia. The ED physician admitted the patient and ordered an antibiotic (Rocephin) which was initiated in the ED. Patient #1 had allergies listed on his/her medical record to include Penicillin, Amoxicillin, Rocephin, Keflex, Aspirin, Theophylline, Acetaminophen, Codeine, Trimox and Etodolac. Registered Nurse (RN) #1 retrieved the Rocephin from the pharmacy (Accu Dose) and mixed the medication accordingly. RN #1 initiated the intravenous infusion of Rocephin at 6:46 AM and Patient #1 was awake and alert on the stretcher. RN #1 was getting ready to transport the patient to his/her room on the floor when the patient fell back on the stretcher, ceased to have a pulse, and was unresponsive. RN #1 failed to ensure Patient #1's safety when she observed the order for Rocephin which was listed on the patient's allergies and administered it without question. These failures placed patients at risk for serious injury, harm, impairment or death. Immediate Jeopardy was determined to exist related to Patient Rights.

Refer to A-144

Refer to A-144.

Based on interview, record review and facility policy review, it was determined the facility failed to ensure care was given in a safe environment. The facility failed to ensure one patient (#1) in the selected sample of eleven (11) patients received care in a safe setting. Patient #1, was admitted with a diagnosis of Pneumonia on 01/22/13. While in the Emergency Department (ED), the physician ordered the resident an antibiotic (Rocephin). Patient #1 had allergies listed on his/her medical record to include Penicillin, Amoxicillin, Rocephin, Theophylline, Aspirin, Codeine, Acetaminophen, Trimox, Keflex and Etodolac. Registered Nurse (RN) #1 retrieved the medication from the pharmacy (Accu Dose) and mixed the medication accordingly. RN #1 administered the Rocephin to Patient #1 via intravenous (IV) infusion at 6:46 AM even though it was listed as an allergy for this patient. At 7:00 AM, Patient #1 was unresponsive and without a pulse. Cardiopulmonary Resuscitation (CPR) was started and Patient #1 did not respond to actions taken by the staff. The CPR was ceased at 7:25 AM and the Patient #1 expired.

The findings include:

A review of the policy entitled, "Medication Administration," dated March 1981 and revised in November 2011, revealed the facility should administer medications to patients and residents of the hospital as ordered by the attending physician. All medications should be administered in accordance with the "Five Rights of Medication Administration": right patient, right medicine, right dosage, right time, and right route. Identify the patient by asking the patient his name and checking his identification bracelet for Name/Birthday and compare with eMAR. Always check "Five Right of Medication Administration" Right patient, Right medication, Right dosage, Right time and Right route. Verifies that there is no contraindications for administering a new medication.

A review of the policy entitled "Allergies Documentation" dated January 1986 and revised May 2009, revealed the facility should document all allergies and sensitivities in the Medical Record and on the appropriated patient care forms as stated by the patient to assure each member of the health care team has access to this information. Patient allergies/sensitivities and description of reaction shall be documented on the following portions of the medical record: The admitting physician's order form, the front of the patient chart with a Drug Sensitivity Label, the Medication Administration Record (MAR), entered in Meditech electronic record in admission assessment or on bulletin board, the face sheet, on the history and physical, and the front of each patient's chart for Home Health and Ambulatory Outpatient Clinic/Services. The admitting RN is responsible for proper documentation of patient allergies/sensitivities upon admission.

Review of the clinical record for Patient #1 revealed he/she came to the ED on 01/22/13 at 2:24 AM, via ambulance with the complaint of chest pain. Review of the diagnostic tests revealed an infiltration and consolidation in the right upper lobe and the laboratory tests revealed an elevated white blood cell count. The ED physician diagnosed the patient with Pneumonia. The physician report completed by the ED physician revealed he ordered the patient an antibiotic (Rocephin) and the nurses notes revealed RN #1 initiated the medication at 6:46 AM while he/she was in the ED. At 7:00 AM, Patient #1 was unresponsive and without a pulse. CPR was initiated and the patient did not respond to actions taken by the staff. CPR was halted at 7:25 AM and Patient #1 expired.

An interview with Patient #1's spouse, on 1/31/13 at 10:00 AM, revealed he/she was in the room with Patient #1 when the physician came in to talk with the patient. The physician never asked Patient #1 if he/she had any allergies and he did not explain what medicine he was going to give him/her after diagnosing the Pneumonia.

An interview with RN #1, on 01/31/13 at 5:21 PM and 02/04/13 at 10:10 AM, revealed she was the nurse caring for Patient #1 on 1/22/13 when he/she became unresponsive. Patient #1 was already in a room, awake and alert when she arrived on duty. She received report from the previous RN and she explained the patient was going to be admitted to the hospital, had an IV, and an antibiotic was ordered but had not been initiated. RN #1 did not question the physician about the order for the Rocephin because the physician had already discussed the medication with the patient. She did not question the patient about allergies prior to starting the medication. She revealed it was the nurse who registered the patient responsibility for asking about allergies and reactions to medications listed as allergies. RN #1 was unaware of the patient's response to the medication if given but she was aware the adverse reactions were listed in the computer. RN #1 verbalized she did not review the patient's allergies after she received the order for the Rocephin and did not clarify the physician's order for the Rocephin before she administered the medication. She stated she was trained to always ask the patient if they have allergies and to double check the allergies when the medications are removed from the Accu Dose. RN #1 stated she did not ask the patient his/her allergies before starting the medication.

An interview with the Director for the ED, on 02/01/13 at 11:57 AM, revealed he did not investigate this incident. He stated the team of the Chief Nursing Office, Compliance Officer and him reviewed the incident to ensure the Accu Dose flagged the Rocephin as an allergy. He talked to RN #1 who informed him she clarified the order with the physician before she administered the medication. The Director of the ED stated he reviewed the chart and identified RN #1 did not document in the record she clarified the order with the physician.

An interview with the Chief Nursing Officer, on 02/01/13 at 9:07 AM, revealed she expected the nursing staff to make it known to the physician if the medication prescribed was identified as an allergy. She stated in this case, the physician knew the allergy and made the decision to administer the medication. She revealed staff are expected to type in the list of allergies but not the response. All staff are trained to ask patient's their allergies and to verify with the physician orders. Nurses are expected to explain the medication prior to the administration and they should be communicating what they are giving.

An interview with Patient #1's daughter, on 02/04/13 at 9:08 AM, revealed she was in the room when the nurse and physician came in to talk with the patient. She reported the nurse did not ask the patient about allergies and the physician sat beside her discussing the diagnostic test results. She heard the conversation with the physician and the patient answered the doctor's questions. The physician did not ask Patient #1 about his/her allergies.

Based on interviews, record reviews and facility policy review, it was determined the facility failed to ensure one patient (#1) in the selected sample of eleven (11) patients, received nursing services furnished in a safe setting. Patient #1 presented to the Emergency Department (ED) on 01/22/13 related to experiencing chest pain at home. The patient was diagnosed with Pneumonia and admitted to the hospital. The ED physician ordered Patient #1 an antibiotic (Rocephin). Allergies listed on Patient #1's medical record included Aspirin, Penicillin, Amoxicillin, Keflex, Trimox, Theophylline, Rocephin, Acetaminophen and Etodolac. The Registered Nurse (RN) assigned to care for the patient pulled the medication from the Accu Dose and prepared the medication accordingly. RN #1 did not clarify the order with the physician prior to administration. RN #1 administered the medication at 6:46 AM and at 7:00 AM, Patient #1 was unresponsive and without a pulse with staff starting Cardiopulmonary Resuscitation (CPR). CPR was started and Patient #1 did not respond to actions taken by the staff. The CPR was ceased at 7:25 AM and the Patient #1 expired. The failure to provide nursing supervision resulted in Patient #1 being administered a medication he/she had a known allergic reaction too. These failures placed patients at risk for serious injury, harm, impairment or death. Immediate Jeopardy was determined to exist related to Nursing Services.

Refer to A-395

Based on interview, record review and facility policy review, it was determined the facility failed to ensure supervision and evaluation of the nursing care for one patient (#1), in the selected sample of eleven (11) patients. Patient #1, who was admitted on 01/22/13 for Pneumonia, was administered an antibiotic (Rocephin) at 6:46 AM which was listed on the patient's medical record as an allergy. At 7:00 AM, Patient #1 was found to be unresponsive and at 7:25 AM the patient had expired.

The findings include:

A review of the policy entitled, "Medication Administration", dated March 1981 and revised in November 2011, revealed patients and residents of the hospital shall receive medications as ordered by the attending physician. All medications must be administered in accordance with the "Five Rights of Medication Administration": right patient, right medicine, right dosage, right time, and right route. Identify the patient by asking the patient his name and checking his identification bracelet for Name/Birthday and compare with eMAR. Always check "Five Right of Medication Administration" Right patient, Right medication, Right dosage, Right time and Right route. Verifies that there is no contraindications for administering a new medication.

Review of the clinical record revealed the facility admitted Patient #1 on 01/22/13 with a diagnosis of Pneumonia. The nurses notes revealed Patient #1's allergies listed included Penicillin, Amoxicillin, Trimox, Keflex, Rocephin, Asprin, Acetaminophen and Etodolac. The physicians reports dated 01/22/13, revealed the physician ordered Rocephin which was listed on Patient #1's allergies. The nurses notes revealed Registered Nurse (RN) #1 administered the medication at 6:46 AM. At 7:00 AM, the patient was unresponsive and without a pulse.

Interview with the admitting physician, on 01/31/13 at 11:54 AM, revealed the patient came in with a complaint of chest pain and he ordered diagnostic and laboratory testing which revealed Pneumonia. He stated when a patient had Pneumonia, Rocephin was the medication often prescribed. He revealed the patient had an elevated temperature but responded with clarity to questions about his/her listed allergies. He discussed his/her allergies and Patient #1 could not recall if he/she had a reaction to Rocephin. He ordered the medication for the patient and nursing did not question him about the order.

An interview with RN #1, on 01/31/13 at 5:21 PM and 02/04/13 at 10:10 AM, revealed she was the nurse that took over care for Patient #1 on 01/22/13. She did not over hear the physician discuss allergies with the patient and she did not over hear Patient #1's response. She stated the physician handed her the patient's chart and stated the patient was being admitted to the hospital. RN #1 verbalized she did not review the patient's allergies after she received the order for the Rocephin and she did not clarify the physician's order for the Rocephin before she administered the medication. She stated she was trained to always ask the patient if they have allergies and to double check the allergies when the medications were removed from the Accu Dose. RN #1 stated she did not ask the patient his/her allergies before starting the medication. She revealed she looked in the computer and saw the patient had the medication three times in the past with nothing indicating the patient had a reaction and administered the medication as it was ordered.

However, review of the patient's electronic medical record revealed an "allergy tab". When expanded by staff, this file included specific information related to the patient's reaction to medications. Review of the record revealed on 03/21/03, Patient #1 received Rocephin and developed reddened, flushed skin over entire body, and had difficulty breathing.

An interview with RN #2, on 01/30/13 at 3:00 PM, and RN #3 on 01/31/13 at 10:16 AM, revealed nurses asking the patient if they have allergies was a part of the triage process. They stated they would remind the physician if an order for a medication was on the patient's list of allergies. Additionally, they stated they would also go back and discuss the type of reaction they experienced when they received the medication.

An interview with the Director for the ED, on 02/01/13 at 11:57 AM, revealed he talked to RN #1 who informed him she clarified the order with the physician before she administered the medication. The Director of the ED stated he reviewed Patient #1's medical record and identified RN #1 did not document in the record that she clarified the order with the physician.

An interview with Chief Nursing Officer, on 02/01/13 at 9:07 AM, revealed she expected the nursing staff to make it known to the physician if the medication prescribed was identified as an allergy. She stated in this case, the physician knew the allergy and made the decision to administer the medication. She revealed the staff was expected to list the allergies but not the reaction to the medication. She stated all staff was trained to verify physician's orders and allergies listed. She revealed the nurse was expected to explain the medication prior to administering it and "that is considered a basic nursing competency".