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Based on observation, interview, record review and document review, the facility failed to ensure an effective governing body was legally responsible for the conduct of the hospital. The governing body failed to ensure nursing services were furnished in accordance with facility policies and procedures (Refer to Tag's A0395, A0397 and A0404). The governing body failed to ensure pharmacy services were furnished in accordance with facility policies and procedures (Refer to Tag's A0500 and A0508). The governing body failed to ensure quality assurance performance services were furnished in accordance with facility policies and procedures (Refer to Tag A0288).

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory mandated care to patients.

Based on interview and document review, the facility failed to trend and implement preventive actions regarding medication errors.

Findings include:

On 11/7/11 at 12:40 PM, the Interim Chief Nursing Officer (CNO) explained due to recent administrative turnover, multiple incident reports had been unearthed and not yet examined. The CNO acknowledged the past medication errors had not been trended and tracked by the Quality Assurance Director.

On 11/9/11 at 9:10 AM, the Director of Quality and Compliance explained the medication error report was provided to her from the pharmacy. The Director stated she was not a nurse, therefore, did not review the medication error reports. The Director explained there was currently a contracted pharmacy services consultant who checked each nursing unit for medication errors on a quarterly basis. The Director stated her responsibilities were to drive the process with pharmacy. The Director stated she was responsible for looking for anomalies and inconsistency with medication error reporting. The Director acknowledged there was not specific trending and tracking regarding medication errors.

The Director of Quality and Compliance explained when a medication error was identified by a nurse, physician or pharmacist, an incident report would be completed and sent to the Assistant Director of Nursing. The incident would be investigated by nursing leadership. After the investigation was completed, the incident report was sent to the Chief Nursing Officer and the pharmacist.

The medication errors reporting data reported a total of 18 medication errors for September 2011. The report documented 13 were administration errors, four were transcribing errors and one was a dispensing error. Eight of the errors did not reach the patient, eight reached the patient but did not cause harm and one required monitoring or intervention.

Thirty one medication/treatment error investigation worksheets were noted for October 2011. The medication/treatment error investigation worksheets had not been investigated or reported to the physicians.

The Director of Quality and Compliance and the Director of Pharmacy related they were not aware there were numerous medication error reports in the CNO's office. The Director of Pharmacy had not received copies of the incident reports.

The Accident/Incident Reporting for Patient/Resident policy reviewed 5/19/10 documented:
"5. Completed worksheet is submitted to the facility's Director of Clinical Services who designates the responsible party to complete the follow-up...6. The designee conducts a complete investigation of all accidents and incidents and documents the findings on the second page of the worksheet and on supplemental investigation worksheets if applicable...7. Accidents or incidents involving a patient/resident that result in an injury are immediately reported to his/her physician and promptly reported to the family or legal representative...9. Once the worksheet is filled out completely and accurately and the investigation is complete, the information is entered into the web-based Incident Reporting Program within five (5) days of the incident..."

On 11/9/11 at 9:40 AM, the administrator explained the Director of Quality and Compliance did not have a clinical background and was not a nurse. The facility had identified a system problem with the medication error reports. The Director of Quality and Compliance had not reviewed the medication error reports to be tracked and trended.

On 11/15/11 at 7:35 AM, the Director of Pharmacy stated he looked at only the higher drug categories which included high alert medications. Included in the discrepancy report were Intravenous tubing and other supplies which the Director of Pharmacy did not review. The discrepancy reports were reconciled on a weekly basis. The Director stated if a potential issue was identified, the pharmacist would notify the Chief Nursing Officer.

On 11/15/11 at 12:35 PM, the Interim Quality Manager and the Corporate Director of Clinical Services were interviewed. The Director explained she had been providing oversight to the facility for the past month and a half. The Director explained system issues with the pharmacy and quality assurance related to tracking and trending medication errors had been identified and the facility had been working on a solution. The CNO was identified to be the future Quality Director. The Director acknowledged the "critical thinking piece" was missing in the Quality Assurance reports. The Director stated the facility had been working on a system to decrease medication errors related to medications ordered for a patient prior to admission to the facility. The pre-admission medications ordered and the admission medication orders were to be reconciled prior to admission of the patient to the facility.

As a result of a baseline audit in January 2011, the Pharmacy and Therapeutic Committee (P&T) had been convened to address the administration of medications and the use of the Pyxis machine. The work plan was a derivative of the CPS Pharmacy Consultant work plan (the consultant pharmacy).

The taskforce identified no consistency in current procedure for medication orders upon patient's transfer to the facility, resulting in medication errors. The pre-admission medications ordered and the admission medication orders were to be reconciled prior to admission of the patient to the facility.

The P&T identified on-going 1:1 education regarding Medication Errors as they occur. There was no documented evidence this had occurred within the facility.

Develop tracking and trending reports based on discrepancy and override reports of medications. Supplies had been moved to a separate category in the Pyxix system so the override report would exclude supplies. There was no documented evidence of the tracking and trending reports.

On 11/15/11, in the morning, the administrator acknowledged many of the P&T projects and policies had not been completed and were rolled over from month to month. The administrator stated the facility had taken steps to improve this process by hiring an Interim Quality Manager and Corporate Director of Clinical Services to provide over site to the facility. The Quality Assurance for tracking and trending medication errors were not corrected since January 2011.

Based on observation, interview, record review and document review, the nursing staff failed to administer medications per physician order (Refer to Tag A0404), the facility failed to assure the staff nurses were competent in medication administration (Refer to Tag A0405), and the facility failed to assure qualified licensed practical nursing staff were administering intravenous procedures (Refer to Tag A0397).

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory mandated care to patients.

Based on interview, record review and document review, the facility failed to assure qualified licensed practical nursing (LPN) staff were administering intravenous procedures.

Findings include:

During the chart review of Patient #1, it was noted an LPN (Employee #28) started an Intravenous (IV) line on the patient.

On 11/8/11 at 9:20 AM, the Assistant Director Of Nursing acknowledged the LPN's were able to start IV's as long as they were IV certified.

There was no documented evidence found in Employee #28's file of IV Certification.

On 11/8/11, the Chief Nursing Officer presented a memo to all LPN's without IV Certification. Eight LPN's were identified without IV Certification in their employee files by the education department. The LPN's were directed to stop all interactions with patients who had IV's until IV certification was presented to the human resource manager.

A review of the Licensed Practical Nurse job description documented the nurse was responsible to practice within the scope of licensure. The job description documented the nurse would adhere to state-specific Nurse Practice Act for administration of medication and parenteral therapy.

Based on observation, record review, interview and document review, the facility failed to assure medications were administered per the physician order for 18 of 20 patients reviewed and for 7 of 7 medication/treatment error investigation worksheets reviewed (Patient's #1, #2, #4, #6, #8, #9, #10, #12, #14, #17, #19, #20, #21, #22, #23, #24, #25, #26 and #27).

Findings include:

Patient #10

Patient #10 was admitted to the facility on 9/27/11 with diagnoses of questionable mitral valve endocarditis, history of paroxysmal atrial fibrillation, congestive heart failure, hypertension and hypothyroidism.

1.) On 10/6/11, the physician wrote an order to change the Vancomycin from every 36 hours to every 24 hours.

The patient received Vancomycin IV (intravenous) on 10/6/11 at 5:00 AM and again on 10/6/11 at 6:00 PM (11 hours after the 5:00 AM dose).

On 10/7/11 at 3:30 PM, a medication/treatment error investigation worksheet identified the patient received Vancomycin 11 hours before the next dose was due.

2.) On 10/15/11 at 8:00 AM, a medication/treatment error investigation worksheet identified the patient received Flagyl without an order at 5:00 AM. There was no documented evidence found on the Medication Administration Record (MAR) or in the nursing progress notes identifying the patient received Flagyl without an order. The medication/treatment error investigation worksheet identified the physician examined the patient at 5:00 PM.

The physician progress notes, dated 10/15/11, documented the patient was examined by the physician at 3:40 PM. The physician did not address the patient receiving Flagyl. The physician documented the patient was receiving IV Vancomycin.

3.) On 10/26/11 at 4:00 PM, a medication/treatment error investigation worksheet identified the patient had Rocephin IV infusing on 10/25/11 at 10:00 AM. The antibiotic belonged to the patient in 516B. Patient #10's medical record identified the patient was allergic to penicillin

The physician progress notes, dated 10/25/11 and 10/26/11, did not address finding the wrong antibiotic. The physician documented the patient was receiving Vancomycin.

The medication/treatment error investigation worksheet identified the nurse hung the antibiotic but did not infuse the medication. The nurse was made aware of the error prior to infusion. The incident was investigated on 11/1/11 by the ADON. The ADON documented the nurse was provided inservice training regarding hanging IV's and checking the physician order and patient.

On 11/9/11 at 11:50 AM, the Lead Pharmacist explained the physician spoke to her regarding Rocephin IV was administered to Patient #10 on 10/25/11 and requested her to write a medication error report. The pharmacist stated the physician had also spoken with the nurse.

On 11/9/11, at 9:10 AM, the Director of Quality and Compliance explained when a medication error was identified by a nurse, physician or pharmacist; the incident report would be completed and given to the Assistant Director of Nursing. The incident would be investigated by nursing leadership. The incident report would be given to the Chief Nursing Officer after the investigation and a copy would be given to the pharmacist.

On 11/9/11 at 12:45 PM, the Director of Pharmacy stated he would expect a medication given and not ordered should have been documented on the patients' MAR.

Patient #9

Patient #9 was admitted to the facility on 9/28/11 and transferred to acute care on 10/4/11 with diagnoses including subarachnoid hemorrhage after a fall, end-stage renal disease, hypertension, coronary artery disease, congestive heart failure and dementia.

On 9/28/11, the physician ordered Dilaudid 2 milligrams (mg) by mouth every six hours as needed for pain.

On 10/3/11, the physician ordered to increase the Dilaudid to every four hours as needed for pain. The order was transcribed onto the MAR as increase Dilaudid to 2 mg IV every four hours as needed for pain. The order was not checked by the primary nurse.

The incorrect order was carried over onto the 10/4/11 MAR and the patient received Dilaudid 2 mg IV at 1:30 AM. The physician was notified at 11:00 AM and the patient was transferred to the acute care facility at 11:30 AM for altered level of consciousness.

On 10/4/11, the physician transfer summary documented "...The patient also is on Dilaudid p.o. (orally) every six hours for pain; this was increased to every four hours. Unfortunately, she got one additional dose last night and somehow was given IV which may be accounted for some of her mental status changes, but because of her underlying history, it is important to get a stat CT to make sure there is no worsening of her condition..."

Patient #20

Patient #20 was admitted to the facility on 8/3/11 with diagnoses including status post acute respiratory failure with pneumonia, right hip fracture, diabetes, and stent placement.

Review of Patient #20's medical record on 11/9/11 revealed the patient was receiving:
- Lantus 36 Units subcutaneously (sq) once a day at bedtime, ordered 9/6/11
- Lasix 40 mg (milligrams) intravenously (IV) two times a day, ordered 9/7/11

Patient #20's physician orders dated 9/15/11 documented:
- Increase Lantus 40 units sq daily
- Decrease Lasix to daily

Documentation on Patient # 20's Medication Administration Record (MAR) revealed the physician orders for the Lasix and Lantus had not been corrected on the MAR by the nursing staff or the pharmacy. Patient #20's MAR revealed the patient received the incorrect dosage of Lasix and Lantus for 6 days, from 9/16/11 through 9/22/11, when the error was identified through a random audit by the pharmacist.

Review of Patient #20's laboratory results revealed the resident's BUN (Blood Urea Nitrogen) level was 38 (Normal 7-25) on 9/22/11 and increased to 40 on 9/24/11. On 9/27/11, after Patient #20's Lasix was decreased, the patient's BUN level was 24.

The 2011 Nursing Drug Reference Handbook indicated Lasix was classified as a diuretic and was indicated for the treatment of hypertension. One of the effects on laboratory test results included an increase in BUN levels (a test done to check kidney function).

Patient #1

Patient #1 was admitted to the facility on 9/11/11 and transferred to an acute facility on 9/20/11 with diagnoses including Cerebrovascular accident with right hemiparesis and atrial fibrillation with cardiomyopathy with ejection fraction of 15% to 20%.

On 9/11/11, an order was written to discontinue Fragmin when the INR (International Normalized Ratio (blood clotting time) is greater than or equal to 2.0.

On 9/15/11, the INR was reported at 2.4 on the Quest laboratory print out sheet. On 9/16/11, the patient received 9000IU (International Units) of Fragmin subcutaneously at 9:00 AM. The order was not discontinued on the Medication Administration Record (MAR).

Patient #2

Patient #2 was admitted to the facility on 10/6/11 and transferred to acute care on 10/30/11 with diagnoses including right fibula fracture, distal leg superficial wound, dementia without agitation, sacral decubitus, urinary tract infection secondary to vancomycin-sensitive enterococcus, clostridium difficile associated diarrhea, Gram-positive cocci in clusters bacteremia and debility.

On 10/30/11 at 12:15 PM, the physician ordered Mylicon 80 milligrams orally every six hours.

The Medication Administration Record (MAR) documented the patient received the medication at 5:00 PM, 11:00 PM, and 11:00 AM.

There was no documented evidence the patient received the 5:00 AM dose of Mylicon.

On 10/14/11, an order to clean the coccyx with normal saline, pat dry and apply hydrogel with dry dressing by the wound care team daily was noted.

On 10/15/11, the physician wrote an order to apply terrasil ointment (the patient's own medication) to the coccyx twice a day and discontinued the order the same day.

On 10/17/11, a new order to apply vasolex to the coccyx and leave open to air by the wound care team was written.

On 10/26/11, an order to apply zinc oxide to the coccyx and peri area twice a day by the nursing staff was written.

Review of the wound treatment and progress record documented there was no wound care provided on 10/20/11, 10/21/11 10/22/11 and 10/31/11 to the coccyx by the wound care team.

Review of the wound treatment and progress record documented zinc to the coccyx and peri area was not administered on the day shift on 10/28/11, 10/29/11, 10/30/11and on the night shift from 10/27/11, 10/28/11 and 10/29/11.

Patient #4

Patient #4 was admitted to the facility on 10/10/11 with a diagnoses of end stage renal disease, debility, thrombocytopenia, deep vein thrombosis, Stage II decubitus, hypertension and status post cholecystectomy.

On 11/4/11, a order to clean the wound with normal saline, pat dry, skin prep around wound, hydrogel to wound every day by nursing staff was ordered. The wound treatment and progress record documented the patient did not receive wound care on 11/6/11.

Patient #6

Patient #6 was admitted to the facility on 11/4/11 with diagnoses including hypertension, history of thorcoabdominal aneurysm, chronic diarrhea and irritable bowel syndrome.

On 11/5/11 a wound care order was written to discontinue Sulfamylon to decubitus. The new order documented to clean the area with normal saline, pat dry, apply hydrogel with dry dressing daily by nursing and to clean the area with personal cleanser, pat dry and apply zinc oxide twice a day by nursing.

On 11/10/11, the MAR revealed the Sulfamylon was applied daily at 9:00 AM by the nurse. There was no documented evidence the order was discontinued on 11/5/11 and the new wound care order was written on the MAR.

Patient #8

Patient #8 was admitted to the facility on 10/27/11 with diagnoses including right lower lobe healthcare-associated pneumonia, colonic ileus, history of cerebrovascular accident, chronic atrial fibrillation, chronic lymphocytic leukemia, seizure disorder, dyslipidemia and gout.

On 11/3/11, the wound care progress notes documented the right big toe was observed to have an abrasion on the medial aspect which measured 1.6 centimeters by 2.6 centimeters.

On 11/3/11, an order to clean area with normal saline, pat dry, apply skin prep around wound, hydrogel to wound bed with dry dressing daily by nursing. The wound treatment and progress record documented the patient did not receive wound care on 11/4/11 through11/8/11.

Patient #12

Patient #12 was admitted to the facility on 10/26/11 with diagnoses including left frontoparietal cerebrovascular accident with hemiparesis, anemia, coronary artery disease and post Coronary Artery By-Pass Graft (CABG).

On 10/27/11, a wound care order was written for the surgical wound to be cleansed with normal saline and pat dry daily by the nursing staff. The wound treatment and progress record documented the patient received wound care on 10/27/11, 10/28/11, 10/31/11, 11/1/11, 11/3/11, 11/4/11, 11/13/11 and 11/14/11.

On 11/4/11, a wound care order to clean the right heel with normal saline, pat dry, apply skin prep every day by the nursing staff. The wound treatment and progress record documented the patient received wound care on 11/4/11, 11/13/11 and 11/14/11.

Patient #14

Patient #14 was admitted to the facility on 10/10/11 with diagnoses including left hip hematoma, rule out abscess, schizophrenia, left hip infection with methicillin resistant staphylococcus aureus (MRSA), history of metastasis of the breast and bones, debility and anemia.

On 10/16/11, a clarification order was written for calamine lotion to inner thighs and sacrum daily and as needed. Review of the patient's MAR revealed the patient had not received the calamine lotion.

On 10/11/11, a wound care order was written to cleanse left heel with normal saline, pat dry and apply skin prep twice a day and as needed by nursing. There was no documented evidence on the wound treatment and progress record the patient received treatment twice a day. There was no documented evidence the patient received treatment on 10/16/11, 10/19/11, 10/20/11, 10/21/11, 10/22/11, 10/25/11-10/27/11, and 10/30/11-11/9/11. The wound care nursing notes on 11/2 and 11/9/11 documented the left heel wound was unable to be measured.

On 10/16/11, a wound care order was written to cleanse the left hip incision with normal saline, pat dry and leave open to air daily by the nursing staff. There was no documented evidence on the wound treatment and progress record the patient received treatment on 10/22/11, 10/25/11-10/26/11, 10/31/11-11/9/11.

On 10/20/11, the orthopedic physician wrote an order to continue daily wound care and to allow the steri strips to fall off naturally. The wound care nursing note documented on 11/9/11, 10 steri strips remained in place.

The following patient's medication errors were obtained from the medication/treatment error investigation worksheets provided to the surveyor on 11/7/11.

Patient #17

Patient #17 was admitted to the facility on 10/15/11 with diagnoses including end stage renal disease with dialysis, transient ischemic attack and diabetes.

Patient #17's medications included an order for Coumadin (an anticoagulant) 4 mg (milligrams) daily, based on the INR (International Normalized Ratio (blood clotting time)).

The physician's order dated 11/7/11 documented "Hold Coumadin today. Resume Coumadin tomorrow at 4 mg po (by mouth) daily when INR less than or equal to 3.0"

Patient #17's INR result dated 11/8/11 indicated the INR was 3.0.

Documentation on Patient #17's MAR dated 11/8/11 indicated Coumadin 4 mg orally once a day when the INR was less than 3. The Coumadin was held on 11/8, since the INR was equal to 3.0.

On 11/9/11 in the afternoon, the charge nurse (Employee # 13), confirmed the order had not been transcribed properly and the Coumadin was held on 11/8 in error.

Patient #19

Patient #19 was admitted to the facility on 11/2/11 with diagnoses including coronary artery disease, status post CABG (Coronary Artery Bypass Graft), diabetes, hypertension, and congestive heart failure.

Patient # 19's medical record indicated the patient was receiving the following medications for hypertension:
- Metoprolol ER (Extended Release) 50 mg (milligrams) orally once a day
- Ramirpril 2.5 mg orally once a day
- Lasix 40 mg orally once a day

A physician's order dated 11/5/11 at 9:30 AM, documented "Stagger AM (morning) BP (blood pressure) medications and Lasix 2 hours apart."

Review of Patient #19's Medication Administration Record (MAR) on 11/9/11, revealed the notation to stagger the BP medications and Lasix 2 hours apart was hand written on the MARs dated 11/6/11, 11/7/11, 11/8/11 and 11/9. The time to administer the Lasix was preprinted on the MAR to be given at 0700 (7:00 AM). Documentation on the MAR revealed the preprinted time of 0700 for the Lasix was overwritten by hand to indicate 0900 and signed by the medication nurse. As per the documentation on the MAR, the Metoprolol, Ramirpril, and Lasix were all administered at 0900 (9:00 am) on 11/6/11, 11/7/11, 11/8/11 and 11//11.

On 11/9/11 in the afternoon, the charge nurse (Employee #13) and the pharmacist confirmed all three medications were administered at the same time, instead of 2 hours apart as ordered.

Patient #21

The pharmacist reported on 10/28/11 an order for NaHCO3 (Sodium Bicarbonate) 325 mg tablets, give three tablets twice a day was ordered on 10/25/11. The patient received a dose on 10/26/11 in the morning and had not received any further doses.

Patient #22

The pharmacist reported on 10/17/11 a nurse removed two chlordiazepoxide 5 mg tablets as an override on 10/9/11. The order was for five tablets. There was no documented evidence the physician was notified by the pharmacist or the nursing staff regarding the medication error.

Patient #23

The nurse reported the physician requested investigation as to why the Coumadin was held on 10/25/11. The MAR documented the Coumadin was held due to INR of 1.1. The order for Coumadin was 5 mg orally every day and to hold if the INR was equal to or greater than 3. There was no documented evidence an investigation was completed.

Patient #24

The pharmacist reported on 10/25/11 the nurse removed Morphine 2 mg IV from the Pyxis on 10/22/11. There was no order for this dose found on the chart. There was no documentation the physician was notified by the pharmacist or the nursing staff.

Patient #25

A nurse reported on 10/14/11 the patient received Aricept instead of Ancef. Aricept was documented on the MAR. The physician order sheet documented the physician ordered Ancef on 10/12 and 10/13/11. The nurse obtained the medication from an override in the Pyxis.

The patient received Insulin as ordered by the physician. There was no documented evidence of two nurse signatures for the dose on the MAR.

Patient #26

The pharmacist reported on 10/17/11 a nurse removed two Hydrocodone/APAP 5/325mg as an override on 10/10/11. The physician order was written as Hydrocodone/APAP 7.5/325mg. There was no documentation the physician was notified by the pharmacist or the nursing staff.

Patient #27

The pharmacist reported on 10/27/11 a nurse removed two nitrofurandanton 50 mg from the Pyxis as an override on 10/26/11. The physician order was for Macrobid 100 mg two times a day. The pharmacist reported the medication was a different salt from the plain nitrofurandanton 50 mg. They were not interchangeable. There was no documentation the physician was notified by the pharmacist or the nursing staff.

On 11/10/11 at 8:30 AM, during a medication pass observation, two IV antibiotics were observed hanging disconnected from the patient in Room 111A.

Zythromax was observed to be hung on 11/9/11 at 10:00 AM and Ceftriaxone was hung on 11/9/11 at 9:00 AM.

A large amount of fluid was noted in both antibiotics. The ADON was shown both antibiotics. The Ceftriaxone was in a 50 cc bag.

The ADON measured out 42 cc's from the bag. The ADON stated she did not measure out the remaining fluid in the Zythromax bag due to the drip chamber was full of fluid and the extra fluid could have been caused by the backup of the flush fluid.

The bag of IV flush fluid was hung on 11/8/11 at 8:52 AM. The ADON stated the IV bags should be changed every 24 hours.

The Registered Nurse assigned to the patient explained the patient was not assigned to the nurse's care on 11/9/11 and could not explain the fluid in the IV bags.

The ADON stated an investigation would occur regarding the extra medication which remained in the IV bag.

On 11/10/11 at 9:20 AM, a partial medication pass was observed with RN #12 for the patient in Room 213A. The RN was observed giving Fragmin as an intramuscular (IM) injection instead of the ordered subcutaneous (subq) route. The RN acknowledged he gave an IM injection instead of subq. The nursing supervisor reported the RN did not know the side effects of the medications and did not check the MAR against the physician orders. The nurse did not pull all the ordered medications and had to keep returning to the Pyxis for additional medications.

On 11/9/11 at 2:25 PM, RN #12 was observed at the Pyxis. Upon observation, the 3:00 PM medication was written on a piece of paper and lying on top of the Pyxis. The medication was for Invanz. The employee was observed holding Cefazol. hen the employee was asked what medication was to be given, he acknowledged he had the wrong antibiotic and went to the Pyxis to obtain the correct antibiotic. The employee explained he would use the patient MAR in the morning to write down the patients medications for the day. The employee was not observed checking the patient's MAR to assure the medication order had not been discontinued.

On 11/7/11 at 12:40 PM, the Interim Chief Nursing Officer (CNO) explained due to recent administrative turnover, multiple incident reports had been found and not yet examined.

Thirty one incident reports were noted for October 2011. The incident reports had not been investigated or reported to the physicians.

On 11/8/11 and 11/9/11, 14 nurses were interviewed. Two LPN's, six RN's and five Charge RN's were interviewed regarding the facility process when a medication error was identified.

RN #9 and RN #10 explained if a medication error was identified during the 24 hour chart check, the order would be corrected and the charge RN notified. RN #10 explained sometimes things were missed and the nurses were expected to fix the MAR's. The nurse stated she would find errors once or twice a month.

RN #11 was a Charge RN. The nurse explained there would be times if an order was transcribed wrong on the MAR, she would just change the MAR. The example provided was if Potassium 40 mill-equivalent (mEq) was ordered and 20 mEq was entered on the MAR, she would just change the MAR. The nurse explained it would "not be a big deal".

On 11/10/11 at 10:40 AM, the wound care nurse explained she started at the facility on 10/12/11. The nurse explained she was currently working with the staff nurses on providing wound care. Each hall had been assigned a day for all wounds to be measured.

The nurse explained when she would assess the patient for a wound, she would decide if the patient was to be treated by the wound care team or if the nursing staff could provide the daily wound care. The nurse explained the nursing staff was provided with a pink wound care sheet and the wound care team documented on a white wound care sheet. The nurse acknowledged there was a concern regarding documentation of wound care from the staff nurses.

The Nursing Medication Administration policy, reviewed 11/3/11 was reviewed.

" ...Policy: 2. Prior to medication administration, licensed clinical staff will verify patient identification using two (2) patient identifiers, name and date of birth. 9. Second provider verification will be completed prior to administration of high alert medications in all patient populations. 18. IV tubing will be changed every (7) seven days and "flagged" with the date, time and initials of the nurse ..."

The Profile Override report was presented on 11/9/11 for 11/8/11.

Ten medications were obtained from an override for the 100 Hall. The medications obtained were Xanax (reason entered for override - acute anxiety), Vitamin K oral (reason entered for override - acute anxiety) and Vitamin K IV (which was returned), Lorazepam (reason entered for override - acute anxiety), Apresoline (reason entered for override - Blood Pressure control), Haloperidol (no reason given), and Diltaizem CD (no reason given). Two IV solutions were pulled. The Lorazepam was witnessed by two nurses.

Two medications were obtained from an override for the 200 Hall and one nebulizer solution. Morphine syringe (reason entered for override - acute pain) and Heparin vial (reason entered for override - maintain patency of IV site). The Morphine was witnessed by two nurses. The Heparin was not witnessed by another nurse.

0.9% NaCl minibag IV solution was pulled on the 300 Hall to maintain patency of IV site.

Two aerosols and 0.9% NaCl 1000ml IV solution were pulled on the 400 Hall. The override reason listed for the IV solution was not an emergency will wait.

Three medications and one 0.9% NaCl 1000ml IV solution were pulled on the 500 Hall. Prilosec (reason entered for override - acute indigestion), Insulin Lantus Pen (no reason documented), anticoagulant sodium cit. 4% (reason entered for override - maintain patency of IV site) and the override reason listed for the IV solution was not an emergency will wait.

There were no overrides for the 600 Hall.

Automated medication dispensing system policy7.10 revised 1/11 was reviewed.

" ...Medication Administration: E. If multiple medications are to be removed at the same time, select all the medications you wish to dispense then press the "Remove Selections/Items" key. The appropriate drawer will open for each medication selected. Verify the count, remove the medication, and close the drawer or each med ..."

" ...Override function: A. A limited number of "urgent" medications have been approved by pharmacy and nursing for which the override function will be available regardless of the patient's medication profile in the Pharmacy Order Entry Software computer. This override function will only be used when the care of the patient would be adversely affected by waiting for the pharmacy to enter the medication into the system ..."

" ...The High Alert Medications policy 3.10 developed 2/11 was reviewed. 5. Insulin, heparin, potassium IV and magnesium IV will require 2 license nurses to check and document on MAR prior to administering dose ..."

The Accident/Incident Reporting for Patient/Resident policy reviewed 5/19/10 was reviewed.
" ...5. Completed worksheet is submitted to the facility's Director of Clinical Services who designates the responsible party to complete the follow-up. 6. The designee conducts a complete investigation of all accidents and incidents and documents the findings on the second page of the worksheet and on supplemental investigation worksheets if applicable... 7. Accidents or incidents involving a patient/resident that result in an injury are immediately reported to his/her physician and promptly reported to the family or legal representative. 9. Once the worksheet is filled out completely and accurately and the investigation is complete, the information is entered into the web-based Incident Reporting Program within five (5) days of the incident ..."

Complaint #NV00029439
Complaint #NV00029753

Based on interview and record review, the facility failed to assure the staff nurses were competent in medication administration for 14 of 14 nursing employee files reviewed (Employees #3, #5, #6, #8, #15, #16, #17, #23, #25, #28, #29, #30 and #31).

Findings include:

Fourteen nurse's files were reviewed for current licensure, yearly competency evaluation and current medication testing and observation. The current Competency Checklist utilized did not include medication administration. There was no documented evidence of medication competency found in any of the nurse's employee files.

On 11/15/11, the Infection Control and Educator explained she had started as the educator late in 2010 and was attempting to observe the nursing staff during medication administration.

Based on observation, interviews, record review and document review, the facility failed to ensure the pharmacy notified staff of potential concerns regarding the safe administration of medications with black box warnings (A500) and to notify the physician of identified medication errors (A404).

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory mandated care to patients.

Based on observation, interview, record review and document review, the pharmacy failed to assure safe guards were implemented with the distribution of medications, including all medications with black box warnings from the Pyxis. There was no documented evidence the facility had a policy regarding medications with black box warnings.

Findings include:

On 11/9/11 at 8:30 AM, the Director of Pharmacy explained he received a daily report for all override medications. The Director stated there were about 20 overrides every day. The pharmacist reviewed the override medications to see if the medication obtained by override was appropriate or inappropriate. The Director explained there were more overrides from the Pyxis from 7AM to 1 PM. The Director stated less than 10% of medication errors resulted from nurses getting medications by over riding the Pyxis.

During Patient #7 chart review on 11/9/11, an order was written on 11/9/11 to "Surgery cancelled for 11/10/11. Resume all medications and previous orders. Resume ASA (Aspirin) and Plavix."

On 11/10/11 at 7:50 AM, the Director of Pharmacy acknowledged the order written on 11/9/11 was not an appropriate order. The Director of Pharmacy explained the physician should have written all the specific medication to have been resumed for the patient.

The Director stated all orders were reviewed for drug, route, dose, frequency and if an as needed medication there was an indication. If the order did not meet the criteria, the pharmacist would get clarification from the physician or nurse.

On 11/10/11 at 12:25 PM, the Lead Pharmacist was shown the order for Patient #7. The pharmacist acknowledged the way the order was written was not an acceptable order. There was no documented evidence found the pharmacist or the nursing staff called the physician to clarify the order.

On 11/9/11, the Director of Pharmacy was requested to provide a list of medications with black box warnings in the facility formulary.

On 11/10/11, at 7:50 AM, the Director of Pharmacy provided a list of medications with black box warnings he found on the internet. The Director of Pharmacy explained a medication with a black box warning was a medication which had a potential for serious side effects in a small group of the population. The Director of Pharmacy provided the example of antidepressants can cause suicidal ideation for some of the population.

The Director of Pharmacy explained he did not have a list of current medications with black box warnings found in the facility formulary. The Director of Pharmacy stated the nurses could override the medications with black box warnings from the Pxysis.

On 11/10/11 at 12:25 PM, the Lead Pharmacist explained the Pyxis had a data base to check warnings and side effects. Currently, there were no warnings in the Pyxis. Medications with black box warnings were not flagged in the Pyxis. High alert, sound alike and look alike medications were currently flagged in the Pyxis.

On 11/10/11, the Director of Pharmacy explained Fragmin should have International Normalized Ratio parameters written by the physician. The Director acknowledged the pharmacy would be responsible to develop the policy. The Director of Pharmacy explained there was not a current policy for parameters of laboratory results and the administration of an anti-coagulant.

The Director stated the discrepancy report was monitored at the corporate pharmacy. The reports have identified wrong medications were pulled from the Pyxis. The Director stated an in-service was provided to the nursing staff regarding extended release medication identified by the discrepancy report. The Director stated he did not report the specific discrepancies, just the results identified by the discrepancy.

On 11/15/11 at 7:35 AM, the Director of Pharmacy was asked to explain the discrepancy reports provided to the surveyor on 11/10/11.The Director stated he looked at the higher drug categories. The discrepancy reports were reconciled on a weekly basis. The Director stated if a potential issue was identified, the pharmacist would notify the Chief Nursing Officer.

The Director was re-interviewed at 1:20 PM. The Director explained the discrepancy report regarding Levaquin and Neurontin resulted in the Pharmacy Technician had overstuffed the medication and filled above the acceptable maximum level. The Director stated the Pharmacy Technician did not know the process for filling the Pyxis. The Director stated he spoke with the Technician and provided additional training.

Automated medication dispensing system policy7.10 revised 1/11 was reviewed.

" ...Medication Administration: E. If multiple medications are to be removed at the same time, select all the medications you wish to dispense then press the "Remove Selections/Items" key. The appropriate drawer will open for each medication selected. Verify the count, remove the medication, and close the drawer or each med ..."

" ...Override function: A. A limited number of "urgent" medications have been approved by pharmacy and nursing for which the override function will be available regardless of the patient's medication profile in the Pharmacy Order Entry Software computer. This override function will only be used when the care of the patient would be adversely affected by waiting for the pharmacy to enter the medication into the system ..."

The Accident/Incident Reporting for Patient/Resident policy reviewed 5/19/10 was reviewed.

" ...5. Completed worksheet is submitted to the facility's Director of Clinical Services who designates the responsible party to complete the follow-up. 6. The designee conducts a complete investigation of all accidents and incidents and documents the findings on the second page of the worksheet and on supplemental investigation worksheets if applicable 7. Accidents or incidents involving a patient/resident that result in an injury are immediately reported to his/her physician and promptly reported to the family or legal representative. 9. Once the worksheet is filled out completely and accurately and the investigation is complete, the information is entered into the web-based Incident Reporting Program within five (5) days of the incident ..."

Based on observation, interview, record review and document review, the pharmacist failed to report medication errors to the physician. The medication error report for September presented to the Quality Assurance Committee did not reflect all the medication errors.

Findings include:

On 11/10/11 at 7:50 AM, the Director of Pharmacy stated the nursing department was to provide the pharmacy with copies of all medication errors. The Director reviewed the errors by drug type and time of day.

On 10/26/11 at 4:00 PM, a medication/treatment error investigation worksheet identified Patient #10 had Rocephin IV infusing on 10/25/11 at 10:00 AM. The antibiotic belonged to the patient in 516B. Patient #10's medical record identified the patient was allergic to penicillin.

On 11/9/11 at 11:50 AM, the Lead Pharmacist explained the physician spoke to her regarding the wrong medication administered to Patient #10 on 10/25/11 and requested her to write a medication error report. The pharmacist stated the physician had also spoken with the nurse.

Patient #22

The pharmacist reported on 10/17/11 a nurse removed two chlordiazepoxide 5 milligram tablets as an override on 10/9/11. The order was for five tablets. There was no documented evidence the physician was notified by the pharmacist or the nursing staff regarding the medication error.

Patient #24

The pharmacist reported on 10/25/11 the nurse removed Morphine 2 mg Intravenous from the Pyxis on 10/22/11. There was no order for this dose found on the chart. There was no documentation the physician was notified by the pharmacist or the nursing staff.

Patient #25

A nurse reported on 10/14/11 the patient received Aricept instead of Ancef. Aricept was documented on the MAR (Medication Administration Record).

Patient #26

The pharmacist reported on 10/17/11 a nurse removed two Hydrocodone/APAP 5/325mg as an override on 10/10/11. The physician order was written as Hydrocodone/APAP 7.5/325mg. There was no documentation the physician was notified by the pharmacist or the nursing staff.

Patient #27

The pharmacist reported on 10/27/11 a nurse removed two nitrofurandanton 50 mg from the Pyxis as an override on 10/26/11. The physician order was for Macrobid 100mg two times a day. The pharmacist reported the medication was a different salt from the plain nitrofurandanton 50 mg. They were not interchangeable. There was no documentation the physician was notified by the pharmacist or the nursing staff.

On 11/15/11 at 1:20 PM, the pharmacist was stated when she would identify a medication error, she would write up the incident then go to the unit to talk with the nursing staff and check on the status of the patient. A copy of the report was given to the Director of Pharmacy and the original given to the ADON (Assistant Director of Nursing) of the unit.

On 11/7/11, thirty one medication/treatment error investigation worksheets were noted for October 2011. The medication/treatment error investigation worksheets had not been investigated or reported to the physicians. There was a large stack of medication/treatment error investigation worksheets for September 2011.

On 11/9/11 at 8:30 AM, the Director of Pharmacy stated he had not received any medication error reports from nursing for awhile. The Director stated the nursing department was to provide the pharmacy with copies of all medication errors. The Director reviewed the errors by drug type and time of day.