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Based on record reviews and staff interviews, it was determined the facility failed to ensure the Registered Nurse supervised and evaluated the nursing care for one patient (#1) in the selected sample of five (5) on 12/20/09 after a medication error was reported. Findings include:

A review of Patient #1's medical record revealed he/she received routine medications of Metformin 1000 milligrams (mg.), Zyprexa 40 mg., Prilosec 20 mg., Abilify 30 mg., Depakote 500 mg., Klonopin 1 mg., and Coumadin 7.5 mg. on 12/20/09 at approximately 7:30 PM. In addition, he/she also received another patient's medications to include Trazodone 50 mg., Claritin 10 mg., Seroquel 400 mg., Thorazine 100 mg., Risperidone 2 mg., Neurontin 800 mg., and Minipress 1 mg. at approximately 7:50 PM. Patient #1 was transferred to the local acute hospital on 12/21/09 at 6:30 AM after experiencing increased sedation, a drop in oxygen concentration (80%), and a change in mental status. He/she presented to the acute hospital with respirations even and unlabored. Patient #1 was transferred from the Emergency Room to the Progressive Care Unit (PCU) where intravenous fluids were continued, oxygen was delivered at 2 liters/minute, and aspiration precautions were implemented after he/she awakened. The hospital course was uncomplicated and he/she was transferred to a medical floor and back to the psychiatric facility on 12/23/09.

An interview on 01/13/10 at 10:40 AM with the Registered Nurse (RN) responsible for supervising the Licensed Practical Nurse (LPN) on 12/20/09 who made the medication error revealed the LPN informed him on 12/20/09 at approximately 8:00 PM that he had a brain infarct and gave medications to the wrong patient. The RN stated he told the LPN to contact the physician, nursing coordinator, and oncoming RN of the error. The RN did not obtain specific information on the patients involved or conduct any follow-up in accordance with facility policy. The RN left the facility at approximately 8:15 PM on 12/20/09 as he was off duty. He stated he was aware of the hospital policies and wished he had done a lot of things different.

An interview on 01/14/10 at 9:20 AM with the LPN responsible for the medication error on 12/20/09 revealed the RN never instructed him to make any notifications or conduct any follow-up. He stated the RN essentially told him not to worry about it and that the patient would be OK even though he had informed the RN one of the medications he had given was listed as an allergy on Patient #1's medical record. The LPN stated he was aware of the hospital's policies and procedures for identifying patients for medication administration, and incident management and could provide no explanation why he had not followed established protocols. Additionally, he had no explanation for why he did not make the covering RN on 12/21/09 aware of the error until 6:45 AM on 12/21/09 (fifteen minutes after Patient #1 was transferred to the acute hospital). He did not complete an incident report until 12/21/09 after Patient #1 had to be hospitalized.

Review of the hospital's standard operating procedures revealed medication errors were to be reported immediately, physicians were to be notified, incident reports were to be completed, and the detailed incident management protocol was to be followed.

Based on record review and staff interview, it was determined the facility failed to ensure essential entries were documented in one patient's (#1) medical record in the sample of five (5). Findings include:

Review of Patient #1's medical record revealed a medication error had occurred on 12/20/09 at approximately 7:50 PM. There was nothing documented in the medical record related to the error until 12/21/09 when the Licensed Practical Nurse (LPN) responsible for the error made a late entry sometime between 6:45 AM and 7:45 AM noting, "gave patient another patients medication". An entry in the nurse's notes on 12/21/09 at 6:30 am noted "lethargic and hypoxic episode - transferred via ambulance, oxygen at 2 liters via nasal cannula".

An interview with the LPN on 01/14/10 at 9:20 AM revealed he had no explanation for why he failed to document the medication error timely in the nurse's notes or why he failed to ensure the RN responsible for Patient #1's care on 12/21/09 was made aware of the medication error until fifteen minutes after the patient had been transferred to the acute hospital for treatment after a decline in his/her condition.