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Based on review of facility documentation and medical records (MR) and staff interviews (EMP) it was determined that the facility failed to ensure that medication orders for rabies prophylaxis were consistent with the Medical Staff By-Laws and facility policy for three of four medical records (MR1, MR2 and MR3).

Findings include:

Review of the UPMC Horizon Medical Staff By-Laws, revised October 2014 revealed, "ARTICLE III MEDICAL ORDERS Section 1. General Requirements: ... (e) All medication orders must indicate the drug name ... the method and frequency of administration."

Review of Policy #PO-14 "Ordering and Administration of Medications," revised March 2015 revealed, "POLICY: The hospital develops, implements, and maintains policies and procedures to support ordering of drugs and the transcription of drug orders that ensures the safe and appropriate use of these medications. ... PROCEDURE: ... II Method of Ordering A. Written/Electronic Orders ... 3. All medication orders must specify ... route of administration ... 13. Orders for the same medication with two or more routes will not be accepted without specific parameters to guide the nurse as to when each route should be utilized."

Review of Policy #ED-08 "Management of Animal Bites," revised February 2012 revealed, "Purpose: ... to provide guidelines for prophylactic treatment to patients with animal bites. ... 5. Post-exposure anti-rabies immunization, if the victim has NOT been previously vaccinated, is achieved as follows: Rabies Immune Globulin (RIG)- given only once, at the beginning of prophylaxis to provide immediate antibodies. Dose- 20IU/kg body weight. 1. If possible one half the dose should be thoroughly infiltrated into the area around the wound. 2. The other half dose should be given intramuscularly in the gluteal area."

Review of Policy #ED-77 "RABIES: POST EXPOSURE RABIES PROPHYLAXIS," revised February 2012 revealed, "PURPOSE: Provide rabies immunization as recommended by the CDC for post-rabies exposure. ... Rabies Immune Globulin (RIG): Provides rapid, passive immunity that persists for only a short time. ... Order rabies vaccine and immunoglobulin injection when indicated. ... Administer medications and treatments as ordered."

1. Review of MR1 revealed an order, dated November 26, 2015, for, "rabies immune globulin, human 1,300 Unit(s) 8.67 mL Route IM." A medication note, dated November 26, 2015, at 4:57 PM revealed, "Pt given rabies immunoglobulin in bilat thighs and bilat outer buttocks area." Further review of MR1 revealed no order for infiltration of the RIG around the wound site or administration of the RIG to more than one site.

2. Review of MR2 revealed an order, dated December 30, 2015, for, "RABIES IMM GLOB (rabies immune globulin, human) 1,560 Unit(s), IM, Once." A medication note, dated December 30, 2015, at 6:49 PM revealed, "2ml given in R deltoid. The remainder 8.4 ml divided between both lateral thighs." Further review of MR2 revealed no order for infiltration of the RIG around the wound site or administration of the RIG to more than one site.

3. Review of MR3 revealed an order, dated November 5, 2015, for, "rabies immune globulin, human 2,620 IntL Unit, IM, Once." A medication note, dated November 5, 2015, revealed the medication was administered at 5:16 PM, "R thigh, R gluteal x2, L gluteal x2, all rabies Immune Globulin administered ... All amount were 3 ml except one gluteal was 3.4 ml." Further review of MR3 revealed no order for infiltration of the RIG around the wound site or administration of the RIG to more than one site.

4. On January 7, 2016, at approximately 11:16 AM, when asked the expectation when RIG is ordered, EMP1 stated, "As much as possible should be infiltrated at the bite site, and the rest administered IM at a distant site." When asked if staff did not inject at the bite site, but completely IM, would that be following the orders, EMP1 stated, "No, that would not be correct." When asked, then, if given that information, do the facility's orders for RIG follow the administration process, EMP1 stated, "No, I do not believe it does."

5. On January 7, 2016, at 11:27 AM, EMP4 confirmed that the orders for administration of RIG for MR1, MR2 and MR3 did not follow facility policy. EMP8, also present for the interview, stated, "It's an error on the prescribing side."