HospitalInspections.org

Based on record review and staff interview, it has been determined that the hospital failed to administer medications in accordance with physician's orders and failed to follow policies for medication administration for 5 of 9 sampled patient's (ID #'s 1,7,8,9, & 10).

Findings are as follows:

1. Physicians Orders

a. Medical record review for patient ID# 1 revealed that at approximately 3:10 AM, the patient was administered Methergine 0.5 milligram injection (a medication used for the prevention and control of postpartum hemorrhage) when the physician's order was for Hepatitis B vaccine.

During surveyor interview with the nurse, staff A, on 6/25/2019 at approximately 4:00 PM she acknowledged that she administered what she thought was Hepatitis B vaccine but instead administered Methergine, in error, and without a physician's order.

b. Medical record review for patient ID # 7, revealed that on 6/15/2019 at approximately 7:10 AM a 1000 milliliter bag of Ringer's Lactate solution was initiated intravenously without a current physician's order.

Patient ID # 7's medication administration record states, in part, "6/15/2019 at 8:56 AM 400 cc hanging...not previously ordered." An additional note states in part, "6/15/2019 at 8:57 AM physician order for Lactated Ringer's injection IV solution 1,000 milliliters."

During an interview with the risk manager, on 6/27/2019 she was unable to explain why the intravenous solution was initiated prior to the physician's order.

c. Medical record review for patient ID # 8 revealed that on 11/20/2018 the patient declined the flu vaccine. Review of the patient's record revealed that on 11/20/2018 the patient was administered the flu vaccine without a physician's order.

During interview with the risk manager on 6/27/2019 she stated that the patient had a physician's order for the Tdap and that the staff also incorrectly administered the flu vaccine which the patient had declined.

d. Medical record review for patient ID #9, revealed a physician's order dated 8/10/2018 for Sandostatin 30 mg IM. During review of medication errors, it was revealed that the patient was administered Sandostatin 20 mg IM.

Surveyor interview with the risk manager on 6/27/2019 at approximately 11:45 AM, revealed that the error was discovered when a discrepancy was noted in the count for the Sandostatin in the Pyxis (computerized medication dispensary).

e. Medical record review for patient ID # 10, revealed a physician order dated 5/29/2019 for Morphine 2-4 milligrams IV push every 3 hours as needed (PRN) for pain, per pain scale (pain scale if pain greater than four...). Review of medication errors revealed that the patient incorrectly was administered 8 mg of Morphine.

During interview with the risk manager on 6/27/2019 at approximately 2:20 PM, she stated that the nurse removed two vials of Morphine 4 mg, instead of two vials of Morphine 2 mg. She stated that this was discovered by a discrepancy in the morphine count in the Pyxis.

2. Policies

Policy titled "Medication Errors", effective date 3/28/2017 states in part;
Sec V. Procedure. i. "medications or medication doses administered in error require documentation on the patient's medication administration record. For electronic medication administration records (eMAR), the pharmacist adds a comment indicating the entry is for documentation purposes".

a. Review of the eMAR for patient ID# 1, lacks documentation that the patient was incorrectly administered a Methergine 0.5 milligram injection (used for the prevention and control of postpartum hemorrhage). The nurse failed to follow the facilities policy relative to medication errors by not recording the Methergine on the patient's medication administration record, nor was there any documentation from the pharmacist.

b. During review of medication errors for patient ID # 9, it was revealed that on 8/10/2018 the patient was administered Sandostatin 20 mg IM and not Sandostatin 30 mg as ordered by the physician. Review of the eMAR failed to note documentation of the Sandostatin 20mg which was administered at 14:02 PM in error, nor was there documentation from the pharmacist.
c. Review of the medication errors revealed that patient ID # 10 was incorrectly administered 8 mg of Morphine on 5/29/2019 at 21:31 when the order was for Morphine 2-4 milligrams every 3 hours as needed for pain.

Review of the eMAR failed to document the incorrect dose of Morphine 8 mg which was administered at 21:31 PM, but instead states Morphine 4 mg was administered. The staff failed to follow the policy by not documenting the incorrect dose of morphine on the eMAR, nor was there documentation from the pharmacist.

Policy titled " Medication: Administration and Standardized Times" effective date 9/14/2017 states in part;
Sec V. Attachment C: Medication Preparation/Administration,
#6. " Steps for CareAdministration (Bar Code) Medication Administration
a. Open the electronic medication administration record
b. Scan the patient's identification band to verify correct patient
i. A list of medication due for the patient is displayed
c. Scan the medication you are administering and complete the electric verification process.
d. Administer the medication to the patient and sign the MAR
e. Verify documentation of administration on the eMAR"


a. During a complaint investigation, medical record review for patient ID# 1 revealed that the patient was delivered via c-section on 11/14/2018 at 1:27 AM. At approximately 3:10 AM, the patient was incorrectly administered Methergine 0.5 milligram injection (used for the prevention and control of postpartum hemorrhage).

The nurse staff A failed to follow the facilities policy relative to medication administration by not scanning the patient's identification band, to verify correct patient, and not scanning the medication (bar code) prior to administration.

During surveyor interview with the nurse, staff A, on 6/25/2019 at approximately 4:00 PM she acknowledged that she failed to follow the medication administration policy by not scanning the bar code prior to administration.

b. During an interview with the risk manager on 6/27/2019 at approximately 11:45 AM regarding patient ID # 9 receiving the wrong dose of Sandostatin, she stated the error was discovered when a discrepancy was noted in the count for the Sandostatin in the Pyxis. The risk manager acknowledged that the nurse failed to follow the medication administration policy by not scanning the medication prior to administration, otherwise the discrepancy would have been noted.

c. Review of the medication errors revealed that patient ID # 10 was incorrectly administered 8 mg of Morphine on 5/29/2019 at 21:31 when the order was for Morphine 2-4 milligrams every 3 hours as needed for pain.

During an interview with the risk manager on 6/27/2019 at approximately 10:45 AM, she stated that this error was discovered by a discrepancy in the morphine count in the Pyxis.

The surveyor also interviewed the director of pharmacy on 6/28/2019 at approximately 10:30 AM, who stated that there would have been a warning triggered if the nurse had scanned both vials of morphine prior to administration, which is the hospital's policy.