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Based on record review and staff interview, it was determined the facility failed to ensure medications were administered according to physician orders for two (#2,#3) of ten sampled patients. This practice may result in the patients' failure to achieve therapeutic goals.


Findings include:

1. During interview on 7/13/11 at approximately 2:00 p.m. , the Risk Manager confirmed the nurse caring for patient #1 on 6/9/11 administered Versed when the patient became agitated. The nurse administered the medication without verifying the medication was ordered for the patient. There was no order for Versed and the medication was listed as one to which the patient was allergic. The Risk Manager also confirmed that the nurse failed to document the administration of the Versed in the medical record and there was no evidence that the nurse notified the physician.

2. Review of the medical record for patient # 2, who was admitted for treatment of exacerbation of chronic obstructive pulmonary disease and pneumonia, revealed the physician wrote an order on 6/4/11 for Levaquin 750 milligrams every 24 hours intravenously (IV). Review of the MAR (Medication Administration Record) revealed the first dose was administered on 6/4/11 at 4:30 p.m. There was no evidence the patient received Levaquin on 6/5/11. The physician had also written an order for Solu Medrol 60 milligrams IV twice daily. Review of the MAR revealed no documentation that Solu Medrol was administered at 10 a.m. on 6/5/11 or at 10 p.m. on 6/6/11. The physician also wrote an order for Spiriva, 1 puff every day. Review of the MAR revealed no documentation that the medication had been administered on 6/5/11.

3. Patient # 3 was admitted to the facility on 6/9/11 with diagnosis of hypertensive crisis with acute mental status change. The physician wrote an order for Lisinopril 20 milligrams twice daily. Review of the MAR revealed no documentation that the medication was administered on 6/10/11 at 10 p.m.

The Patient Safety Officer confirmed the findings for patients #2 and #3 on 7/12/13 at approximately 2:30 p.m.

Based on record review and staff interview the written physicians order for sedation failed to include the level of sedation or two (#1, #4) of ten patients selected for review.


Findings Include:



1. Review of the medical record for patient #1 revealed the patient was placed on mechanical ventilation and admitted to the MICU on 6/9/11. The physician ordered critical care agitation/sedation orders protocol with propofol. The agitation /sedation orders protocol are preprinted orders that provide the physician selection of medications to be used for sedation, the dosage to be given and the sedation parameters. Review of the medical record revealed that the patient's level of sedation was monitored while the patient was receiving the propofol. The nursing staff use the Ramsey score (RASS) to assess level of sedation. The nursing staff documented the score between -1 (awakens to voice greater than 10 seconds and -2 (light sedation, briefly awakens to voice, less than 10 seconds. Review of the order revealed the physician neglected to indicate the desired level of sedation.

2. Review of the medical record for patient #4 revealed the same failure. The order did not include the goal RASS score. The level was monitored and was -2 to -3 (moderate sedation, movement or eye opening. No eye contact).

3. The Patient Safety Officer confirmed the findings during interview on 7/13/11 at approximately 2:30 p.m. She stated that the goal range is usually -1 -2 and agreed the desired parameters were not indicated by the physician.