HospitalInspections.org

Based on record review and interview the facility failed to ensure nursing staff notified the physician of patient's admission for one (#1) of 10 patients reviewed for medications according to professional standards, resulting in the potential for less than optimal outcomes.
Findings include:

On 8/16/18 at approximately 1020 a.m., patient #1 was observed in her room. An interview was conducted with the patient of concern (#1) at that time. She said that she had been in the facility for approximately 6-7 days. The patient said she had Epilepsy and that her seizures were mainly controlled by 3-4 medications. The patient said that she took Vimpat (used to treat seizure disorders), Topamax (used for seizures), Depakote (used for seizures and mood disorder), Klonopin (used for seizures) and Neurontin (used for seizures and nerve pain).

According to patient #1 she did not receive any of her medications for 3-4 days following her admission. The patient said she had experienced six seizures since her admission. The patient said that on one occasion she hit her head on the side of the bed during a seizure. The patient said on that day she was sent out to the hospital. When asked to explain if she suffered any injuries the patient stated, "I just know that I hit my head on the side of the bed."

A review of the patient's medical record was conducted with Staff E on 8/16/18 at 1050 and revealed the patient (#1) was admitted to the facility on 8/10/18 at 1014. A review of the patient's home medication regime included:
Vimpat 250 milligram (mg) twice per day. Topamax 100 mg per day. Cogentin 1 mg twice per day as needed. Rexulti 4 mg. Atorvastin 20 mg at night. Lisinopril 2.5 mg daily. Naltrexone 50 mg daily. Prazosin 5 mg 2 capsules at night. Flonase 50 microgram (mcg) inhaler twice per day. Zofran 4 mg as needed.

A review of the patient's Admission nurse to nurse report note dated 8/10/18 at 0645 documented the patient had received Topamax 100 mg at 2100 on 8/9/18 and the patient had received Vimpat 50 mg and Xanax 0.25 mg at 0400 on 8/10/18 at facility (B).

A review of medication orders revealed there were only orders dated for 8/10/18 at 1620 for the patient to have received Haldol 5 mg and Ativan 2 mg at the facility of concern (A). There were no further medications ordered for the patient until 8/11/18 at 1122 a.m., documented in the medical record.

A review of the patient's History and Physical (H&P), dated 8/11/18 at 1000 a.m. documented the patient's chief complaint was psychiatric disturbance/mental status changes and medical follow up had been requested by psychiatry. The H&P documented the patient had a previous medical history of seizures, hypertension, asthma, hypercholesterolemia, substance and tobacco abuse. Current medications: documented "see chart". A review of systems documented the patient has seizures when assessed for neurological deficits. A review of the medical doctor's medication review documented the patient's active inpatient medications were "pending".

Additionally, the medical doctor documented:
Seizure disorder: home anti seizure medications, seizure precautions, follow up with primary care physician and neurology.

A review of the patient's initial psychiatric evaluation dated 8/11/18 at 1100 a.m. documented:
The patient was hospitalized via emergency room on a petition filed by the mental health therapist from the Community Mental Health Clinic stating that the patient cannot contact for safety...The patient was off of her medications for the last week because she was supposed to have some procedure for seizure disorder. Medical history: Asthma and epilepsy. Diagnoses:
1. Bipolar. 2. PTSD (post traumatic stress disorder). 3. Depression. 4. Substance abuse. 5 Epilepsy and asthma.

At that time Staff E was asked to explain who was responsible for obtaining admission orders including medications for new patients. Staff E said the typically the patient would be examined by the physician and medication orders would be transcribed thereafter. However, Staff E was not able to explain why the patient's (#1) medications were not ordered on the day of admission. Staff E said I looked there are no notes that indicated that the patient refused to be seen by the medical doctor on her day of admission (8/10/18 at 1014 a.m.)

Further review of the medical record revealed the patient's medications were ordered on the following dates and times:
On 8/11/18 at 1132: Vimpat 250 mg twice per day, patient's own medication start date 8/11/18.
On 8/11/18 at 1317: Depakote 250 mg twice per day "High Risk" medication alert.
On 8/11/18 at 1318: Aripirazole 5 mg every morning.
On 8/11/18 at 1318: Klonopin 0.5 mg at bedtime.
On 8/11/18 at 1350: Vimpat 250 mg twice per day, patient's own medication start date 8/11/18.
On 8/11/18 at 1359: topiramate (Vimpat) 100 mg now.

A review of the patients (MAR's) revealed the patient was administered the following medications more than 24 hours after her admission to the facility:
On 8/11/18 at 1359 Vimpate 100 mg.
On 8/11/18 at 1729 Depakote 250 mg at 1729 and at 2045.
On 8/11/18 at 1729 Klonopin 0.5 mg.
On 8/11/18 at 1730 Vimpat 250 mg.
On 8/12/18 at 0850 Aripirazole mg.

On 8/16/18 at approximately 1520 a phone interview was conducted with Staff I. Staff I said she recalled admitting the patient on 8/10/18. When asked to explain if she notified the medical doctor of the patient's admission Staff I said no I didn't. She explained I've never done that, usually the doctors are here. She (Staff I) said, I was not aware that the patient had not been seen by the medical doctor. When asked if she recalled asking the patient about her seizure disorder or if she recalled the patient requesting to be given any of her medications, Staff I said she did not recall.

On 8/16/18 at approximately 1540 an interview and record review was conducted with the Chief Nursing Officer (CNO). When queried regarding the facility's processes for communicating with the medical doctor of patient admissions and review of patient medication the CNO stated, "We have doctor's here all the time at least 12 hours and as needed per day." The CNO confirmed the nurse should have notified the medical doctor of the patient's admission.

On 8/16/18 at approximately 1600 an interview and record review was conducted with Staff K.
Staff K said she recalled seeing patient #1's home medications in the medication room. Staff K said she could not recall the exact day but she confirmed she documented each medication according to the labels listed on each bottle/package. Staff K said she did not recall the patient asking her for any medications.

A review of the facility's "Admission Procedure" policy dated January 20, 2014 documented:
D. Charge Nurse/Designee
1. "Contact the attending physician to obtain admission orders. If the attending physician is unavailable, contact the Medical Director...4. Document in progress notes, admission process and status of the patient."

A review of the facility's "Medication Reconciliation/Verification" policy dated revision July 24, 2018 documented:
"At time of admission: the nurse completing the admission assessment will obtain and document the patient's current medications taken at home. These medications will be listed on the 'Home Medication' section of the Electronic Medication Administration Record (E-MAR)."