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Based on interview and record review, the facility failed to ensure that an effort was made by nursing to communicate with physicians in order to ensure that drugs in the form of oral medications were administered in acordance with the orders of the practitioner for 1 opf 6 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient was admitted to the facility in the late afternoon of 12/07/18.

Physician orders of 12/07/18, which were issued prior to the placement of a new Nasogastric Tube on 12/09/18 and its documented absence on 12/10/18, had included the following tablet medications, among others. The ones listed would have required afternoon and evening administrations. They are: Hydralazine (Apresoline) tablet 50 milligrams (mg.) three timess a day (TID), Furosemide (Lasix) tablet 40 mg. TID, Atorvastatin (Lipitor) tablet 20 mg. nightly, Amiodarone (Pacerone) tablet 400 mg. two times per day (BID), and Carvedilol (Coreg) tablet 25 mg. BID with meals. The route was shown on the computer as being for oral administration.

Physician orders of 12/07/18 at 7:14 PM, read, "NPO (nothing by mouth) status: Strict NPO."

In addition to the above medication orders, the facility had a policy, titled "Medication Administration" which allowed an order written as PO (by mouth) to also be given via a feeding tube, if one were present. The policy read, "In the presence of a functioning enteral tube (Dobhoff, NG (nasogastric), PEG (Percutaneous Endoscopic Gastrostomy), J-tube (Jejunostomy), etc.), nursing may administer orders written as PO either PO or via the enteral tube...." Thus, if a feeding tube was absent there would be a conflict between the medication orders, the policy and the orders for strict NPO. In such a situation, no PO medications could be given.

Physician orders of 12/09/18 at 10:17 AM read, "Nasogastric tube insertion." An X-ray to confirm placement (after insertion) was performed on 12/09/18 at 12:46 PM. A nurse's note of 12/10/18 at 7:20 PM read, "Patient refuse NG tube to be re-inserted."

The need for re-insertion on 12/10/18 could only be attributed to the Nasogastric Tube (of 12/09/18) having somehow been removed. This narrative entry, along with the 12/10/18 Medication Administration Record (MAR) , revealed that the patient was without feeding tube access at some point during the day on 12/10/18, after morning tablet medications had been successfully given.

A review of the MAR revealed that tablet medications were not given after 12 PM on 12/10/18, where "not given" statements that indicated the absence of a NG Tube were written during medication pass attempts. The involved medications and their corresponding times of non-administration are as follows: Amiodarone at 11 PM, Atorvastatin at 11 PM, Carvedilol at 9:38 PM, Furosemide at 1:38 PM and 10 PM, and Hydralazine at 1:37 PM and 11 PM.

There was no evidence in the medical record that the physician was made aware of the inability to provide medications during this time frame, due to an absent NG Tube.

During an interview of the Administrator on 2/01/18 at approximately 1 PM, she confirmed the finding.