HospitalInspections.org

Based on observation, review of medical records, review of policy and procedures and interview it was determined the facility staff failed to:

1. Notify the physician of medication not being available for administration.

2. Document on the Medication Administration Record (MAR) accurately.

3. Transcribe medications to the MAR accurately.

4. Dispose of medications not given safely.

This had the potential to affect all patients served and did affect Medical Record (MR) # 1, # 2, # 3 and # 5. This affected 4 of the 5 records reviewed.

Findings include:

Policy: Medication Administration

The following policies will govern administration of medication in this institution:

" Medication Administration Record will be compared with the physician's orders prior to preparation of any medication at least one (1) time each shift. The individual administering the medication will verify the medication selected for administration is the correct medication based on the medication order and the medication product label...The individual administering a medication will discuss any unresolved, significant concerns about the medication with the patient's physician... and/or relevant staff involved with the patient's care, treatment and services. The discussion will be documented in the patient's medical record...
Each dose of medication administered is to be properly recorded in the patient's medical record...
Indicate an omitted dose with a circle around the administration time. Indicate PRN (as needed) and non-recurring doses in the appropriate space. Explain in the nurses notes, the reason for each PRN, non-recurring or omitted dose..."

Medical record findings:

1. MR # 1 was admitted to the facility 3/23/14 with diagnoses of Dyspnea, Congestive Heart Failure, Hypertension and Chest Pain.

On 3/25/14 at 9:20 AM, a medication pass observation was performed by the surveyor with Employee Identifier (EI) # 3, Registered Nurse. The medications were prepared and EI # 3 informed the surveyor that a note was in the patient's drawer from pharmacy regarding no I-Caps or Finasteride was available. When asked if the physician was notified the medication was not available EI # 3 stated she was sure he knew since the patient had been in the facility for several days.

A review of the medical record confirmed that no one had notified the physician of the non-availability of the two medications and no one had contacted the physician for any substitute for these two drugs since the patient's admission 3/23/14.

EI # 3 failed to mark the Finasteride as NA (not available) on the MAR, instead she initialed the medication as if given.

MR # 1 had an order for HCTZ (Hydrochlorothiazide)12.5 mg (milligrams) by mouth qd (every day). EI # 3 removed the medication from the drawer commenting that the dose was 25 mg so she would have to half the pill. EI # 3 obtained the pill cutter from a drawer and proceeded to cut the pill in half. EI # 3 disposed of the 1/2 tablet in the trash can with the packages she had removed the other drugs from.

EI # 3 failed to dispose of the medication in the sharp's container for safety and failed to clean the pill cutter before and/or after use.

2. MR # 2 was admitted to the facility 3/21/14 with diagnoses of Dyspnea, Congestive Heart Failure and Chest Pain.

On 3/25/14 at 9:35 AM, a medication pass observation was performed by the surveyor with Employee Identifier (EI) # 3, Registered Nurse. The medications (meds) were prepared and the surveyor noted the MAR had (asterisk) * by all of the medications on one sheet of the MAR which included the following medications:
Lovenox 40 mg SQ (subcutaneous) daily
ASA (aspirin) 81 mg po (by mouth) qd (daily)
Citalopram 20 mg po qd and
Valsartan-HCTZ 100/25 po daily.

The MAR had a notation, " * (asterisk) pt (patient) own meds."

The only medication of the patients to be used was the Valsartan-HCTZ 160/25 po daily in a zip lock bag in the drawer of the medication cart in a prescription bottle from the local pharmacy. EI # 3 noted the dose transcribed on the MAR was 100/25 not the ordered 160/25 on the prescription bottle. EI # 3 changed the 100 on the MAR to 160, prepared the medication from the patients bottle and proceeded to administer the medications.

In an interview with EI # 1, the Director of Nursing on 3/26/14 at 9:30 AM confirmed the above information.

3. MR # 3 was admitted to the facility 3/10/14 with diagnoses of Anemia, Sickle Cell in Crisis, Hypovolemia and Periapical Abscess.

The medication orders included Pepcid 20 mg IV (intravenous) pb (piggy back) q12h (every twelve hours) ordered 3/10/14.

The MAR had the medication scheduled at 8 (8:00 AM) and 20 (8:00 PM). On 3/10/14 the 8:00 PM dose had initials circled by the staff as not given.
On 3/11/14 the 8:00 AM block was blank and the 8:00 PM had a circle drawn inside the block.

A review of the medical record confirmed the patient arrived to room 105 at 1:25 PM on 3/10/14. The nurses failed to document in the medical record the patient did not receive the Pepcid IV and failed to notify the physician the patient did not receive the medication.

In an interview with EI # 1, the Director of Nursing on 3/26/14 at 9:30 AM confirmed the above information.

4. MR # 5 was admitted to the facility 2/28/14 with diagnoses of Anemia, Cholecystitis and Abdominal Pain.

The physician ordered 2 units of PRBC (packed red blood cells) to transfuse with the patient to receive Lasix 40 MG IV between each unit.

A review of the MAR confirmed documentation of unit # 1 given 3/1/14 with the identification # from the blood, however the # 2 unit had no identifying information on the MAR, only that it was given 3/2/14 at 0215 (2:15 AM).

In an interview with EI # 1, the Director of Nursing on 3/26/14 at 9:30 AM confirmed the above information. EI # 1 stated that the nurses know to write in the # if no sticker is available.





30952

Based on observations, CDC guidelines for hand hygiene in health care settings and interview it was determined the hospital failed to:

1. Perform hand hygiene after contact with inanimate objects and prior to medication administration.

This had the potential to affect all patients served by this facility.

Findings include:

www.cdc.gov
Morbidity and Mortality Weekly Report
Recommendations and Reports October 25, 2002 / Vol. 51 / No. RR-16
Centers for Disease Control and Prevention

Guideline for Hand Hygiene in Health-Care Settings
Recommendations for Hand Hygiene

"...C. Decontaminate hands before having direct contact with patients
F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, lifting a patient)
I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient
J. Decontaminate hands after removing gloves..."

On 3/25/14 at 9:20 AM, a medication pass observation was performed with Employee Identifier (EI) # 3, Registered Nurse. The medications were prepared in the nurses station, the nurse failed to perform hand hygiene prior to starting to prepare the medications. EI # 3 entered the patient room verified patient's armband and administered the medication. EI # 3 failed to perform hand hygiene before medication preparation and prior to medication administration.

An interview following the medication pass with EI # 1, the Director of Nursing on 3/26/14 at 9:30 AM confirmed hand hygiene was to be performed before medication preparation and prior to medication administration.


Carol Williams, RN


30952