HospitalInspections.org

Based on record review and interview the hospital failed to ensure medications were administered according to physician's orders and/or accepted standards of practice as evidenced by:
1) failing to administer medications as per physician's orders for 1 of 5 sampled patients (#F5).
2) failing to ensure nursing staff monitored patient's heart rate prior to the administration of Digoxin and Atenolol as indicated in the hospital's Drug Reference Book titled, "Nursing 2008 Drug Handbook" for 2 of 5 sampled patients (#F1, #F2).
3) failing to monitor vital signs at time intervals as ordered by the patient's physician as parameters for administering prn (as needed) Blood Pressure medication for 1 of 5 sampled patients (#F2). Findings:

1)
Patient #F5: Medical record review revealed orders dated 12/15/10 at 4:30 p.m. for 200 u of Miacalcin to be administered by spray in both nostrils daily. Review of the medical record including the medication administration record revealed no documentation to indicate that the Miacalcin was administered to the patient on 12/16/10. Review of the medication administration record revealed that the first dose of Miacalcin was not administered to Patient #F5 until 12/17/10 at 9:00 a.m. This review revealed a medication error occurred (omission of Miacalcin on 12/16/10) while providing care to Patient #F5.

In an interview on 12/20/10 at 1:15 p.m., the Administrator reviewed the medical record of Patient #F5 and confirmed that there was no documentation to indicate that the Miacalcin was administered to Patient #F5 on 12/16/10. The Administrator reported that no medication variance was completed on this medication error. The Administrator reported that there was no documentation to indicate that the ordering practitioner was notified of the medication error.

2)
Patient #F1: Review of Patient #F1's medical record revealed the patient was admitted to the hospital on 11/24/2010 with physician's orders that included Digoxin 0.125 milligrams by mouth every morning. Further review revealed a que on the Patient's Medication Administration Record (MAR) regarding Digoxin administration indicating, "Record Apical Pulse on MAR, Hold if
During a face to face interview on 12/20/2010 at 10:30 a.m., Mental Health Technician SF6 indicated he had worked at the facility for 8 months. SF6 further indicated the practice at the hospital was for Mental Health Technicians to take all patient's vitals signs to include their pulse. SF6 indicated pulse rates were taken by use of an automated device. SF6 indicated it was not the practice of Mental Health Technicians to take apical pulses.

During a face to face interview on 12/20/2010 at 10:35 a.m., Director of Nursing SF2 confirmed there had been no documented evidence that nursing staff had been monitoring apical pulses to ensure it was safe to administer Digoxin prior to administering the medication. Further SF2 confirmed that Digoxin had been administered to Patient #F2 at 9:00 a.m. on 12/13/2010 when the patient's "A.M. (morning) brachial pulse had been recorded as "50" with no documented time. #F2 indicated that a heart rate of 50 would warrant holding the patient's Digoxin and notifying the patient's physician.

Review of the hospital's Drug Reference Book titled, "Nursing 2009 Drug Reference" page 449 revealed in part, "Excessively slow pulse rate (60 bets/minute or less) may be a sign of digitalis toxicity. Withhold drug and notify prescriber."

Patient #F2: Review of Patient #F2's medical record revealed the patient was admitted to the hospital on 12/17/2010 with physician's orders for Atenolol HCL 100/25 milligrams every morning by mouth. Further review revealed a que on the Patient's Medication Administration Record (MAR) regarding Atenolol administration indicating, "Record Apical Pulse on MAR, Hold if
During a face to face interview on 12/20/2010 at 1:30 p.m., Director of Nursing SF2 confirmed there was no documented evidence that Patient #F2's apical pulse had been taken prior to the administration of Atenolol. SF2 indicated the nurse administering Atenolol to Patient #F2 should have taken and documented the patient's apical pulse prior to administering Atenolol in order to determine if it was safe to administer the medication.

Review of the hospital's Drug Reference Book titled, "Nursing 2009 Drug Handbook" page 359 revealed in part, "(Atenolol) Check apical pulse before giving drug; if slower than 60 beats/minute, withhold drug and call prescriber.

3)
Patient #F2: Review of Patient #F2's medical record revealed a physician's order dated 12/17/2010 at 1655 (4:55 p.m.) for Clonidine 0/1 milligrams by mouth every 6 hours as needed systolic blood pressure greater than 170 or diastolic blood pressure greater than 94. Review of Patient #F2's entire medical record revealed no documented evidence that the patient's blood pressure was taken every 6 hours to determine the need for Clonidine. Further review revealed Patient #F2's blood pressure had been taken two times per day as recorded on the patient's (#F2) graphic sheet. Review revealed no documented times as to when the blood pressures had been taken.

During a face to face interview on 12/20/2010 at 1:30 p.m., Director of Nursing SF2 confirmed that Patient #F2's blood pressure had been monitored only two times per day with no documented time as to when the blood pressures had been taken. SF2 further indicated that without knowing Patient #F2's blood pressure, on a time interval of every six hours (4 times in a 24 hour period), the nursing staff would not know if the patient needed to have Clonidine administered as per physician's prn (as needed) order.



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