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Based on document review and interview, nursing services failed to address alternative route needed for prescribed patient medication administration, failed to administer prescribed medication for 6 (six) consecutive days and failed to supervise the care being provided to patient in restraints, for 1 of 10 patients (P #1); and failed to implement and complete training/education for nursing as identified from facility documentation. See Tag A0395

The cumulative effect of this deficient practice prevented the facility from providing a safe environment by the nursing staff.

Based on document review and interview, nursing services failed to address alternative route needed for prescribed patient medication administration, failed to administer prescribed medication for 6 (six) consecutive days and failed to supervise the care being provided to patient in restraints for 1 of 10 patient medical records reviewed (P #1); and failed to implement and complete training/education for nursing as identified from facility documentation.

Findings include:

1. Facility policy titled "Medication Administration", Policy & Procedure No. 40-31 S, last reviewed 9/12/2023, indicated 8. Administration Process: d. 6) Factors modifying medication - e.g. ability to be crushed, split, release mechanism. Consult pharmacist or physician if medications to be crushed or switched to liquid form.

2. Facility policy titled "Restraints Medical Surgical and Behavioral/Violent", policy and procedure No. 40-19, last reviewed 11/7/2023 indicated on page 4, B. Registered Nurses: Responsible for initial application and removal of restraints, assessment, monitoring and documentation related to patients in restraints. The nurse is also required to attend annual education as outlined in this policy.

3. Facility documentation indicated one report titled: Medication- submitted on 10/2/2023, indicated Patient #1 was on valproic acid for seizures. Patient lost enteral access on 9/24/2023 and medication was held from 9/25/2023 until 10/01/2023. No documentation of anyone reaching out for alternative route since patient did not have enteral access.
Action Plan approval on 11/15/2023 indicated:
Processes - Action Item: 1. Creating a pharmacy protocol to change determined medication from PO to IV and obtained appropriate approval. a. Educate pharmacy staff of new protocol. b. Educate nursing staff through NERP (facility monthly education for nurses online system) - Anticipated completion date: 1/31/2024.
Education/Training - Action Item: 2. Education of Central Line dislodging actions to all clinical staff. a. NERP- Nursing education - Anticipated Completion Date 1/1/2024.
Standardized provider training to include: medication reviews, set up reports, education on views and reports to all current providers - anticipated completion date: 11/17/2023.

4. RCA (Root Cause Analysis) report indicated patient #1 on valproic acid for seizures, lost enteral access on 9/24/2023 and medication was held from 9/25/2023 until 10/1/2023. No documentation of anyone reaching out for alternative route. Patient was found unresponsive in room on 10/1/2023 that required code blue for emergency intubation. MRI (Magnetic Resonance Imaging) of brain showed multiple acute infarcts. There is concern for seizure activity. Patient did not receive prescribed valproic acid from 9/25/2023 through 10/1/2023. Report indicated error reached patient #1 and required a higher level of care and possible prolonged hospitalization.

5. Enrollments and Completions for Nursing education on Pharmacy: Oral PO to IV Protocol, assigned on 12/8/2023, with an anticipated completion date of 1/31/2024, indicated unit D400 (NeuroSurgical Unit) had a compliance of 79% (percent) as of 3/22/2024 of staff completion. Facility wide compliance as of 3/22/2024, had a completion status of 72%.

6. Facility Skills Education: Medication Administration, indicated if the patient's ability to swallow is in question, the medication should be held temporarily, and the practitioner should be asked to change the medication order to an alternative route (e.g., IV or enteral).

7. Patient #1 MR (Medical Record) indicated Valproic acid acid 1250 mg (milligram) oral every 12 (twelve) hours was ordered by MD (Medical Doctor) on 9/5/2023 at 0924 hours for seizure diagnosis. Medication Administration Record (MAR) indicated nursing staff did not administer medication from 9/25/2023 through 10/1/2023.

8. MR lacked documentation of Nursing personnel notifying providers of patient not being administered seizure medication for 6 (six) consecutive days due to ordered route not functioning.

9. MR lacked documentation of nursing staff contacting pharmacy or MD to have medication switched to an available route.

10. Nursing note dated 10/01/2023 at 0134 hours indicated patient was being assisted to restroom by sitter. Patient reached up and pulled PICC (Peripherally Inserted Central Catheter) line out of his/her neck. No bleeding at the site. MD was paged at 0134 hours. At 0142 hours, rapid response called. Patient became unresponsive on toilet.

11. MR lacked documentation that an RN removed patient #1 wrist restraints per policy.

12. In interview on 3/22/2024 at approximately 1740 hours with A6 (pharmacy), he she indicated new pharmacy protocol had a start date of March 2024 for auditing and findings. A6 also indicated action plan items were not completed by the dates anticipated and the action plan was not updated.

13. In interview on 3/22/2024 at approximately 1815 hours with N2, Registered Nurse, he/she indicated on 9/30/2023 received report from outgoing nurse that NG (nasogastric) tube was not functioning and medications were being held.

14. In interview on 3/22/2024 at approximately 1920 hours with N3, Registered Nurse, he/she indicated patient was assigned to their care multiple times, patient was not receiving valproic acid for seizure medication due to lack of enteral access in the week prior to patient going unresponsive. N3 indicated he/she did not alert MD due to receiving in nurse to nurse report that medication was being held.

15. In interview on 3/25/2024 at approximately 1950 hours with N1 (Patient Care Assistant, PCA), he/she indicated early morning of 10/1/2023, P#1 was in restraints in bed. He/she had requested to get up and use restroom. PCA undid restraints and assisted patient to the restroom. Patient had an IJ in place. Once patient was sat on toilet, PCA indicated he/she turned his/her head to grab toilet paper and reach for a washcloth, P#1 grabbed IJ and pulled the IJ out. PCA called nurse for assistance.

16. In interview of 3/26/2024 at approximately 1600 hours with MD1 (Doctor of Osteopathy), he/she indicated was not made aware of patient not receiving prescribed seizure medications or that nursing services consulted to have medications changed to an available route. MD1 also indicated when paged about P#1 incident in the restroom, he/she was concerned that the patient was out of bed with only a sitter and not in restraints as ordered. MD1 indicated P#1 had behavioral outbursts and according to past medical history had pulled out PEG tube numerous times.