HospitalInspections.org

Based on interview and document review, the hospital failed to ensure patients were given medications per physician orders for 2 of 2 patients (P1, P2) on the inpatient psychiatry unit when registered nurse (RN-A) did not follow physician orders and gave P1 and P2 medications to "knock them out." This had the potential to affect all patients receiving medications from RN-A. The failure resulted in an Immediate Jeopardy (IJ). As a result, the hospital was found out of compliance with the Condition of Participation of Nursing Services at 42 CFR 482.23.

A condition-level deficiency was issued.

See A-0405.

Based on interview and document review, the hospital failed to ensure patients were given medications per physician orders for 2 of 2 patients (P1, P2) on the inpatient psychiatry unit when registered nurse (RN-A) did not follow physician orders and gave P1 and P2 medications to "knock them out." This had the potential to affect all patients receiving medications from RN-A. The failure resulted in an Immediate Jeopardy (IJ).

The IJ began on 11/19/23, when RN-A failed to follow facility practice/policy and administered multiple as needed psychotropic medications and other medications at one time outside of the physician order parameters which caused sedation and resulted in P1 and P2 being sedated. The Vice President (VP) Chief Nursing Officer (CNO), System Director of Regulatory & Accreditation, and two System Program Manager in Regulatory & Accreditation were notified of the IJ findings on 12/7/23, at 12:00 p.m. The IJ was removed on 12/8/23, at 1:35 p.m. after verification of an acceptable removal plan, but a condition level deficiency was issued.

Findings include:

P1 Admission record indicated P1 admitted to the hospital on 11/19/23 with diagnoses that included bipolar disorder, most recent episode manic, severe with psychotic behavior.

P1's Physician Orders dated 11/19/23 included:
-haloperidol (Haldol, an antipsychotic medication) 5 milligrams (mg) by mouth (po) every 8 hours as needed (PRN). Administration instructions: Emergency use for agitation.
-lorazepam (Ativan, an antianxiety medication) 2 mg po every 8 hours PRN. Administration (Admin) instructions: Emergency use for agitation.
-diphenhydramine (Benadryl, an antihistamine medication) 50 mg po every 8 hours PRN. Administration instructions: Emergency use for agitation.
The Physician Order directed to GIVE HALOPERIDOL, LORAZEPAM and DIPHENHYDRAMINE AT THE SAME TIME.
-hydroxyzine (Atarax, an antihistamine medication) 25 mg po every 4 hours PRN. Admin instructions: Administer only if there is no other oral medication ordered prn for anxiety. Consider discontinuing if another PRN is ordered for anxiety.
-olanzapine (Zyprexa, an antipsychotic medication) 10 mg po 3 times daily PRN. Admin instructions: Not to exceed 30 mg in 24 hours. Doses should be at least 2 hours apart. Olanzapine to be used first line for agitation, unless otherwise specified.

On 11/19/23, at 8:05 a.m. P1's medication administration record (MAR) indicated the following medications were given by RN-A: diphenhydramine 50 mg po, haloperidol 5 mg po, lorazepam 2 mg po, olanzapine 10 mg po, and hydroxyzine 25 mg po. At 1:58 p.m. a progress note written by RN-A indicated P1 was agitated, animated and hyper-verbal that morning.

P2's Admission Record indicated R2 admitted to the hospital on 10/27/23, with diagnoses included schizophrenia, schizoaffective disorder, chronic with acute exacerbation, depression, and suicidal ideation.

P2's Physician Orders dated 11/19/23 included:
-alprazolam (Xanax, an antianxiety medication)1 mg po 2 times daily PRN for anxiety.
-chlorpromazine (Thorazine, an antipsychotic medication) 25-50 mg po 3 times daily PRN.
-hydroxyzine (Atarax) 50 mg po every 4 hours PRN. Admin Instructions: Administer only if there is no other oral medication ordered prn for anxiety. Consider discontinuing if another PRN is ordered for anxiety.
-lorazepam (Ativan) 0.25 mg po 1 time daily PRN.

On 11/19/23 at 8:09 a.m., P2's MAR indicated chlorpromazine 50 mg po, hydroxyzine 50 mg po and lorazepam 0.25 mg po were given at the same time by registered nurse (RN)-A. At 11:33 a.m. a progress note written by RN-A indicated he gave P2 PRN thorazine for auditory hallucinations, and PRN ativan and hydroxyzine for increasing anxiety.

On 12/5/23 at 9:53 a.m., RN-F stated the provider would set up the time and the parameters for PRN medications. RN-F stated nurses in the inpatient psychiatry units were expected to take a set of vital signs and assess patients prior to medicating patients with PRN medications.

On 12/5/23 at 10:00 a.m., the nurse manager, RN-D stated on 11/19/23 at approximately 11:24 a.m. RN-B notified her via text that RN-A had intentionally over medicated P1. RN-D stated she instructed RN-B to call the hospitalist if further guidance was needed, and to file an internal incident report. RN-D stated RN-A was allowed to finish his day shift, as well as an afternoon shift which included providing care to patients, including medication administration. RN-D stated the facility reviewed P1 and P2's MAR for 11/19/23, but did not look other days P1 and P2 may have been given incorrect medications by RN-A, nor did they look at any other patients who may have been given incorrect medications by RN-A.

On 12/5/23 at 1:17 p.m. RN-B stated on 11/19/23 during shift report handoff, RN-A was informed P1 had been administered Ativan 2 mg at 7:07 a.m. RN-B stated after receiving report RN-A stated, "I wished I could give a B52 (a medication combination of Ativan, Benadryl, and Haldol) to P1." RN-B stated later that shift, RN-A told him he had intentionally over-medicated P1. RN-B stated RN-A had stated he was "two for two" for knocking out patients that shift. RN-B stated he had observed P1 on 11/19/23 at approximately 7:30 a.m., and P1 did not have any behaviors. RN-B stated he had assessed P1 at approximately 9:00 a.m. and at that time, P1 appeared overly sedated. RN-B stated the Pyxis (automated medication cart) would not let you double medication at close intervals unless you canceled a previous medication administration record. RN-B stated RN-A did cancel a previous medication administration record in order to give P1 Ativan 2 mg again.

On 12/5/23 at 2:13 p.m., nurse practitioner (NP)-A stated a week and half prior to the incident on 11/19/23, she raised a concern over how RN-A was administering PRN Ativan and Thorazine at the same time to P2, even though P2 already had scheduled medications to keep him calm. NP-A stated when she confronted RN-A he seemed receptive to the correction.

On 12/5/23 at 3:50 p.m., the pharmacy manager (PM)-A stated she expected nurses to follow medication orders as given by the clinicians to prevent misuse or medication errors. PM-A acknowledged there would be a risk of respiratory distress/sedation if Ativan 2mg, Haldol 5 mg, Benadryl 50 mg, Hydroxyzine 25mg, and Zyprexa 10 mg were given all at the same time, as had happened with P1.

On 12/5/23 at 4:11 p.m., the psychiatric unit director of nursing (DON) stated RN-A had been coached previously about medication administration included the parameters and the frequencies. The DON stated it was not the hospital process to give olanzapine and hydroxyzine along with Ativan, Haldol and Benadryl. The DON stated there was no system in place to prevent further occurrence; they trained their nurses and trusted them to follow physicians' orders.

On 12/6/23 at 10:00 a.m., RN-C stated on 11/19/23 at 7:07 a.m. she gave P1 Ativan 2mg, documented that in the MAR, and gave a verbal report to RN-A. RN-C stated when she came back to work at 3:00 p.m., she realized her documentation on P1's Ativan was modified to "not given" by RN-A. RN-C stated she notified RN-D via email to address the issue.

On 12/6/23 at 4:16 p.m., the CNO stated the hospital completed an investigation, and determined RN-A intentionally did not follow physician's orders for P1 and P2 related to medication administration. The CNO also stated RN-A did not monitor vital signals on P1 and P2 which placed both patients at a safety risk.

The hospital investigation dated 11/29/23 indicated:

For P1: The provider order includes for Ativan 'This drug may cause significant respiratory depression. Monitor respiratory status and vital signs carefully for 1 hour after each dose'. Vital signs were not completed. And no patient assessments were completed. This was verified by the flowsheet and video surveillance. This patient was non-responsive and mumbling when the provider tried to assess him. Vital signs are ordered every shift.

For P2: The first line treatment for anxiety was hydroxyzine, RN-A administered Ativan. During the investigative interview RN-A reported the patient said hydroxyzine was not effective, but this was administered anyway. This patient also received lisinopril which can reduce heart rate and blood pressure. Vitals were not obtained before administering this medication. There were no vital signs taken until 6:53 p.m. It is standard/best practice to obtain vitals before administering blood pressure medications. Vital signs are ordered every shift. Several of RN-A's coworkers reported he verbalized intentionally overmedicating patients stating, "You guys, I'm intentionally overmedicating my patients today; I'm going to say I found a pill on the floor, I'm two for two in knocking them out."

The facility Medication Administration policy reviewed 11/22/22 directed its purpose is to ensure the safe and effective management of medications throughout administration and monitoring processes, as well as meet regulatory compliance and adherence to established best practice standards. The policy directed nurses to assess and document vital signs prior to and/or after medication administration as appropriate to the medication or based on parameters within the order or protocol.

The IJ was removed on 12/8/23, at 1:35 p.m. after the following actions were completed: The medication administration policy was reviewed. A mandatory education of current policies and processes around PRN medication administration including justification of use for appropriate indications and stacking of medications was provided to all nursing staff who administer psychoactive medication. This was to be completed prior to the start of their next shift, any staff on leave were required to complete prior to their first shift. The DON reviewed all medication administration records for those patients assigned to RN-A on 11/19/23 to ensure no other patients were overmedicated. This was verified through staff interview and document review.