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Based on record review and interview the facility failed to provide care in a safe setting when The Facility's Medication Reconciliation policy was not being enforced, placing patients at risk for adverse drug reactions or inadequate medical treatment for preexisting conditions.
(Patients #2 and #10)

Findings include:

Review of Admission Assessment revealed Patient #2 a 56-year-old male was admitted on 8/18/17, presenting voluntarily due to suicidal ideation, depression, Bipolar and Schizoaffective disorder. Admit height was 5 feet 3 inches and weight was 248 lbs. (pounds)

Review of the Nurses Note dated 8/18/17 at 9:35 p.m. reflected, "...patient reports medical history of HTN (hypertention), DM (diabetes mellitus) and undiagnosed sleep apnea no treatment at home. Vital signs stable. AOx3, Skin and safety check performed. No signs of acute distress at this time. Will monitor for safety. Pt. provided w/sleep wedge."

Review of Patient #2's handwritten Physician's Orders dated 8/18/17 at 8:25 p.m. reflected in part,
"Medication Reconciliation
Clozapine 200mg (milligrams) PO (by mouth) Q HS (at bedtime) Mood (the 2 in the 200 mg had been written over a 1, making it unclear what the actual order is)
Seroquel 200 mg PO QHS Mood
Celexa 10 mg PO Q HS Mood
Wellbutrin XL (extended release) 150 mg PO QAM Mood (the XL, was added in at a later date and was not transcribed on the medication administration record (MAR) by the floor nurse)
Trazadone 150mg PO QHS Insomnia
Temazepam, 7.5mg PO QHS Mood (the decimal point in the 7.5 was very faint and was transcribed as 75 mg on MAR by the floor nurse)
Exforge HCT 10/320/25mg 1-tab PO QAM HTN
Aspirin .81mg PO QAM Heart (the .81 should have been written as 0.81 or clarified to prevent an error, the floor nurse transcribed the order as 81 mg on the MAR, which is a standard dose)
Janumet 50/1000mg 1 tablet PO QAM DMII
Novolog Flex Pen 18units PO[sic] BID DM (insulin is administered subcutaeneous not by mouth, the route of administration was not transcribed onto the MAR)
Lantus 40units PO[sic] BID DM (insulin is administered subcutaeneous not by mouth, the route of administration was not transcribed onto the MAR)
Nexium 40mg PO QAM GERD ...
The orders were signed by Staff #10, RN.

During an interview on the morning of 8/31/17 Staff #8, Risk Manager, when shown the (6) six errors to the medication list, confirmed the findings. The facilities internal investigation only identified the incorrect correction to the Clozapine.

Review of the handwritten Medication Administration Record (MAR) reflected, "Temazepam 75mg, Trazadone 150mg, Clozapine 200mg and Seroquel 200 mg were all given at 2215 (10:15 p.m.) by Staff #1, RN.

Review of the Medication Administration presentation (undated) provided on 8/29/17 by the facility reflected Anti-Psychotics (Seroquel & Clozapine) common adverse effects dizziness, seizure, orthostatic hypotension, Anti-Depressant (Trazadone) Adverse Reactions drowsiness, dizziness, orthostatic hypotension. Hypnotic (Temazepam) was not reviewed in the presentation; an adverse reaction is hypotension and cardiac arrhythmias.

Review of the Nursing Progress Note dated 8/19/17 at 0145 revealed, "During MHTs rounds, MHT summoned the nurse. Nurse found patient unresponsive, no pulse, no visible signs of respirations. RN observed white foam around Pt. mouth. MHT assisted RN in moving Pt. to the floor. CPR initiated by this RN. At 0147 911 was called by MHT RN continues compressions, Staff #1 RN gave breaths with Ambu[sic] bag and O2, RN activated AED and attached the patient, no shock advised. CPR continued no pulse palpable....EMS took over care of patient...."

Review of the Memorandum of Transfer (MOT) dated 8/19/17 at 2:12 a.m. reflected Patient #2 was transported by 911 Travis County to South Austin Hospital. The diagnosis: HTN, High Cholesterol, Bladder Ca (cancer), Suicidal ideation. The MOT did not include the Equipment or Personnel needed and did not indicate if the Medication record had been sent. The patient did not have a documented history of Bladder Ca. During an interview on the morning of 8/30/17 in the facility conference room Staff #8, Risk Manager stated, "...the medication administration list should have been sent over with the patient, they must have forgotten to mark it."

Review of, Staff #10's employee file reflected a hire date of 3/8/15. Staff #10's file contained a job description title of "Admissions Registered Nurse (RN)...Staff #10 had received multiple disciplinary actions regarding order errors.
3/27/17 - Reason: Error on Orders
5/1/15 - Reason: Errors on Orders, Previous Counseled or Discipline for same/similar Reason(s) was marked, No.
1/13/16- Reason: Errors on orders, Previous Counseled or Discipline for same/similar Reason(s) was marked, No.
Staff #10's employee file did not contain yearly evaluations or any documented additional training received to prevent further errors.

During an interview on the morning of 8/30/17 in the facility conference room Staff #13, Admissions Director stated, "I am Staff #10's supervisor...I had her on a performance improvement plan. She (Staff #10) would write an order and then she would have the nurse supervisor double check the order." Review of the performance improvement plan ended 6/2015. No further training or review was documented.

When asked about the lack of evaluations Staff #13 stated, "Staff #10 was full time, then she did not work for a while. She didn't have any problems, but she wasn't working here, she just recently started picking up shifts. ...she (Staff #10) wasn't pulled from the schedules, I told her she was going to receive a write up when she returned."

When asked about the XL added to the Wellbutrin order, Staff #13 stated, "that's not her (staff #10's) handwriting. I don't know who added it...."

Additional patient record reviewed revealed patient #10 was admitted on 1/6/17 at 1:06 a.m. with a diagnosis of Psychiatric schizophrenia, htn, herpes, glaucoma. Staff #11, RN completed the Admitting Orders/ Medication Reconciliation form.

Review of Patient #10's admitting medications list included in part,
Risperdal 2 mg PO Q am
Risperdal 4 mg PO Q HS
Divalproex sodium 250 mg oral tablet, delayed release: 1 tab(s), PO (oral), Q HS
Divalproex sodium 500 mg oral tablet, delayed release: 2 tab(s), PO (oral), Q HS
Gabapentin 300 mg oral capsule: 1 capsules, PO (oral), tid
Gabapentin 800 mg oral capsule: 1 capsules, PO (oral), tid
Valacyclovir 500 mg oral tablet: 1 tab(s), PO (oral), q Day

Patient #10's transcribed Medication Reconciliation list reflected The Risperdal 2 mg was transcribed to be given in the am not at bedtime and the Risperdal 4 mg was not transcribed, the Gabapentin 800 mg (used for nerve pain and anticonvulsant), Divalproex Sodium 250 and 500 mg (used for seizures) and Valacyclovir 500 mg (used to treat herpes) medications were not transcribed to the medication reconciliation form for the physician to review.

During an interview on the morning of 9/1/17 in the facility conference room Staff #12, Chief Operating Officer confirmed the finding and when asked why Patient #10's medication list did not match the Medication reconciliation list Staff #12 stated, "...they should be writing all the medications and letting the doctor decide which ones to continue...I don't know if she was working off another list...I plan to add the medication reconciliation to the training next week...our forms need to be updated, it doesn't include everything in the policy...." Staff #12 confirmed the policy was not being fully utilized.

FACILITY POLICIES

Review of the facility provided document job description for Admissions Registered Nurse (RN) (dated October 2015) "...KEY RESPONSIBLILITIES...5. To obtain as accurate a medication list as possible. 6. To write orders given by the physician accurately...Nursing Responsibilities...Completes the medication reconciliation for potential admissions to the hospital...Completes physician's orders accurately and legibly as dictated by the physician...."

Review of the facility provided Medication Reconciliation Policy (dated 6/19/14) reflected, "Policy: Medications shall be reviewed at the time of admission, transfer and discharge, to ensure the most accurate listing of medications is available throughout the continuum of care, and forwarded to the next provider at the time of discharge.
Procedure:
1. At the time of admissions staff will record the list of medications provided by the patient, family/guardian, care provider or medical records accompanying the patient on the Home Medication List form. The information recorded shall include the following:

a. Source of information
b. Allergies
c. List of medications
d. Name of medication
e. Dose
f. Times of days when taken by patient
g. Last time the dose taken (date and time)
h. Report of compliance with each medications
i. Verification of the information

2. The staff documenting medication shall sign the form. The patient, family/guardian (if available), shall sign the list recorded to confirm accuracy.
3. On the unit, the nurse conducting the admission shall review with the physician the list of medications and determine which medications will be continued or discontinued.
4. Rationale for discontinuation of any medications shall be document in the. [sic]
5. Any discrepancies, omissions, duplications, adjustments, deletions, additions are reconciled and documentedwhile the patient is in the hospital...."

Review of the facility provided document Basic Rights of all Patients reflected, "...Care and Treatment...29. You have the right not to be given medication you don't need or too much medication...."

Based on interview and record review the facility failed to provide an organized nursing service; the medication reconciliation policy was not followed or enforced placing patients at risk for harm.

Refer to A0386

Based on interview and record review the facility failed to provide an organized Nursing Services when the nursing administration did not implement, monitor or enforce the use of the Medication Reconciliation policy by the admissions nurses placing patients at risk for incorrect, subtherapeutic and overmedicated dosing resulting in possible harm or death.

Findings include:

Review of Admission Assessment revealed Patient #2 a 56-year-old male was admitted on 8/18/17, presenting voluntarily due to suicidal ideation, depression, Bipolar and Schizoaffective disorder. Admit height was 5 feet 3 inches and weight was 248 lbs. (pounds)

Review of the Nurses Note dated 8/18/17 at 9:35 p.m. reflected, "...patient reports medical history of HTN (hypertention), DM (diabetes mellitus) and undiagnosed sleep apnea no treatment at home. Vital signs stable. AOx3, Skin and safety check performed. No signs of acute distress at this time. Will monitor for safety. Pt. provided w/sleep wedge."

Review of Patient #2's handwritten Physician's Orders dated 8/18/17 at 8:25 p.m. reflected in part,
"Medication Reconciliation
Clozapine 200mg (milligrams) PO (by mouth) Q HS (at bedtime) Mood (the 2 in the 200 mg had been written over a 1, making it unclear what the actual order is)
Seroquel 200 mg PO QHS Mood
Celexa 10 mg PO Q HS Mood
Wellbutrin XL (extended release) 150 mg PO QAM Mood (the XL, was added in at a later date and was not transcribed on the medication administration record (MAR) by the floor nurse)
Trazadone 150mg PO QHS Insomnia
Temazepam, 7.5mg PO QHS Mood (the decimal point in the 7.5 was very faint and was transcribed as 75 mg on MAR by the floor nurse)
Exforge HCT 10/320/25mg 1-tab PO QAM HTN
Aspirin .81mg PO QAM Heart (the .81 should have been written as 0.81 or clarified to prevent an error, the floor nurse transcribed the order as 81 mg on the MAR, which is a standard dose)
Janumet 50/1000mg 1 tablet PO QAM DMII
Novolog Flex Pen 18units PO[sic] BID DM (insulin is administered subcutaeneous not by mouth, the route of administration was not transcribed onto the MAR)
Lantus 40units PO[sic] BID DM (insulin is administered subcutaeneous not by mouth, the route of administration was not transcribed onto the MAR)
Nexium 40mg PO QAM GERD ...
The orders were signed by Staff #10, RN.

During an interview on the morning of 8/31/17 Staff #8, Risk Manager, when shown the (6) six errors to the medication list, confirmed the findings. The facilities internal investigation only identified the incorrect correction to the Clozapine.

Review of the handwritten Medication Administration Record (MAR) reflected, "Temazepam 75mg, Trazadone 150mg, Clozapine 200mg and Seroquel 200 mg were all given at 2215 (10:15 p.m.) by Staff #1, RN.

Review of the Medication Administration presentation (undated) provided on 8/29/17 by the facility reflected Anti-Psychotics (Seroquel & Clozapine) common adverse effects dizziness, seizure, orthostatic hypotension, Anti-Depressant (Trazadone) Adverse Reactions drowsiness, dizziness, orthostatic hypotension. Hypnotic (Temazepam) was not reviewed in the presentation; an adverse reaction is hypotension and cardiac arrhythmias.

Review of the Nursing Progress Note dated 8/19/17 at 0145 revealed, "During MHTs rounds, MHT summoned the nurse. Nurse found patient unresponsive, no pulse, no visible signs of respirations...."

Review of the Memorandum of Transfer (MOT) dated 8/19/17 at 2:12 a.m. reflected Patient #2 was transported by 911 Travis County to South Austin Hospital. The diagnosis: HTN, High Cholesterol, Bladder Ca (cancer), Suicidal ideation. The MOT did not include the Equipment or Personnel needed and did not indicate if the Medication record had been sent. The patient did not have a documented history of Bladder Ca. During an interview on the morning of 8/30/17 in the facility conference room Staff #8, Risk Manager stated, "...the medication administration list should have been sent over with the patient, they must have forgotten to mark it."

During an interview on the morning of 8/30/17 in the facility conference room Staff #13, Admissions Director stated, "I am Staff #10's supervisor...I had her on a performance improvement plan. She (Staff #10) would write an order and then she would have the nurse supervisor double check the order." Review of the performance improvement plan ended 6/2015. No further training or review was documented.

When asked about the lack of evaluations Staff #13 stated, "Staff #10 was full time, then she did not work for a while. She didn't have any problems, but she wasn't working here, she just recently started picking up shifts. ...she (Staff #10) wasn't pulled from the schedules, I told her she was going to receive a write up when she returned."

When asked about the XL added to the Wellbutrin order, Staff #13 stated, "that's not her (staff #10's) handwriting. I don't know who added it...."

Additional patient record reviewed revealed patient #10 was admitted on 1/6/17 at 1:06 a.m. with a diagnosis of Psychiatric schizophrenia, htn, herpes, glaucoma. Staff #11, RN completed the Admitting Orders/ Medication Reconciliation form.

Review of Patient #10's admitting medications list included in part,
Risperdal 2 mg PO Q am
Risperdal 4 mg PO Q HS
Divalproex sodium 250 mg oral tablet, delayed release: 1 tab(s), PO (oral), Q HS
Divalproex sodium 500 mg oral tablet, delayed release: 2 tab(s), PO (oral), Q HS
Gabapentin 300 mg oral capsule: 1 capsules, PO (oral), tid
Gabapentin 800 mg oral capsule: 1 capsules, PO (oral), tid
Valacyclovir 500 mg oral tablet: 1 tab(s), PO (oral), q Day

Patient #10's transcribed Medication Reconciliation list reflected The Risperdal 2 mg was transcribed to be given in the am not at bedtime and the Risperdal 4 mg was not transcribed, the Gabapentin 800 mg (used for nerve pain and anticonvulsant), Divalproex Sodium 250 and 500 mg (used for seizures) and Valacyclovir 500 mg (used to treat herpes) medications were not transcribed to the medication reconciliation form for the physician to review.

During an interview on the morning of 9/1/17 in the facility conference room Staff #12, Chief Operating Officer confirmed the finding and when asked why Patient #10's medication list did not match the Medication reconciliation list Staff #12 stated, "...they should be writing all the medications and letting the doctor decide which ones to continue...I don't know if she was working off another list...I plan to add the medication reconciliation to the training next week...our forms need to be updated, it doesn't include everything in the policy...." Staff #12 confirmed the policy was not being fully utilized.

FACILITY POLICIES

Review of the facility provided document job description for Admissions Registered Nurse (RN) (dated October 2015) "...KEY RESPONSIBLILITIES...5. To obtain as accurate a medication list as possible. 6. To write orders given by the physician accurately...Nursing Responsibilities ...Completes the medication reconciliation for potential admissions to the hospital...Completes physician's orders accurately and legibly as dictated by the physician...."

Review of the facility provided Medication Reconciliation Policy (dated 6/19/14) reflected, "Policy: Medications shall be reviewed at the time of admission, transfer and discharge, to ensure the most accurate listing of medications is available throughout the continuum of care, and forwarded to the next provider at the time of discharge.
Procedure:
1. At the time of admissions staff will record the list of medications provided by the patient, family/guardian, care provider or medical records accompanying the patient on the Home Medication List form. The information recorded shall include the following:

a. Source of information
b. Allergies
c. List of medications
d. Name of medication
e. Dose
f. Times of days when taken by patient
g. Last time the dose taken (date and time)
h. Report of compliance with each medications
i. Verification of the information

2. The staff documenting medication shall sign the form. The patient, family/guardian (if available), shall sign the list recorded to confirm accuracy.
3. On the unit, the nurse conducting the admission shall review with the physician the list of medications and determine which medications will be continued or discontinued.
4. Rationale for discontinuation of any medications shall be document in the. [sic]
5. Any discrepancies, omissions, duplications, adjustments, deletions, additions are reconciled and documentedwhile the patient is in the hospital...."

Review of the facility provided document Basic Rights of all Patients reflected, "...Care and Treatment...29. You have the right not to be given medication you don't need or too much medication...."

Based on record review and interview the facility failed to administer pharmaceuticals according to the physician's prescribed orders when Patient #10 received 10 times the ordered dose of Temazepam.

Findings include:

Review of Admission Assessment revealed Patient #2 a 56-year-old male was admitted on 8/18/17, presenting voluntarily due to suicidal ideation, depression, Bipolar and Schizoaffective disorder. Admit height was 5 feet 3 inches and weight was 248 lbs. (pounds)

Review of the Nurses Note dated 8/18/17 at 9:35 p.m. reflected, "...patient reports medical history of HTN (hypertention), DM (diabetes mellitus) and undiagnosed sleep apnea no treatment at home. Vital signs stable. AOx3, Skin and safety check performed. No signs of acute distress at this time. Will monitor for safety. Pt. provided w/sleep wedge."

Review of Patient #2's handwritten Physician's Orders dated 8/18/17 at 8:25 p.m. reflected in part,
"Medication Reconciliation
Temazepam, 7.5mg PO QHS Mood (the decimal point in the 7.5 was very faint and was transcribed as 75 mg on MAR by the floor nurse)

Review of the handwritten Medication Administration Record (MAR) reflected, "Temazepam 75mg, Trazadone 150mg, Clozapine 200mg and Seroquel 200 mg were all given at 2215 (10:15 p.m.) by Staff #1, RN.

Review of the Medication Administration presentation (undated) provided on 8/29/17 by the facility reflected Hypnotic (Temazepam) was not reviewed in the presentation; an adverse reaction is hypotension and cardiac arrhythmias.

Review of the Nursing Progress Note dated 8/19/17 at 0145 revealed, "During MHTs rounds, MHT summoned the nurse. Nurse found patient unresponsive, no pulse, no visible signs of respirations. RN observed white foam around Pt. mouth. MHT assisted RN in moving Pt. to the floor. CPR initiated by this RN. At 0147 911 was called by MHT RN continues compressions, Staff #1 RN gave breaths with Ambu[sic] bag and O2, RN activated AED and attached the patient, no shock advised. CPR continued no pulse palpable...."



During an interview on the morning of 9/1/17 in the facility conference room Staff #12, Chief Operating Officer confirmed the finding and when asked why Patient #10's medication list did not match the Medication reconciliation list Staff #12 stated, "...they should be writing all the medications and letting the doctor decide which ones to continue...I don't know if she was working off another list...I plan to add the medication reconciliation to the training next week...our forms need to be updated, it doesn't include everything in the policy...." Staff #12 confirmed the policy was not being fully utilized.

FACILITY POLICIES

Review of the facility provided document job description for Admissions Registered Nurse (RN) (dated October 2015) "...KEY RESPONSIBLILITIES ...5. To obtain as accurate a medication list as possible. 6. To write orders given by the physician accurately...Nursing Responsibilities...Completes the medication reconciliation for potential admissions to the hospital...Completes physician's orders accurately and legibly as dictated by the physician...."

Review of the facility provided Medication Reconciliation Policy (dated 6/19/14) reflected, "Policy: Medications shall be reviewed at the time of admission, transfer and discharge, to ensure the most accurate listing of medications is available throughout the continuum of care, and forwarded to the next provider at the time of discharge.
Procedure:
1. At the time of admissions staff will record the list of medications provided by the patient, family/guardian, care provider or medical records accompanying the patient on the Home Medication List form. The information recorded shall include the following:

a. Source of information
b. Allergies
c. List of medications
d. Name of medication
e. Dose
f. Times of days when taken by patient
g. Last time the dose taken (date and time)
h. Report of compliance with each medications
i. Verification of the information

2. The staff documenting medication shall sign the form. The patient, family/guardian (if available), shall sign thelist recorded to confirm accuracy.
3. On the unit, the nurse conducting the admission shall review with the physician the list of medications and determine which medications will be continued or discontinued.
4. Rationale for discontinuation of any medications shall be document in the. [sic]
5. Any discrepancies, omissions, duplications, adjustments, deletions, additions are reconciled and documentedwhile the patient is in the hospital ...."

Review of the facility provided document Basic Rights of all Patients reflected, "...Care and Treatment...29. You have the right not to be given medication you don't need or too much medication...."