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29108

Based on observations, staff interviews, document, and medical record review, the hospital failed to ensure an active, effective, ongoing, hospital-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program had been developed, implemented, and adjusted in order that the hospital could achieve sustainable regulatory compliance when nursing staff providing direct patient care could not demonstrate proficient knowledge and/or skill to validate facility education and training. This occurred when:

1. Nursing staff could not demonstrate sufficient knowledge to initiate the time-critical management of a patient with Malignant Hyperthermia (MH; a rare inherited genetic disorder of the skeletal muscles triggered in susceptible individuals in most instances by inhalation anesthetic agents and/or succinycholine, resulting in hypermetabolism, skeletal muscle damage, hyperthermia and death, if untreated), (Refer to Tag A0283);

2. The facility could not demonstrate that adequate education was provided to nursing staff when administering opioid pain medications with range orders to prevent medication errors, (Refer to Tags A0283 and A0405);

3. The facility did not fully implement a previous plan of correction that pertained to scanning high risk medications upon removal from an automated dispensing cabinet, (Refer to A0283) and;

4. The facility did not ensure staff followed the procedure for reporting medication errors, (Refer to A0283 and A508).

This failure to adequately assess staff knowledge and skills through a fully developed and functioning QAPI program had the potential to compromise the quality of care provided to patients in the facility.

The cumulative effect of these systemic failures resulted in the inability of the hospital to comply with the statutorily mandated Condition of Participation Quality Assessment Performance Improvement Services.

29108

Based on observations, staff interviews and document review, the hospital failed to identify and implement areas for performance improvement, measure its success, and track performance to ensure that improvements were sustained when:

1. The facility could not demonstrate sufficient performance improvement in the area of patient care, specifically, the initiation of the time-critical management of a patient with Malignant Hyperthermia (MH; a rare inherited genetic disorder of the skeletal muscles triggered in susceptible individuals in most instances by inhalation anesthetic agents (such as Halothane, and, Sevoflurane) and /or succinycholine, an anesthetic agent given intravenously, resulting in hypermetabolism, skeletal muscle damage, hyperthermia and death, if untreated) when:

1a. 4 of 5 Registered Nurses (RN 2, RN 4, RN 5, and the Operating Room Educator (ORED)), from the Outpatient Surgery Center (OPSC) and the Emergency Department (ED) could not demonstrate timely access to supplies;

1b. 2 of 2 licensed staff (RN 2, RN 3) in OPSC did not know how to alert others of a MH crisis, as specified in the 3/24/16 MH policy and procedure;

1c. Staff roles during a MH crisis were not clearly defined and;

1d. The 3/24/16 MH policy process for restocking the MH carts was inconsistent with facility practice.

These deficiencies were identified during the previous CMS (Centers for Medicare and Medicaid Services) complaint validation survey completed 2/28/16. These failures continue to have the potential to affect health outcomes, patient safety and the quality of care of the patient with MH.

2. Adequate education was not provided for opioid (Schedule II drugs for pain) range orders to prevent medication errors. This was evidenced when medications were not administered in accordance with physician orders in 3 of 5 patient records (Patients 1, 2 and 3) reviewed for opioid range orders. This failure had the potential of causing severe side effects of opioids including respiratory depression, over sedation and death;

3. Two medication errors (identified by the facility during an audit) were not reported in the facility's medication error reporting system. This failure prevented the hospital from tracking and analyzing adverse drug reactions, evaluating the adverse reactions for being potentially caused by medication errors, and taking action to prevent future recurrences and;

4. Policies and procedures were not fully implemented for removal of high risk medications (drugs that bear a heightened risk of causing significant patient harm when they are used in error) from the automated dispensing cabinet (ADC) when two nurses bypassed the scanning of norepinephrine (used to increase blood pressure during cardiopulmonary arrest) when removing it from the ADC. This failure could lead to medication errors and expose patients to serious side effects.

Findings:

1a. On 4/26/16 at 9:10 a.m., a tour was conducted of the OPSC with the Interim Surgery Director (SD), the ORED and the Family Birth Center Director (FBD). An observation was made of the MH cart. A 9/2013 MH Drug List was on the cart and included the medications found in the MH cart, such as Dantrolene (a muscle relaxant that lessens contraction in muscle cells, and is the primary drug used for the treatment and prevention of malignant hyperthermia). The list also specified that "Regular Insulin 100 units/10 milliliter (ml) vials" and "Normal Saline (0.9% solution of sodium chloride for intravenous infusion) 1000 ml x 3 (chilled)" were located "in the Omnicell (a brand of automated dispensing cabinet) refrigerator". The expiration dates for the insulin and normal saline were not documented on the drug list. As evidenced "Malignant Hyperthermia Cart Check List" in use, drug expiration dates were one of the elements checked daily by nursing staff. In addition, a review of the current (2016) MH policy with its revised attachments indicated the MH Drug List in use at the OPSC was outdated.

Observations were made of a locked medication room in the OPSC on 4/26/16 at 9:30 a.m. with the ORED, the FBD and RN 2. RN 2 was asked to remove a 1 liter bag of chilled normal saline from the Omnicell. RN 2 was observed scrolling through the list of medications on the Omnicell display screen. Despite numerous attempts and variations of the solution "normal saline", RN 2 could not find a selection for 1 liter bags of cold normal saline.

In a concurrent interview with the FBD, she explained the Omnicell should display a selection such as "malignant hyperthermia kit" or "normal saline malignant hyperthermia" to access normal saline in the Omnicell refrigerator.

At the same time, the ORED was observed opening an unlocked refrigerator in the medication room (not a part of the Omnicell). Inside the refrigerator were three 1 liter bags of normal saline. The ORED acknowledged she did not know the saline was in the unlocked refrigerator.

Further observations revealed the ORED was also unable to find a selection for normal saline from the Omnicell display. When prompted to "override" by the surveyor, the ORED did not demonstrate the ability to "override", but instead left the room to call pharmacy. Lastly, the ORED acknowledged that an alternative method to unlock the Omnicell and access the chilled normal saline in case of an emergency would be to select an alternative refrigerated medication (and when the refrigerator opened to access the alternative drug, the chilled normal saline could be removed).

During an interview with the FBD on 4/26/16 at 9:45 a.m., she stated the RNs should be able to "override" 1 liter bags of cold normal saline from the Omnicell in OPSC. The FBD also clarified that 1 liter bags of normal saline for intravenous infusion should be stocked in the Omnicell refrigerators throughout the hospital, including the OPSC, for consistency.

On 4/27/16 at 9:25 a.m., observations were made of the Emergency Department. A MH cart was located in a small hallway of the ED, easily accessible and visible to staff. A review of the binder on top of the cart revealed an 4/2014 (outdated) MH Drug List. The list did not include expiration dates for insulin or chilled normal saline. The folder contained a 2012 copy (outdated) of the MH policy. In a concurrent interview, the Emergency Department Director (EDD) stated the old Drug List would be removed from the cart. The EDD was asked how an ED staff member during her daily MH cart check would know, by looking at the Drug List, whether or not the insulin or normal saline had expired. The EDD acknowledged staff would have no way of knowing (outside of looking for the medications and their expiration dates in the Omnicell).

RN 4 was interviewed in the ED on 4/27/16 at 9:40 a.m. RN 4 was asked to access a 1 liter bag of cold normal saline from one of the medication rooms. In the medication room, RN 4 could not demonstrate removal of chilled normal saline from the Omnicell despite various attempts. RN 4 said she couldn't access the normal saline by "overriding". RN 4 stated she couldn't remove the normal saline from the Omnicell without a physician order.

On 4/27/16 at 10 a.m., RN 4 was asked to open the MH cart in the ED hallway. RN 4 could not find the key and did not know the numerical code to unlock the cart. RN 4 walked away from the cart and returned with the Emergency Department Charge Nurse/Supervisor (EDS). The EDS lifted the hard plastic liner from the top of the cart. Under the liner, the key and numerical code to unlock the cart were observed. In a concurrent interview with the EDS, she stated she expected that all RNs in the ED to know how to open and access supplies from the MH cart. Later, in a Quality Assessment and Performance Improvement group interview on 4/28/16 at 11:45 a.m., the Director of SSA Risk/Quality Services (DRQ), the EDD and the Vice President of Operations (VPOP) acknowledged the locking mechanisms on the MH carts were unnecessary.

RN 5 was observed in the ED on 4/27/16 at 10:20 a.m. A request was made by the surveyor for RN 5 to remove a cold 1 liter bag of normal saline from the medication room. RN 5 said, "I don't know how to access the normal saline" In the medication room, she was observed looking around the Omnicell refrigerator for a "key" or [numerical] code" to open it. RN 5 continued looking and said, "[there is] a code around here somewhere." It took over 6 minutes to eventually open and access cold normal saline from the Omnicell. RN 5 acknowledged the importance of being prepared for the rare event a MH reaction in the ED. She stated she recently had a patient state they were allergic to "Halothane", a type of inhalation anesthetic gas. RN 5 also acknowledged succinycholine was commonly used to sedate ED patients prior to intubation.

During a QAPI group discussion on 4/28/16 at 11:25 a.m., Pharmacist 1 stated medications in the ED Omnicell are "non-profiled", meaning all RNs should be able to access chilled normal saline from the Omnicell refrigerator.

According to the 2016 facility policy titled, "Malignant Hyperthermia", for the emergency management of MH:..."In the event of a MH crisis [in the hospital or OPSC], a Malignant Hyperthermia Alert is called and key resources and staff respond to care for the patient..." The majority of these crucial supplies are found in a MH cart, including time critical medications. "The key to successful treatment is the timely administration of Dantrolene Sodium...Establish two large bore [intravenous] access ports, if possible. 4. Anticipate the need for patient cooling..." As directed by the MH policy "Addendum B", "Infuse cold saline intravenously."

In a later interview with the EDD on 4/27/16 at 10:40 a.m., she stated she did not expect a telemetry nurse (RN 4) that worked primarily in the ED to "participate in a MH code/crisis" or know how to open the MH cart to access supplies. The EDD was uncertain if a "tele" nurse could override/access cold normal saline from the ED Omnicell. For clarification, the EDD was asked if RN 4 was needed to help during a MH crisis, what role would she have. The EDD explained RN 4 should be "aware" of the MH cart but not treat or manage a patient with MH.

1b. During an interview with Post Anesthesia Care Nurse, RN 2 on 4/26/16 at 10:15 a.m. in the OPSC, she was asked how she would alert others in the department in the event of a patient MH reaction. RN 2 explained she would contact the anesthesiologist and make a call to the Operative Room. RN 2 stated she would call out for help. RN 2 said she would not call a MH Alert overhead to avoid disturbing other patients or family in the waiting room.

RN 3 was interviewed in OPSC on 4/26/16 at 10:30 a.m. RN 3 did not know how to overhead page a "Malignant Hyperthermia Alert".

Observations were made of the preoperative area of the OPSC on 4/26/16 at 11:05 a.m. In a concurrent observation with the SD and FBD, a sign was posted under the counter of the nursing station, behind a telephone. The sign read: [To overhead page], "Dial x 7000702. Wait for '2 dings'. Dial 02 and start speaking." Later, in a QAPI group interview on 4/28/16 at 11:50 a.m., the Director of SSA Risk/Quality Services (DRQ) and the Vice President of Operations (VPOP) acknowledged the current OPSC paging process would be challenging to remember.

According to the 2016 facility policy titled, "Malignant Hyperthermia", in the OPSC, staff should" 1. Dial 911 and notify them of the emergency. 2. Overhead page 'Malignant Hyperthermia Alert' and the location of the patient..."

1c. The EDD was interviewed on 4/27/16 at 10:40 a.m. When asked, the EDD could not describe specific roles or assignments staff may have when attending to a patient with MH. "Everyone shows up; too many can be dangerous," the EDD said.

During the QAPI group meeting on 4/28/16 at 12:18 p.m., the Director of SSA Risk/Quality Services (DRQ) acknowledged that the current MH policy and procedure did not define specific staff roles or assignments to initiate timely, efficient and effective interventions. The DRQ and EDD acknowledged the importance of assigned roles during an MH code, much like those during a Code Blue.

According to the 2016 facility policy titled, "Malignant Hyperthermia", in the case of a "Hospital MH Alert", "key facility personnel will respond to the MH Alert", including the "Administrative Nursing Supervisor, the Anesthesiologist or Certified Nurse Anesthetist, an ED physician (if outside OR), the OR Charge Nurse (if in OR), the ED Charge Nurse (if in ED), the OB Charge Nurse (if in OB), a member(s) of the Rapid Response Team, a Pharmacist, laboratory [staff] and a Respiratory Therapist...Key OPSC personnel will respond to the MH Alert in OPSC until Emergency Medical Personnel arrive. Charge Nurse, Anesthesiologist, Anesthesia Tech and ancillary staff assigned by Charge Nurse..." Neither the policy nor the attachments defined specific roles for staff responding to a MH crisis.

In an interview with the ORED on 4/26/16 at 9:30 a.m., she acknowledged no MH Drills were completed in OPSC since the Department's last visit to the facility (2/26/16).

1d. In an interview with RN 4 in the ED on 4/27/16 at 9:50 a.m., RN 4 stated, to restock the MH cart she would tell the ED secretary who would call central supply and pharmacy.

According to the 2016 facility policy titled, "Malignant Hyperthermia", when a MH event is over: "1. The Pharmacy Department will be notified by the clinical department to restock the medications in the MH cart and the cold saline in the Omnicell. 2. The clinical department will replace all non-medication supplies. 3. The clinical department will re-lock the MH cart and place a new tracking lock on the cart that was obtained by pharmacy...6. On the last week of the month, the clinical department is responsible for opening the cart and checking every item for outdated supplies."

During a group discussion about the facility's QAPI program on 4/28/16 at 11:45 a.m., Pharmacist 1 clarified that the pharmacy department restocked the medications for the MH cart (and Omnicell) and checked the expiration dates for all these medications. "The blue [tracking] seal on the MH cart was from pharmacy," Pharmacist 1 said. Pharmacist 1 acknowledged the current MH policy and procedure stated that the individual units were responsible for resealing the carts with the blue lock after a MH cart was used. She stated that the facility was in the process of changing the MH policy and procedure to reflect what was actually being done to restock the carts.

2) On 4/27/16 at 11 a.m., a list of documents indicating patients receiving opioid range orders for pain in the last 30 days was reviewed along with registered pharmacist Pharm 1 (a deficiency was cited on previous survey for this finding).

During review of 3 of 5 (Patient 1, 2 and 3) patient records, medication errors were identified in opioid range orders for pain (See A405). These medication errors were confirmed by registered pharmacist Pharm 1 on 4/27/16 between 11 a.m. and 1:30 p.m.

Patient 1 was administered 2 tablets of Norco (for pain) instead of 1 tablet on 4/23/16 at 12:58 a.m. as a first dose prescribed by the physician. Patient 1 was also treated with Narcan (opioid reversal agent) as he was found unresponsive.

Patient 2 was administered 6 mg (milligram) of IV (intravenous, injected through the vein) morphine (for pain) on 4/24/16 at 10:47 p.m., instead of 2mg ordered by the physician for the first dose.
Patient 3 was administered 4mg instead of the physician ordered 2 mg on 4/21/16 at 9:46 p.m.

Facility plan of correction submitted for the previous survey of 2/26/16 for a similar deficiency indicated "Education was provided to the responsible RN and to the staff in the ED (emergency department) via Pharma Gram (education material) providing specific information on dose ranges, using a case-specific example."

Review of the Pharma Gram indicated that the first dose medication errors were not addressed.

During a QAPI meeting on 4/28/16 at 11:25 a.m., EDD confirmed that in an audit done by her on 4/21/16 on 6 opioid range orders, two medication errors were identified. EDD stated that she had not followed up on the errors with one of the nurses and there had been no changes to the Pharma Gram education provided.

In a concurrent interview EDD also acknowledged that she thought about 80% of the emergency department nurses had received the education so far.

3) The facility plan of correction for the survey dated 2/26/16 indicated "Monitor: 10 Range Order Audits monthly in the Emergency Department to include: medication administration follows provider order..."

Review of the audit documents "CMS Audit: Range orders in the Emergency Department" provided by the EDD indicated that 2 of 6 audits included a medication error.

During a QAPI group interview on 4/28/16 at 12:15 p.m. EDD stated that she did not report the two medication errors that she identified during the audits into the facility medication error reporting system. EDD stated, "I should have."

Review of facility policy "Patient Safety Event Reporting and Management" dated 3/24/15 indicated "Staff who observe, discover, or are directly involved in an event should initiate an event report within 24 hours of becoming aware of the event or request that one be completed on their behalf."

4) The facility plan of correction for the survey dated 2/26/16 indicated "The Medication Administration policy was revised to include; when the high risk medication is removed from the Omnicell (ADC), the nurse will be required to scan the high risk medication and verify it is correct prior to leaving the medication preparation area."

During an interview on 4/26/16 at 9:45 a.m. the Vice President of Operations (VPOP), stated that a process had been set up since 4/21/16 whereas all high risk medications had to be scanned out of the ADC by the nurse removing the medication.

During a concurrent observation registered nurse RN 1 removed a high risk medication oxytocin (used to enhance uterine contractions) and the ADC beeped and required RN 1 to scan the barcode on the bag of oxytocin. It was observed in order to bypass the scanning the ADC required initial steps for the nurse to complete.

Review of document indicating removal of high risk medications without scanning the barcode showed 3 bags of norepinephrine were removed from the intensive care unit (ICU) ADC without scanning the barcode.

During an interview on 4/28/16 at 1:20 p.m. ICU manager, ICUM stated that she spoke with the nurses who bypassed the scanning (after surveyor identified the issue). ICUM said that one of the nurses was a per diem nurse who said she did not get the education for the new process and the other nurse was a night nurse who did not remember the education.

During the QAPI meeting on 4/28/16 at 11:25 a.m. members of the group acknowledged that reading the education material was not adequate without a method to validate the education was effective.

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29108

Based on observation, interview and record review, the facility failed to ensure that medications were administered in accordance with physician orders when errors were identified in 3 of 5 records (Patients 1, 2 and 3) reviewed for opioid (for pain) range orders. This failure had the potential of causing severe opioid side effects including respiratory depression, over sedation and death.

Findings:

a) On 4/27/16 at 11 a.m., a list of documents indicating patients receiving opioid range orders for pain in the last 30 days was reviewed along with registered pharmacist Pharm 1 (a deficiency was cited on the previous 2/26/16 survey for this finding).

Review of Patient 1's clinical record indicated that he was 76 years old and admitted to the facility on 4/19/16 and his past medical history included respiratory failure due to COPD (chronic obstructive pulmonary disease, a lung disease that makes it hard to breathe).

Review of Patient 1's eMAR (electronic medication administration record) indicated that on 4/23/16 Patient 1 was administered 2 tablets of Norco (opioid for pain) 5/325 milligrams (mg) at 12:58 a.m. and Narcan (opioid reversal agent) at 7:39 a.m.

Review of Patient 1's physician order for Norco dated 4/19/16 indicated to administer 1 to 2 tablets every 4 hours as needed for moderate to severe pain. "Start with 1 tab, assess response after 30 minutes. May repeat x1 dose after 30 minutes if pain goal not achieved. If 2 tabs (tablets) effective, continue with 2 tabs for subsequent dosing."

During an interview on 4/27/16 at 1:10 p.m. Pharm 1 confirmed that Patient 1 did not routinely take Norco before admission of 4/19/16 and should have been given 1 tablet per physician order instead of 2 that were administered on 4/23/16 at 12:58 a.m.

Review of physician report dated 4/23/16 at 7:45 a.m. indicated "Rapid Response (is a team of health care providers that responds to patients with early signs of clinical deterioration on non-intensive care units to prevent respiratory or cardiac arrest) called just now. Per RN (registered nurse), pt. largely unresponsive now...was also given 2 Norco tabs last night."

Further review of Patient 1's eMAR indicated that on 4/23/16 Patient 1 was administered Narcan (opioid reversal agent) at 7:39 a.m., in response to Patient 1's unresponsiveness and the opioid (2 Norco tablets) given earlier.

Review of hospital policy "Medication Management" dated 12/4/14 indicated "Use all of the components of the seven rights for every medication administered...Right dose...The patients eMAR must always be within view for visual verification of the seven rights of medication administration."

Review of Lexi Comp, an online drug data base, indicated for Norco (generic name hydrocodone) "Use hydrocodone with caution in patients with pre-existing respiratory compromise...COPD...Dosing: Geriatric Doses should be titrated to appropriate analgesic effect; 2.5-5mg of the hydrocodone component every 4-6 hours. Elderly: Use with caution in the elderly; may be more sensitive to adverse effects." Some of the adverse effects indicated in Lexi Comp for Norco included: cardiac arrest, clouding of consciousness, coma, dizziness, drowsiness and respiratory failure."

2) Review of Patient 2's clinical record indicated that he was admitted to the facility on 4/24/16. Patient 2's physician orders dated 4/24/16 included morphine (opioid for pain) 2 to 6mg IV (intravenous, injected through the vein) every 4 hours as needed for pain "For FIRST DOSE ONLY: Give 2mg every 15 minutes prn (as needed) up to dose per pain scale."

Review of Patient 2's eMAR indicated that 6mg of morphine was administered as the first dose on 4/24/16 at 10:47 p.m.

During an interview on 4/27/16 at 11:07 a.m. Pharm 1 and emergency room director EDD confirmed that Patient 2 was given 6mg of morphine instead of 2mg as a first dose.

Schedule II opioid agonists including morphine have the highest potential for abuse and risk of producing fatal overdose due to respiratory depression.

3) Review of Patient 3's clinical record indicated that he was admitted to the facility on 4/21/16 and his physician orders dated 4/21/16 included morphine 2 to 6mg IV every 4 hours as needed for pain "For FIRST DOSE ONLY: Give 2mg every 15 minutes prn (as needed) up to dose per pain scale."

Review of Patient 3's eMAR indicated that 4mg of morphine was administered as the first dose on 4/21/16 at 9:46 p.m.

During an interview on 4/27/16 at 11:03p.m., Pharm 1 confirmed that Patient 3 was given 4mg of morphine instead of 2mg as a first dose.

Based on observation, interview and document review facility failed to ensure that unusable drugs were not available for use when opened and used, single dose containers were stored in the pharmacy for compounding (mixing) oral preparations. This failure had the potential of exposing patients to contaminated drugs.

Findings:

During a tour of the inpatient pharmacy on 4/26/16 at 9:15 a.m., two opened and used bottles of saline solution for irrigation and sterile water were observed. In a concurrent interview registered pharmacist Pharm 1 stated that the bottles were used for compounding oral preparations including vancomycin (antibiotic).

Review of the manufacturer label on the opened bottles indicated the saline solution and sterile water were single dose containers and to discard unused portion.

Review of facility policy "Medication Control & Storage Inspection" reviewed date 1/15 indicated the purpose of the policy as"...to ensure proper storage conditions, security, drug availability, expiration date and other safety factors are met."



31272

34272

Based on staff interview and facility policy review, the facility failed to ensure that the duration of use for medication was limited in accordance with manufacturer directions. The facility policy for automatic stop orders did not reflect the manufacturer direction to limit ketorolac, an anti-inflammatory medication, use to five days for both injectable and oral administration.

This failure had the potential for patients to receive medication inconsistent with the manufacturer directions, thereby increasing the risk of internal bleeding, heart attack and stroke associated with prolonged use of ketorolac.

Findings:

On 4/26/16 at approximately 8:30 a.m., the most recent facility policy for medication stop orders was requested. Review of the provided policy, titled "Automatic Stop Orders", dated 10/22/15, indicated "Injectable ketorolac has an automatic stop date of five days."

On 4/26/16 at 12:46 p.m. during a review of the Automatic Stop Orders policy and concurrent interview with the Interim Chief Nurse Executive (CNE), the CNE acknowledged the policy did not include a stop date for oral ketorolac.

On 4/26/16 at 1:14 p.m., during an interview with the Senior Quality Director (QD), the QD confirmed the Automatic Stop Orders policy, dated 10/22/15, was the policy available for facility staff and provider use.

A review of the manufacturer package insert for ketorolac indicated, "Combined use of ketorolac...injection and tablets is not to exceed 5 days of use because of the potential of increasing the frequency and the severity of adverse reactions..."

According to Lexicomp Online (a medication information resource), "Ketorolac is indicated for the short-term (up to 5 days in adults) management of moderately severe acute pain...The total combined duration of use of ketorolac tablets and injection should not exceed 5 days." In addition, Lexicomp showed ketorolac has a Food and Drug Administration boxed warning (documented potential problems, including adverse reactions) that prolonged use may increase the risks of developing bleeding, cardiovascular events (including heart attack) and stroke.

29108

Based on interview and record review, the facility failed to ensure that two medication errors (identified by the facility during an audit) were not reported in the facility's medication error reporting system.

This failure prevented the hospital from tracking and analyzing adverse drug reactions, evaluating the adverse reactions for being potentially caused by medication errors, and taking action to prevent future recurrences.

Findings:

The facility plan of correction for the survey dated 2/26/16 indicated, "Monitor: 10 Range Order Audits monthly in the Emergency Department to include: medication administration follows provider order..."

Review of the audit documents "CMS (Centers for Medicare and Medicaid Services) Audit: Range orders in the Emergency Department" provided by the Emergency Department Director (EDD), indicated that 2 of 6 audits included a medication error.

During a group interview on 4/28/16 at 12:15 p.m. EDD stated that she did not report the two medication errors that she identified during the audits into the facility medication error reporting system. EDD stated, "I should have."

Review of facility policy "Patient Safety Event Reporting and Management" dated 3/24/15 indicated "Staff who observe, discover, or are directly involved in an event should initiate an event report within 24 hours of becoming aware of the event or request that one be completed on their behalf."