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Based on record review and interviews, for one of ten sampled patients (Patient #1), the hospital failed to ensure that Physician #3 reviewed Patient #1's administration history of antibiotics (Levaquin), resulting in Patient #1 receiving three Levaquin doses in 24 hours instead of one dose in 48 hours, as intended.

Findings include:

The Hospital Internal Investigation Report, dated 09/13/2017, indicated that Patient #1 received three doses of Levaquin in less than 24 hours when the intention was one dose every 48 hours.

On 08/03/17 at 1:05 A.M., Physician #1 ordered Levaquin intravenous 750 milligram (mg) once and, at 1:13 A.M., Levaquin was administered. On 08/03/17 at 4:17 A.M., Physician #2 ordered Levaquin 750 mg by mouth every 48 hours and, at 6:26 A.M., Levaquin was administered. On 08/03/17 at 11:52 P.M., Physician #3 ordered Levaquin 750 mg by mouth every 48 hours and, on 08/04/17 at 1:32 A.M., Levaquin was administered.

The Surveyor interviewed Physician #3 on 9/21/17 at 11:30A.M. Physician #3 stated he was unaware that Patient #1 received two prior doses of Levaquin.

Based on record review and interview for two of ten sampled patients (Patient #1 and Patient #2), the Hospital failed to ensure safe administration of medications which resulted in Patient #1 receiving three doses of Levaquin (antibiotic) in 24 hours instead of one dose in 48 hours as intended and Patient #2 receiving his/her usual dose of Lantus (long-acting) insulin twice.

Findings include:

The policy titled, Medication Administration, dated 03/2017, indicated that after each medication was ordered and acknowledged, the medication needs to be posted in the medication administration record (MAR). For each medication, the registered nurse (RN) must review the medication order, checking start and end dates, number of doses to be administered and noting any free text instructions. The RN should verify and adjust the suggested schedule as needed.

The policy titled, Standard Medication Administration Times, dated 04/2017, indicated as necessary to adjust the schedule to reflect patient preferences/routines, specific order instructions and nonstandard administration times for medications.

The hospital internal investigation report for Patient #1, dated 09/13/17, and the incident report dated 08/14/17 indicated the ordering and administration of Levaquin was as follows:

On 08/03/17 at 1:05 A.M., Physician #1 ordered Levaquin intravenous 750 milligram (mg) once and, at 1:13 A.M., Levaquin was administered. On 08/03/17 at 4:17 A.M., Physician #2 ordered Levaquin 750 mg by mouth every 48 hours and the nursing staff failed to adjust the schedule of Levaquin per the ordered frequency of 48 hours and instead administered Levaquin at 6:26 A.M, only 5 hours after previous dose. On 08/03/17 at 11:52 P.M., Physician #3 ordered Levaquin 750 mg by mouth every 48 hours and the nursing staff failed to adjust the schedule of Levaquin per the ordered frequency and instead administered Levaquin on 08/04/17 at 1:32 A.M., only 19 hours after previous dose.

The Surveyor interviewed Nurse #1 at 12:20 P.M. on 9/14/17. Nurse #1 said she administered Patient #2 his/her daily dose of Lantus insulin and then went to another patient's room because of an emergency with that patient. Nurse #1 said because she was busy with the emergency, Nurse #2 offered assistance to care for Patient #2. Nurse #1 said she reported to Nurse #2 that Patient #2 needed his/her meal time insulin.

The Surveyor interviewed Nurse #2 at 12:30 P.M. on 9/14/17. Nurse #2 said she reviewed Patient #2's MAR and saw that Lantus and Regular insulin was not documented as administered. Nurse #2 said she prepared the insulin, checked the dose with another staff RN and then administered the insulin to Patient #2.

The Surveyor reviewed Patient #2's medication administration records, dated 5/24/17 on 9/14/17, and discovered that the daily insulin administration for Patient #2 was not recorded as administered by Nurse #2.