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Based on a medical record review, observations, policies and procedures and staff interviews, it was determined that the facility failed to ensure that medications were administered according to facility policies and accepted standards of care for one (P#1) of four sampled patients.

Findings include:
A review of P#1's medical record on 10/10/21 revealed reported medication allergies to Benadryl (medication used for allergies) and Bactrim DS (antibiotic). Benadryl was administered while P#1 was at the facility and a a written prescription for Bactrim DS was given to P#1 at discharge.

Refer to A-045 as it relates to nursing services failure to safely administer drugs based on accepted standards of practice.

Based on a medical record review, observations, policies and procedures and staff interviews, it was determined that the facility failed failed to ensure that medications were safely administered according to facility policies and accepted standards of care for one (P#1) of four sampled patients. Specifically, a review of P#1's medical record revealed reported medication allergies to Benadryl (medication used for allergies) and Bactrim DS (antibiotic). Benadryl was administered while P#1 was at the facility and a a written prescription for Bactrim DS was given to P#1 at discharge.

Findings included:

A medical record (MR) review revealed that P#1 was transferred to the facility on a 1013 (medical order for an involuntary mental health evaluation) on 10/10/21 at 5:40 p.m. due to an intentional overdose as a suicide attempt. P#1 had an admitting diagnosis of bipolar disorder (extreme mood swings that include emotional highs and lows), post-traumatic stress disorder (PTSD) (thoughts, feelings, and/or dreams related to exposure to a traumatic event), depression, and anxiety. A continued review of the "Medications Brought to Facility" form revealed that P#1 had brought in Sulfamethoxazole/Trimethoprim (Bactrim DS).

Further review of the MR revealed that P#1 had medication allergies listed for Diphenhydramine (Benadryl) and Sulfamethoxazole/Trimethoprim (Bactrim DS) on the following documents:
"Psychiatric SBAR- Intake to Unit Patient Worksheet" dated 10/10/21
"Adult PRN OTC Orders" dated 10/10/21 at 7:00 p.m.
"Admission Orders" dated 10/10/21 at 7:00 p.m.
"Admission Medication Reconciliation" dated 10/10/21 at 7:00 p.m.
"Acute Risk Notification" dated 10/10/21 at 7:20 p.m.
"History and Physical Medical," dated 10/11/21 at 8:30 a.m.
"Adult Nursing Admission History" dated 10/11/21 at 6:00 p.m. by Registered Nurse (RN) DD
"Physician ' s Orders" revealed that both medications were listed as medication allergies on 10/10/21. However, only Sulfamethoxazole/Trimethoprim was listed as an allergy from 10/11/21 to 10/14/21.
"Medication Administration Record" (MAR) revealed no allergies listed from 10/10/21 to 10/13/21. On 10/14/21, Bactrim was listed as an allergy. A note on the form revealed that Benadryl was not an allergy; it only caused nausea.

A continued review of the "Physician ' s Orders" revealed that on 10/10/21 at 6:00 p.m., a verbal order was given by Medical Director (MD) II and received by RN DD for Benadryl to be given now, once. A review of the MAR revealed that Benadryl was given to P#1 intramuscularly (IM) at 6:15 p.m. by RN DD.

A review of a "Psychiatric Evaluation/Admission Note" dated 10/10/21 at 7:00 p.m. by MD II revealed that P#1, in P#1 ' s own words, stated that she needed Benadryl IM to calm her down. She claimed to be allergic to all psychotropic medications (affected a person ' s moods, behavior, or thoughts).

A review of the "Physician ' s Orders" revealed that on 10/10/21 at 7:50 p.m., an order was entered by MD II for Benadryl to be given every six (6) hours PRN (as needed). A continued review revealed that at 9:15 p.m., a verbal order was given by Nurse Practitioner (NP) JJ and received by RN DD for an additional dose of Benadryl to be given now. A review of the MAR revealed that Benadryl was given to P#1 intramuscularly (IM) at 9:15 p.m. by RN DD.

A review of the "Night Shift RN Assessment and Progress Note" dated 10/10/21 at 10:15 p.m., written by RN DD, revealed that P#1 was "lying in bed and moaning throughout night, will continue to monitor."

A review of the "Q15 Safety Precaution Observation Sheet" dated 10/10/21 revealed documentation for 10/11/21 at 5:50 a.m. that read, "Patient was loud most of the night moaning and grunting, complaining about not being to be still so that she could sleep. Very steady on feet. And hard to understand speech."

A review of the "Physician ' s Orders" dated 10/11/21 at 11:15 a.m. revealed that the allergy to Benadryl was discontinued.

A review of a ' Day Shift RN Assessment and Progress Note" dated 10/13/21 at 8:30 a.m. revealed that P#1 requested a previously prescribed Bactrim for post-status staph infection to prevent a rash from spreading.

On 10/13/21 at 10:20 a.m., a "48-Hour Antibiotic Review and Order" was signed for oral Bactrim DS.

P#1 was discharged on 10/14/21 with a written prescription for oral Bactrim DS.

A tour of the facility was conducted on 4/19/23 at 12:00 p.m. with RM AA. A tour was conducted of the child/adolescent acute care unit, located on the third floor. The unit Nurse Manager (NM) GG explained that medication allergies were located in several places in a patient ' s MR. An observation revealed a sticker across the front of the MRs that stated if a patient was allergic to any medications or the name of the medications a patient was allergic to. RM AA explained that a medication allergy was written on the Risk Assessment Form. The form was a red piece of paper that was handed directly to the admission nurse when the patient arrived at the unit. NM GG explained that the admission nurse would document drug allergies on the initial nursing assessment. The nurse would document any drug allergies on the patient ' s MAR. It was also listed on the physician ' s medication order form.

A review of the facility ' s policy titled "Medication Administration," policy # MM 3.08, last revised 6/2021, revealed that it was the policy of the facility to ensure the safe administration of medications. The licensed nurse was responsible for the preparation, administration, and documentation of the medications based upon physician ' s orders. Prior to the medications being administered, the nurse would ensure that the six (6) rights of medications had been addressed. RIGHT medication, RIGHT patient, RIGHT dose, RIGHT time, RIGHT method of administration, and RIGHT method of administration. Further review of the policy revealed that the nurse would document the medication administration in the MAR.

A review of the facility ' s policy titled "Adverse Drug Events," policy # MM 2.11, last revised 6/2021, revealed that the facility was to report and systematically analyze the occurrence of all adverse drug events, which was defined as medication administration variances and adverse drug reactions. The definition of a "medication variance" were as follows: A medication variance was any preventable event that may cause or lead to an inappropriate use or patient harm while the medication was in the control of the health care professional, patient, or consumer.

An interview was conducted on 4/18/23 at 3:00 p.m. with the Chief Nursing Officer (CNO) BB in the conference room. CNO BB stated that she had been the CNO for five years. CNO BB explained that medication allergies were entered for patients on intake and admission. She said that medication allergies were entered into the intake assessment, nursing assessment, admission order, and MAR. CNO BB explained that prior to medications being administered to a patient, the nurse would ask the patient their name. In addition, there was a picture of the patient on the MAR to add an additional verification step. Also, the nurse would ask a technician familiar with the patient to verify the patient.

A telephone interview was conducted on 4/18/23 at 5:00 p.m. with Registered Nurse (RN) DD. RN DD stated that she had worked at the facility for a year and a half. She said that she did not recall P#1. RN DD explained that medication allergies were listed on the top of the MAR in the patient ' s MR. In addition, she informed the patient what medication she would administer before the patient took it.

A telephone interview was conducted on 4/19/23 at 10:15 a.m. with RN EE in the administrative conference room. RN EE stated that she had been employed since January 2021. RN EE stated that she did not recall P#1. She explained that medication allergies were documented on the front of the patient ' s chart, Pyxis (automated medication dispensing system), MAR, and the physician ' s medication orders. RN EE said that the nurse would notify the physician and obtain another order for an alternative medication if a patient was allergic to a medication.

An interview was conducted on 4/19/23 at 10:32 a.m. with RN (FF) in the conference room. RN FF stated that she had been employed at the facility for five years. She said that she could not recall P#1. RN FF explained that if a patient were allergic to an ordered medication, she would call the physician or the nurse practitioner (NP) to obtain an order for another medication. She further stated that medication allergies were posted on the front of the patient ' s chart, MAR, and the physician ' s orders in the MR.

An interview was conducted on 4/19/23 at 11:40 a.m. with the Intake Counselor (IC) HH in the Risk Management office. IC HH explained that a "level of care assessment" was completed that included documenting any drug allergies. Any drug allergies were listed on the intake assessment and Risk Notification Form. The patient also documented any drug allergies on their registration paperwork.

A follow-up telephone interview was conducted on 4/19/23 at 3:30 p.m. with RN DD in the conference room. RN DD stated that medication allergies were usually reported verbally by patients. She explained that the information a patient reported was not always accurate, and the patient might change what was said later. RN DD said that sometimes patients would say they were allergic to a medication because they did not like how it made them feel or did not want to take the medication. RN DD said she would ask the patient how the medication made him/her feel and what reaction the patient had when taking it. This would be documented in the nursing notes.She explained that if she had a patient with a drug allergy listed and a physician had ordered the medication, she would contact the physician to discuss the facts and allow the physician to make the ultimate call on whether to administer the medication.

A follow-up interview was conducted on 4/19/23 at 3:30 p.m. with IC HH in the conference room. He stated that patients were not always transparent about their medical history during intake. IC HH said that he often learned of medication allergies from clinical information (hospital records, mobile crisis, pharmacies) if the patient could not verbalize during processing.

A telephone interview was conducted on 4/20/23 at 9:00 a.m. with Medical Director (MD) II. He explained that he was the medical director of the facility. MD II stated that he did not recall P#1 but did have P#1 ' s MR at the time of this interview to reference. He said that his process when he received a new patient was to look at the outside of the MR, which listed the patient ' s name and if the patient was allergic to any medications. He then reviewed all orders, the nursing assessment, laboratory results, and any outside records. He continued by explaining that the nurse documented the patient ' s allergies, but if he saw the patient prior to the nurse, he would document it. MD II stated that patients often said they were allergic to a medication because they did not like how it may feel or did not want an injection. MD II stated that when he called in a verbal order for medication, the nurse would inform him of any medications the patient was currently taking and if the patient was allergic to any medications. MD II said that he could not recall if the nurse had informed him if P#1 had any medication allergies prior to him giving the verbal order for Benadryl. Additionally, MD II said that he remembered documenting on the progress note to remove the Benadryl allergy from P#1 ' s MR because P#1 did not react to receiving Benadryl. He confirmed that Sulfamethoxazole/Trimethoprim (Bactrim DS) was an additional allergy in P#1 ' s MR. He explained that it should have been removed as well because there was documentation in P#1 ' s MR that P#1 had taken it for a urinary tract infection with no reactions or issues. He said he would have written the discharge prescription for Bactrim DS based on P#1 ' s previous medication history.

A telephone interview was conducted on 4/20/23 at 9:50 a.m. with Nurse Practitioner (NP) JJ. She stated that she did not recall P#1. NP JJ explained that she could locate a patient ' s medication allergies on the front of the MR or the top of the physician ' s order form. She continued to explain that she requested the nurse to tell her about any medication allergies prior to placing a verbal order for a medication to ensure that she did order a medication that a patient was allergic to. When this surveyor asked NP II what medications she would avoid ordering if a patient was allergic to Diphenhydramine, she replied she would not order Benadryl.