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Based on interview, record review and review of the facility's policy/procedure, it was determined the facility failed to ensure medications were administered as ordered by the physician for six patients (#1, #2, #3, #5, #7 and #9), in the selected sample of ten patients.

Findings include:

Review of the facility's policy/procedure "Documentation Guidelines for PCA/Epidural Medication" revealed PCA (Patient Controlled Analgesia) pumps are initiated and documented in the patient's electronic medical record to include the "date/time loading dose was given or infusion began and number of mg (milligrams) in loading dose, if applicable."

1. Review of Patient #1's medical record revealed the patient presented to the Emergency Room on 11/30/11 and was admitted with an infected right knee. (Patient #1's initial right lateral knee release surgery was conducted on 08/15/11.) Patient #1 underwent a "Right Knee Synovectomy, Irrigation and Debridement with IV antibiotics of Telfro for staph coverage, gram negative coverage and gram positive" on 11/30/11. The physician's post operative orders included "Morphine PCA 4 mg load, 2 mg every 10 minutes." Review of Patient #1's "Surgical Case Record" revealed the PCA pump was initiated and set up in the post-anesthesia recovery room by two nurses. One nurse entered the settings as ordered by the physician, with the exception of the loading dose, and a second nurse verified the entered settings for accuracy with the physician's ordered settings. Patient #1 was transferred to the nursing floor and there was no documentation of the patient receiving the loading dose of Morphine 4 mg while in post anesthesia recovery and/or after being transferred to the nursing floor.

2. Review of Patient #2's medical record revealed Patient #2 was admitted on 12/12/11 for a "Right Total Knee Arthroplasty." The physician's post operative orders were as follows: "Morphine PCA 4 mg load, 2 mg every 10 minutes." Review of Patient #2's "Surgical Case Record" revealed the PCA pump was initiated and set up in the post-anesthesia recovery room by two nurses. One nurse entered the settings as ordered by the physician, with the exception of the loading dose, and a second nurse verified the entered settings for accuracy with the physician's ordered settings. Patient #2 was transferred to the nursing floor and there was no documentation of the patient receiving the loading dose of Morphine 4 mg while in post anesthesia recovery and/or after being transferred to the nursing floor.

3. Review of Patient #3's medical record revealed Patient #3 was admitted on 12/12/11 for a "Right Hip Revision." The physician's post operative orders were as follows: "Morphine PCA 4 mg load, 2 mg every 10 minutes." Review of Patient #3's "Surgical Case Record" revealed the PCA pump was initiated and set up in the post-anesthesia recovery room by two nurses. One nurse entered the settings as ordered by the physician, with the exception of the loading dose, and a second nurse verified the entered settings for accuracy with the physician's ordered settings. Patient #3 was transferred to the nursing floor and there was no documentation of the patient receiving the loading dose of Morphine 4 mg while in post anesthesia recovery and/or after being transferred to the nursing floor.

4. Review of Patient #5's medical record revealed Patient #5 was admitted on 12/12/11 for a "Right Total Hip Arthroplasty." The physician's post operative orders were as follows: "Morphine PCA 2 mg load,1 mg every 10 minutes." Review of Patient #5's "Surgical Case Record" revealed the PCA pump was initiated and set up in the post-anesthesia recovery room by two nurses. One nurse entered the settings as ordered by the physician, with the exception of the loading dose, and a second nurse verified the entered settings for accuracy with the physician's ordered settings. Patient #5 was transferred to the nursing floor and there was no documentation of the patient receiving the loading dose of Morphine 2 mg while in post anesthesia recovery and/or after being transferred to the nursing floor.

5. Review of Patient #7's medical record revealed Patient #7 was admitted on 10/10/11 for a "Right Total Hip Arthroplasty." The physician's post operative orders were as follows: "Morphine PCA 2 mg load, 1 mg every 10 minutes." Review of Patient #7's "Surgical Case Record" revealed the PCA pump was initiated and set up in the post-anesthesia recovery room by two nurses. One nurse entered the settings as ordered by the physician, with the exception of the loading dose, and a second nurse verified the entered settings for accuracy with the physician's ordered settings. Patient #7 was transferred to the nursing floor and there was no documentation of the patient receiving the loading dose of Morphine 2 mg while in post anesthesia recovery and/or after being transferred to the nursing floor.

6. Review of Patient #9's medical record revealed Patient #9 was admitted on 10/24/11 for a "Left Total Knee Arthroplasty." The physician's post operative orders were as follows: "Morphine PCA 2 mg load, 2 mg every 10 minutes." Review of Patient #9's "Surgical Case Record" revealed the PCA pump was initiated and set up in the post-anesthesia recovery room by two nurses. One nurse entered the settings as ordered by the physician, with the exception of the loading dose, and a second nurse verified the entered settings for accuracy with the physician's ordered settings. Patient #9 was transferred to the nursing floor and there was no documentation of the patient receiving the loading dose of Morphine 2 mg while in post anesthesia recovery and/or after being transferred to the nursing floor.

An interview with Registered Nurse (RN) #1 (Recovery Room Nurse), on 12/14/11 at 2:00 PM, revealed she set up Patient #1's Morphine PCA pump in the recovery room on 11/30/11. She confirmed a second nurse, RN #2, verified the settings were correct and entered as ordered by the physician. She stated the loading dose of Morphine is not entered and/or administered to the patient in the recovery room. She revealed that patients are not given access to the use of the PCA pumps until after the patients have been transferred to the floor. She revealed the surgical nurses follow the orders given by anesthesia in regards to administering medication for pain relief while the patient remains in the surgery department. She stated the Morphine PCA pump loading dose is the responsibility of the receiving nursing staff.

An interview with RN #2 (Recovery Room Nurse), on 12/14/11 at 2:40 PM, confirmed that she verified the settings were correct on Patient #1's Morphine PCA pump on 11/30/11. She confirmed that the recovery room nurses do not administer the ordered loading dose of Morphine. She stated the nurses on the floor administer the loading dose.

An interview with RN #3 (Recovery Room Nurse), on 12/14/11 at 3:00 PM, verified the recovery room nurses do not enter the loading dose of Morphine on the PCA pump. The PCA pumps' lock out interval is set up according to the physician's orders by a recovery room nurse and a second recovery room nurse verifies the amount entered as correct and according to the physician's order. The loading dose is administered by the nurse on the floor.

An interview with RN #4 (5th Floor Nurse), on 12/15/11 at 11:00 AM, revealed when patients are transferred to the floor from the recovery room, their PCA pumps are already set up. She stated that she "assumed the staff who set up the PCA pump administered the loading dose of medication as ordered." She revealed the floor nurses use to set up the PCA pumps until a few months ago when new PCA pumps were obtained and the decision was made to let surgery set up the PCA pumps. She stated "I just always thought if you set the pump up, you'd administer the loading dose as ordered."

An interview with RN #5 (5th Floor Nurse), on 12/15/11 at 2:25 PM, revealed that the loading dose of Morphine was not scanned in the computer and not documented as administered to Patient #1 after he/she was transferred to the 5th floor from the recovery room.

An interview with RN #6 (Charge Nurse 5th Floor), on 12/14/11 at 2:45 PM, revealed that the recovery room nurses set up the PCA and enter the lock out interval settings according to the physician's orders. She stated, "that is all they do with the PCA pump." She stated the floor nurses review the physician's orders, complete a nursing assessment, and if a loading dose of Morphine is administered or not, depends on the condition of the patient when assessed by the nurse. She stated the responsibility of giving the loading dose of medication is the floor nurses' responsibility. She further revealed that if a patient was assessed as drowsy or sedated, the loading dose of medication would not be given by the nurse.

An interview with RN #7 (5th Floor Nurse), on 12/14/11 at 4:15 PM, revealed patients' PCA pumps are usually set up and ready to go when they arrive to the floor from surgery. She stated that the "loading dose of pain medication is usually not needed because the patients are still so sedated." She confirmed that if the patient is sedated she does not administer the loading dose of Morphine and "just leaves the loading dose entry blank." She stated, "We chart by exception." She revealed that she would not make the physician aware and/or document why the loading dose was omitted. She stated the "Admission Physical Assessment" performed on all patients upon their arrival to the floor, addressed if the patient was in pain or not. She stated "why administer a loading dose of Morphine to a patient that is not in pain and/or is sedated."

An interview with the Vice President of Patient Care Services, on 12/15/11 at 5:00 PM, confirmed there were issues discovered during the investigation related to loading doses of Morphine via PCA pumps not being administered as ordered and/or no documentation to address why the loading doses were not administered. Furthermore, there was confusion by some nurses on who was responsible for administering the loading dose and/or if the loading dose of Morphine was not administered, where was the information documented. She stated the problems would be immediately addressed and corrected.