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Based on observation, interview, record review and facility policy review, it was determined the Condition of Participation was not met for 42 CFR 482.23 Nursing Services. Standard A-395 was not met as the facility failed to ensure supervision and evaluation of nursing care performed. The in-patient census was 99.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure supervision and evaluation of nursing care was performed for two (2) of ten (10) sampled Patients, (Patient #1 and #8). Registered Nurse (RN) #7 administered Patient #1 a dosage of 0.35 mg of Clonidine (blood pressure and mood stabilizer medication), which was seven (7) times the dosage the physician prescribed, which caused Patient #1 to require an Emergency Room (ER) visit for evaluation and treatment. In addition, the facility staff failed to administer Miralax (used for the management of chronic constipation) for fifteen (15) days (30 opportunities) to Resident #8 who had a diagnosis of Fecal Impaction.


The findings include:

Review of the facility's policy regarding Physician Orders: Written, Verbal and Phone, revised November 2005, revealed to ensure only authorized nursing staff accept and process physician's orders. A physician's written, verbal, or phone order was required for admissions, discharges, medications, medical and psychiatric treatments and diagnostic tests. Registered Nurses (RN) and Licensed Practical Nurses (LPN) were authorized to accept orders from physicians on patients. The nurse accepting the verbal or telephone order must write down the complete order and then read it back and receive verification from the physician/ARNP. Once the order had been verified, the nurse would sign-off with Verified Verbal Order (V.V.O) and sign the physicians name followed by the nurse's name and title.

Review of the facility's policy regarding Medication Administration, revised 01/17/07, revealed RN's may administer all classes of medication prescribed by a Medical Doctor (M.D.). The nurse must know about each medication she was administering: common usage and dosage; contraindications; side effects; and, toxic effects.

Review of the facility's policy regarding Transcription of Physician Orders, reviewed March 2002, revealed the purpose was to ensure that transcription of physician orders was done only by trained personnel. Transcription of medication orders would be done by the medication nurse. Two (2) nurses, one being an RN would check the transcription of medication orders for accuracy. At each change of shift, the oncoming and off-going medication nurse would check all patient Medication Administration Records (MAR) to ensure signatures, initials, and documentation of medications was completed. At the beginning of each shift, the medication nurse would check the MAR against the M.D. orders written during the past twenty-four (24) hours.

Review of the facility's policy regarding Verbal Medication Orders, revised May 2009, revealed miscommunication or misinterpreted abbreviations and other communications were often the source of preventable medication errors. To reduce confusion pertaining to these types of errors, the following recommendations had been developed for verbal orders to include the following elements: name of the patient; age and weight of the patient; drug name; and, dosage form. All staff members involved in the care of patients were strongly encouraged to question the prescriber when questions arose about verbal orders. Questions should be resolved prior to the preparation, dispensing, or administration of the ordered medication.

1. Closed record review for Patient #1 revealed the facility admitted the eight (8) year-old patient on 04/17/15 with diagnoses of Post Traumatic Stress Disorder, Suicidal Ideations, Episodic Mood Disorder and Bradycardia (low pulse).

Review of Patient #1's Physician Admission Orders, documented by RN #3, on 04/17/15, revealed the phyician ordered Patient #1 Clonidine 0.35 mg po every 7:00 AM, 11:00 AM and 4:00 PM three (3) times a day for sleep and mood. Blood pressure and pulse should be taken prior to each dose. The staff was to hold the medication if the blood pressure was less than eighty-five over fifty-five (85/55) and the pulse was greater than one hundred and twenty (120) or less than sixty (60). No height, weight or age was provided on the order, though the sticker that was placed on the Physician Admission Orders was noted to have a date-of-birth. RN #4 documented she verified the telephone order (VTO) by the doctors and her name. The physician order was dated 04/17/15 at 10:20 PM. The order was then verified by a second nurse, RN #2, on 04/17/15 at 10:24 PM.

Interview with RN #2, on 04/30/15 at 6:36 AM, revealed when she verified the orders that RN #3 had written, she found the orders were transcribed correctly from the Physician Admission Order to the Medication Administration Record (MAR). RN #2 stated she compared to make sure the drugs matched on the MAR, the correct frequency was documented and the right route was provided. RN #2 stated she did not normally work with children and the Clonidine 0.35 mg order did not catch her eye, although the highest she had seen administered to a child was Clonidine 0.2 mg. RN #2 stated she was aware she was on a Childrens Unit when she verified the admission orders. RN #2 stated she was aware Clonidine was used for Hypertension and if someone was given a high dose of the medication their blood pressure could bottom out or become really low and cause serious harm. RN #2 stated she was aware RN #3 was a new nurse and did not think to look at RN #3's verbal orders more closely. RN #2 stated she received training from the Director of Nursing on 04/30/15, in which the DON went over Medication Administration.


Interview with RN #1, on 04/29/15 at 12:22 PM, revealed when she received verbal orders she verified the medications with the physician by reading back and verifying. If any drug was questionable, she would call the Medical Doctor. RN #1 further explained when the nurse documented she had received the verbal orders, she must write down verified verbal order (V.V.O). RN #1 stated they had to have a second nurse verify and look at the medications to ensure the order and the MAR had the right patient, right dosage, right time and right strength documented. The second nurse would sign if he/she felt the orders were correct. RN #1 stated in Patient #1's case, she would have not signed Patient #1's orders, because the dose of Clonidine at 0.35 mg was too high and could cause an overdose. RN #1 stated she received training from the Director of Nursing on 04/28/15 in regards to Medication Administration.

Interview with RN #6, on 04/29/15 at 10:50 AM, revealed when she received verbal orders from a Doctor, she would document the orders immediately onto the Physician order sheet. RN #6 stated she would verify the orders with the Doctor and document V.T.O. RN #6 stated she would have another nurse verify the orders. The nurse verifying the orders would verify the MAR had the right times, right dosage, and right person, etc. The nurse would then sign when she felt everything was correct. RN #6 stated she had verified orders before and would have questioned the Clonidine 0.35 mg for the eight (8) year old child. RN #6 stated it was questionable and would have called her supervisor and if her supervisor did not know the answer she would have called the Doctor. RN #6 stated she would not sign the verification signature if the order was questionable and would inform the nurse who obtained the order to call the Doctor first, then sign when the order was corrected. RN #6 stated she was informed the orders were to always have a weight and height documented onto the Physician Order before faxing to the Pharmacy. RN #6 stated if a child was given Clonidine 0.35 mg the child's heart rate and blood pressure could drop and the child may pass out. RN #6 stated there was a drug book in the medication rooms for reference. RN #6 stated she had not received any training on Medication Administration at this time.

Interview with the Director of Nursing (DON), on 04/29/15 at 1:50 PM, revealed when the nurses called the Physician to obtain orders, the nurses were to read the order back to the Physician. Once the order had been acknowledged as correct, the nurse would transcribe the order onto the MAR. The nurse had to have a second nurse look at the order and compare the order to what was on the MAR, to ensure the order was written correctly. The DON stated she did not train the nursing staff verifying the orders, to monitor for the dosage of the medication, just that the medication was documented correctly from the Physician Order sheet onto the MAR. The Nurse who takes the order from the Physician must clarify the order. The DON stated the nursing staff was to always place the height, and weight on the Physician Order.

Observation of the Medications Rooms, on Unit 3 on 04/29/15 at 11:05 AM, on 1 West Medication Room on 04/29/15 at 10:45 AM and on 1 East Medication Room on 04/29/15 at 12:36 PM, revealed 2015 Drug books were in place for use.

Review of Patient #1's MAR with a start date of 04/17/15, revealed Clonidine was transcribed as 0.35 mg by mouth three times a day at 7:00 AM, 11:00 AM and 4:00 PM and signed by RN #2 and RN #3 as being correct.

Review of Patient #1's MAR, revealed RN #7 held Patient #1's 7:00 AM dose on 04/18/15 because Patient #1's blood pressure and pulse reading was eighty over forty-seven (80/47) and pulse was seventy-four (74).

Review of Patient #1's MAR, revealed RN #7 administered Clonidine 0.35 mg, on 04/18/15 at 11:00 AM. Patient #1's blood pressure was eighty over sixty-two (80/62) and pulse was eighty-four (84).

Interview with RN #7, on 04/29/15 at 12:43 PM, revealed in the morning she withheld the first dose of medication because Patient #1's blood pressure was to low. RN #7 stated when she looked at the medication she thought the dosage of the medication was too high and made a mental note to call the supervisor. RN #7 stated when it was time to administer the 11:00 AM dose, Patient #1's blood pressure was identified to be within normal limits. RN #7 stated she did not think to call the Doctor; however, she did call the Shift Supervisor. RN #7 stated she asked the Shift Supervisor about the dosage, because the dosage was an odd amount. RN #7 stated she remembered giving Clonidine 0.35 mg to an adult once and this amount of medication did not make her feel comfortable. RN #7 stated she was aware the Shift Supervisor was not a Doctor. RN #7 further stated she did not think to look at the drug book. RN #7 stated the Shift Supervisor said to go ahead and administer the medications. RN #7 administered the medications as directed.

Interview with the Shift Supervisor, on 04/29/15 at 9:30 AM, revealed on 04/18/15 in the late morning, she received a phone call from RN #7 asking her how do you give 0.35 mg of Clonidine? The Shift Supervisor informed RN #7 to administer three (3) 0.1 mg tablets and a half (1/2) of 0.1 mg to make 0.05 mg. The Shift Supervisor stated she answered RN #7 in that manner because she asked the question, how do you give it? RN #7 did not state the medication was for a child. If RN #7 would have informed her who the medication was for, the dosage would have caught her attention. If RN #7 had asked the question about the drug being right or wrong the Shift Supervisor stated she would have given RN #7 the right answer. The Shift Supervisor stated she had seen 0.1 mg of Clonidine being administered to a child, but never 0.35 mg of clonidine. The Shift Supervisor stated Clonidine could lower a patients blood pressure and become dangerously low.

Review of Patient #1's Observation Rounds, on 04/18/15 at 1:15 PM through 3:15 PM, revealed Patient #1 was resting with eyes closed in the classroom.

Review of Patient #1's Footsteps Unit Points, on 04/18/15 for the hours of 1:00 PM to 2:00 PM, revealed Patient #1 was asleep. On 04/18/15, for the hours of 2:00 PM to 3:00 PM, revealed Patient #1 was asleep and was compliant when awakened.

Review of Patient #1's Physician Orders, dated 04/17/15, revealed Patient #1's Doctor, documented on the Physician Order: 04/18/15 at 3:33 PM that the Clonidine 0.35 mg should be 0.05 mg at 7:00 AM, 11:00 AM and 4:00 PM and signed his signature.

Interview with Patient #1's Doctor, on 04/29/15 at 9:05 PM, revealed upon review of Patient #1's Physician Orders, he discovered the Clonidine was ordered at the wrong dose. The Doctor stated he informed RN #7 that the dose was not accurate and RN #7 informed the Doctor that she had administered an 11:00 AM dose to Patient #1. Patient #1's Doctor stated at the time Patient #1 was verbal and engaged, had appropriate conversation and appeared to be tired. The Doctor asked Patient #1 how he/she felt and Patient #1 informed the Doctor that he/she was fine. The Doctor stated he instructed RN #7 to call Poison Control and Poison Control informed RN #7 the patient would need direct cardiac (heart) monitoring. The Doctor stated the first four (4) hours of the medication would have a sedating effect; however, the cardiac affects of the medication could take longer to get through the system and there was some vulnerability there and could affect the system up to two (2) days.

Further interview with Patient #1's Doctor, revealed upon admission he obtained an Electrocardiogram (EKG) of Patient #1's heart and found Patient #1 to have bradycardia. The Doctor stated he had never ordered a dose of Clonidine higher than 0.1 mg. The Doctor stated when nurses obtained orders, the nurses would re-read and clarify step-by-step the orders. The Doctor stated he could recall repeating himself a couple of times to RN #3. The Doctor stated he may have stated Clonidine 0.05 mg three (3) times a day. The Doctor stated he could not recall RN #3 reading back and verifying the drug to be 0.35 mg. The Doctor stated if he would have heard the nurse say 0.35 mg he would have informed the nurse that was not the dosage he had ordered.

Interview with RN #7, on 04/29/15 at 12:43 PM, revealed the Doctor interrupted her at about 3:00 PM, to inform her there had been a medication error. RN #7 stated the Doctor had informed her to call the Hospital. The Hospital informed RN #7 to call Poison Control. Poison Control recommended for the Patient #1 to have closer observation that could not be provided by the facility and the Doctor gave the order to send Patient #1 to the hospital.

Review of Patient #1's Physician Orders, dated 04/18/15 at 4:20 PM, revealed the Doctor gave the order to transport Patient #1 to the Local Hospital Emergency Room for observation per Poison Control recommendations.

Review of Patient #1's Multidisciplinary Group Note, on 04/18/15 at 4:30 PM, revealed Patient #1 kept his/her head down throughout the group and did not participate. Patient #1 refused to speak when called upon.

Review of the Nursing 2015 Drug Handbook for the drug Clonidine, revealed children should start the medication at an 0.05 mg by mouth daily, may increase by 0.05 mg every three (3) to seven (7) days to maximum dosage of 0.3 to 0.4 mg daily. Adverse reactions to Clonidine may cause cardio vascular system to become bradycardic (low pulse), severe rebound hypertension (blood pressure elevation) and orthostatic hypotension (blood pressure suddenly falls upon standing up or stretching). The signs and symptoms of overdose were early hypertension, then hypotension, bradycardia, respiratory and central nervous system (brain and spinal cord, the processing centers of the body) depression, hypothermia (body temperature below 35 degrees celsius), drowsiness, and weakness.

Review of Patient #1's Progress Note by RN #7, dated 04/20/15 at 12:10 PM, revealed a late entry that stated Patient #1's vitals were eighty over forty-five (80/45) with a pulse of sixty (60). Patient #1 voiced being cold and was alert and oriented times three (person, place and time). Patient #1 appeared to be sleeping and placing his/her head on his/her desk; however, answered each time staff said his/her name.

Interview with the Risk Manager, on 04/28/15 at 3:15 PM, revealed she was notified of the incident on 04/18/15 at about 10:30 PM and came to investigate the incident on 04/19/15. The Risk Manager reviewed the incident report (which was a part of Quality Assurance) and found the Doctor, Family, Poison Control and Department of Community Based Services (DCBS) were all notified on 04/18/15. The Risk Manager stated when she reviewed the event, she realized there were some documentation concerns. Patient #1's medications were documented as wrong dose and transcribed onto MAR in error. The Risk Manager stated she interviewed Patient #1's Doctor and he stated the nurse read back and verified the medications. The Doctor informed RN #3, when he ordered the medication he wanted Patient #1 to have Clonidine 0.05 mg three times a day, but the nurse wrote Clonidine 0.35 mg. The Risk Manager stated the 7:00 AM dose on 04/18/15 was not available because the medications were actually delivered on 04/18/15 at 8:47 AM. The Risk Manager then questioned RN #7 if she had questioned the dosage. RN #7 stated she felt uncomfortable with the dosage and called the Shift Supervisor. RN #7 was not clear about the dosage and after she talked to the Shift Supervisor, RN #7 administered the medication. RN #7 stated she did not notice anything unusual with Patient #7 and at 3:00 PM, the Doctor walked in and saw the order was written in error and directed RN #7 to call Poison Control. Poison Control then informed RN #7 Patient #1 would need constant monitoring and Patient #1's doctor then sent Patient #1 to the Local Hospital for observation and treatment. The Risk Manager stated through her investigation, she observed the documentation to be lacking. The Risk Manager asked for RN #7 to write a late entry because there was no documentation of the incident in the progress notes. The Risk Manager stated she called the Pharmacy to talk about fail safes in regards to weight and height documentation. When the Pharmacy delivered the medication they did not recognize the medication was for a child, because there was no weight and height provided on the Physician orders sheet.

Interview with the Pharmacy Manager, on 04/29/15 at 9:58 AM, revealed Clonidine 0.35 mg was a very high dose for a child. She stated 0.1 mg three times a day was more appropriate. The Pharmacy Manager stated if the treatment was for mood disorder, she stated the treatment would be based off of weight. The Pharmacy Manager stated if a child was given Clonidine 0.35 mg at one time, the medication would cause drowsiness, lethargy, Orthostatic Hypotension, Gastric Intestinal affects, Cardiovascular and Central Nervous System affects. The Pharmacy Manager stated though the weight and height was not documented onto the Physician Orders, the Pharmacist filling the prescription should have caught the medication was for a child because there was a sticker placed by the facility onto the Physician Orders which documented the child's birthday. The Consulting Pharmacist stated there was no red flag or an alert that would catch the eye of the Pharmacist, he or she would have to just review the birthday. If a weight or height was provided, the Pharmacist would know right away that it was a child because he or she would have to input the information into the computer. We have initiated a corrective plan as of 04/20/15 with the facility in which the facility would identify the height, weight and date of birth on all physician orders.

Further interview with the Risk Manager, on 04/29/15 at 2:45 PM, revealed she found through review of the incident and clinical records, that the documentation was lacking: the read back and verification of orders; chart checks completed by nursing staff; and, transcription and clarification of physician orders before administering medications was a concern. Nurses were not using the drug book as a resource. The Risk Manager stated she identified all of this within the first twenty-four (24) hours of the incident. The Risk Manager stated she had instructed the Shift Supervisors to make sure if the nurses had any questions about medication to call the Doctor. The Risk Manager stated she talked to the Director of Nursing (DON) and informed her of all the information that needed to be educated and the education needed to be completed as soon as possible. Starting with the four (4) nurses who missed the drug error and then all nursing staff. The Risk Manager stated she talked to the Medical Director and he stated to place Clonidine on the high risk list which was located in each medication room.

Interview with the Director of Nursing (DON), on 04/29/15 at 1:50 PM, revealed she had not followed up or educated RN #3 (who took the order from Patient #1's Doctor). The DON stated typically the Manager followed up with the nursing staff. The DON stated she did talk to RN #7 on 04/20/15 about the medication error, because this was a serious matter. RN #7 stated she was not sure what had happened. RN #7 stated she called the Shift Supervisor and should have called Patient #1's Doctor. The DON stated when there was a concern, the Risk Manager would investigate the concern, then sign off that she reviewed the concern, pass the concern to the DON, who then would pass to the Unit Managers to follow up on. The Unit Managers would then document the corrective actions. The DON stated she educated the nurse who completed the medication error, but did not talk to any other nursing staff. The DON stated if a patient was to receive the wrong dosage of Clonidine the patient could go into distress. The DON stated she was aware she dropped the ball and failed to educate the nursing staff members. The DON stated she identified the medication error as the physician order sheet was not completed and the Shift supervisor was called instead of the Doctor.

Interview with Unit Manager #1, on 04/29/15 at 1:28 PM, revealed when she came in on Monday 04/20/14, she did not see any incident reports and she had been working the unit a lot. Unit Manager #1 stated the Doctor had informed her of the concern when he came in on Monday. The Unit Manager stated the only education she provided was to RN #7 as it related to calling the physician and not the Shift Supervisor and not administering Clonidine 0.35 mg to children. The Unit Manager stated she did not complete education on any other nursing staff. She further stated she had not received any training on Medication Administration from the DON.

Interview with the DON, on 04/28/15 at 3:25 PM, revealed she began training on Medication Administration on 04/28/15, out of forty-six (46) nursing staff she had only completed education on ten (10) nursing staff.

Interview with the Administrator, on 04/24/15 at 3:00 PM, revealed he was familiar with the situation with the Patient #1. The Administrator stated he was notified on 04/19/15 by the Nursing Supervisor. The Administrator stated he wanted to focus on all the nursing staff receiving training as soon as possible. The Administrator stated he assumed the DON had completed the training. The Administrator stated the interdisciplinary team met regularly every morning. The Administrator stated he could not believe the medication order went through four (4) nursing staffs hands and no one caught the error.

Review of the Local Hospital Emergency Room documentation, on 04/18/15, revealed Patient #1 arrived at 5:39 PM with a blood pressure of one hundred and five over fifty-three (105/53) and a heart rate of fifty-seven (57). Patient #1's altered status was lethargic and showed signs of toxic symptoms such as somnolence (a state of strong desire for sleep, or sleeping for unusually long periods) and bradycardia. Orders were given by the Emergency Doctor, to send Patient #1 to a Childrens Hospital located in another city, on 04/18/15 at 7:38 PM, for further cardiac monitoring because of an overdose on Clonidine 0.35 mg and required continuous cardiac/EKG monitoring. Patient #1 was discharged from the Local Hospital, on 04/18/15 at 10:20 PM, with a blood pressure of one hundred and four over sixty-two (104/62) and a pulse of fifty-one (51) and was sent to a Childrens Hospital located in another city. Further reveiw of the ER documentation revealed the potential risk of transfer may include Deterioration of condition/death and displacement of intravenous or other tubes enroute.

Review of Patient #1's Childrens Hospital stay located in another city, revealed Patient #1 arrived on 04/18/15 at 11:22 PM. Patient #1's vitals were eighty-four over fifty-eight (84/58) and pulse of sixty-eight (68). Review of Patient #1's Childrens Hospital Discharge Summary, dated 04/20/15, revealed initially Patient #1 had some Sinus Bradycardia with heart rates in the upper forty's (40) to fifty's (50) with sleep. Patient #1 had some episodes of vomiting and explosive diarrhea. Patient #1 continued to be monitored and after the next twenty-four (24) hours his/her bradycardia resolved and his/her blood pressure returned to normal limits. Patient #1 was discharged home on 04/20/15.
However, through record review and interview there was an opportunity for four (4) Registered Nurses to ensure the accuracy of the medication, before the Clonidine 0.35 mg was given.

2. Review of Patient #8's clinical record revealed the facility admitted the patient on 01/22/15, with diagnoses of Chronic Post Traumatic Stress Disorder, Mood Disorder, Sexual Abuse, Sexually Acting Out and Bowel and Fecal Impaction.

Review of Patient #8's Progress Note, dated 02/02/15 at 11:14 AM, revealed the facility contacted a Pediatric Gastroenterologist (a physician who specializes in treatments of the colon) for consult and treatment referral.

Record review of a Portable Abdominal Electromagnetic Radiation (X-RAY), date of service on 02/23/15, revealed Patient #8 had a fecal impaction in the rectosigmoid colon (the rectosigmoid colon is an often overlooked part of the digestive system. It is located near the end of the large intestine and serves to join the distal, or most distant, part of the sigmoid colon to the rectum) and constipation throughout the colon. There was no evidence of bowel perforation (a hole made my piercing). No soft tissue mass, lesions, or pathologic calcifications seen. Bony structures were normal.

Review of a Portable Abdominal X-RAY, date of service on 03/12/15, revealed compared to the previous abdominal films dated 02/23/15, there was persistent constipation throughout the colon with fecal impaction in the rectosigmoid colon. No free peritoneal air was seen. No soft tissue mass or pathologic calcifications were seen. The bony structures were normal.

Review of Patient #8's Physician Orders, revealed the Physician ordered Miralax (to treat chronic constipation) seventeen (17) grams in eight (8) ounces of fluid twice a day to be administered to Patient #8, on 04/02/15 at 3:47 PM.

Review of a Portable Abdominal X-RAY, date of service on 04/03/15, revealed there was constipation in the colon. No free peritoneal air or significant air-fluid levels were seen. There was no evidence of bowel obstruction or perforation. No soft tissue mass, lesions, or pathologic calcifications were seen. No bony fracture or destructive boney lesions were seen.

Review of Patient #8's Physician Orders, on 04/05/15 at 12:15 PM, revealed Patient #8's Miralax was to be held for seven (7) days and to start Lactulose (used for chronic constipation) fifteen (15) milliliters (ml) by mouth every day for seven (7) days. Then to repeat portable abdominal X-RAY in seven (7) days to rule out continued impaction.

Review of Patient #8's MAR, on 04/03/15 through 04/17/15, revealed Patient #8's Miralax order was held on 04/05/15. Lactulose started on 04/05/15 and continued for seven days, until 04/12/15. Further record review of Patient #8's MAR, revealed the Miralax order was not restarted. Patient #8 did not receive Miralax from 04/13/15 through 04/28/15 a total of fifteen (15) days and thirty (30) missed opportunities.

Interview with RN #8, on 04/30/15 at 11:37 AM, revealed she was familiar with Patient #8 and was aware at times Patient #8 would have leakage of stool and would cause Patient #8 to be incontinent on self. The Gastroenterologist was trying to determine if there was damage to Patient #8's colon which could have occurred through sexual abuse. RN #8 stated Patient #8 had been having continuous bowel movements up to about a week ago. Review of the Physician Order sheet, RN #8 realized she was the one who had wrote the order down and transcribed onto the MAR. RN #8 stated another nurse signed her signature that the order was written correctly onto the MAR. Review revealed two (2) nurses had signed off on the order, on 04/05/15 at 1:00 PM, that the orders were documented correctly onto the MAR. RN #8 stated she would normally flagged the order and the next shift nurse would check the order. RN #8 stated she should have marked out the seven (7) days with an X for the Miralax order then yellowed out the MAR and not restart the Miralax medications. RN #8 stated the order was checked a third time, because another nurse came behind her to complete a 24 hour check of Patient #8's record as well. RN #8 stated it was important for Patient #8 to receive the Miralax to prevent Patient #8 from becoming impacted again.

Interview with Unit Manager #1, on 04/28/15 at 10:22 AM, revealed the night shift nursing staff completed twenty-four (24) hour chart checks and the day shift completed a 7:00 AM to 7:00 PM chart check. Unit Manager #1 stated the next shift or the Shift Supervisor could sign the order was verified. RN #8 should have written the order to hold the medication and then to restart the medication after seven (7) days.

Review of Patient #8's Portable Abdominal XRAY, date of service on 04/12/15, revealed there was constipation in the colon. No free peritoneal air or significant air-fluid levels were seen. There was no evidence of bowel obstruction or perforation. No soft tissue mass, lesions, or pathologic calcifications were seen. No bony fracture or destructive bony lesions were seen.

Interview and observation of Patient #8, on 04/30/15 at 12:10 PM, revealed Patient #8's stomach appeared to be distended (swollen due to pressure from inside; bloated). Patient #8 stated he/she had a bowel movement the morning of 04/30/15. Patient #8 stated his/her stomach did not ache or feel hard.

Observation of the Medication Pass, completed on 04/29/15, revealed no medication errors. Nurses observed to be providing Clonidine medications were observed to obtain blood pressures and administer the right strength.

Interview with Unit Manager #1, on 04/30/15 at 12:00 PM, revealed with the two medication errors occurring on her units, she stated the interdisciplinary team needed to come to together to assess their protocols closely. The Unit Manager stated a part of her duty was to complete a chart check of four (4) records a month and give documentation to the DON. The Unit Manager stated reviewing MARs and Physician Orders were not a part of the chart check. The Unit Manager stated she only checked what was documented on her chart check sheet. An example would be to make sure items were timed and dated, no holes or gaps in the MAR and that all doses had been signed out.

Interview with Unit Manager #2, on 04/30/15 at 12:15 PM, revealed she was only required to complete four (4) chart audits a month, but took it upon herself to complete all chart reviews weekly. Unit Manager #2 stated the auditing tool they utilized did not specify to audit Physician Orders or MAR's. Unit Manager #2 stated she took it upon herself to look at those items because she wanted to ensure no medications were missed.

Interview with the DON, on 04/30/15 at 12:00 PM, revealed the chart audit tool was utilized before she worked at the facility. The Unit Managers were always encouraged to look at the Patients charts, though there was no tool for auditing Physician Orders or MAR's. The DON stated she had never instructed the Unit Managers to check the MAR's or Physician Orders for accuracy. The DON stated she reviewed the chart checks which were completed by the Unit Managers and then she would report the audits to the Administrator. The DON stated she had not completed random audits on the auditing tool utilized by the Unit Managers nor had she audited the Patient Records.

Review of the Auditing tool utilized by the Unit Managers, revealed the Unit Managers were to audit the MAR for completeness with signatures and times. Telephone orders were all read with V.T.O with time and date of the order and transcribed.

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