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Tag No.: A0396
Based on record review and staff interview, the hospital failed to ensure the nursing staff developed and kept current an individualized, comprehensive nursing care plan for each patient as evidenced by failing to include patients' medical diagnoses/problems in the Master Treatment Plan for 2 (#5, #7) of 16 (#1-#16) sampled patients.
Patient #7
Review of the clinical record for Patient #7 revealed the patient was a 45 year old male admitted to the hospital on 03/04/13 with diagnoses of Chronic Paranoid Schizophrenia and Polysubstance Dependence. Review of the psychiatric evaluation dated/timed 03/04/13 at 11:45 p.m., revealed the patient had a Colectomy with a colostomy 4 days ago for adenocarcinoma of the colon, and would probably undergo chemotherapy. Further review of the psychiatric evaluation revealed the patient had been admitted to the hospital prior to the surgery and was referred to Hospital "a" on 02/21/13 for abdominal pain.
Review of the physician orders dated/timed 03/04/13 at 11:30 p.m. revealed orders for pain medication as needed. Further review of the physician orders dated 03/07/13 at 4:42 p.m. revealed orders for daily ostomy care, vital sign parameters to report to the physician, and wound care instructions. Review of the orders dated 03/12/13 revealed orders for double portions of food and supplements.
Review of the Master Treatment Plan, updated 03/12/13 revealed no documented evidence the patient's surgery, pain management, wound care, colostomy care, or nutritional needs were included in the treatment plan.
In a face-to-face interview on 03/14/13 at 9:55 a.m., S1 Director of Nursing (DON) reviewed the clinical record for Patient #7. S1DON verified the Master Treatment Plan did not include the patient's medical diagnoses of Colectomy with colostomy, Adenocarcinoma of the colon, pain management, or nutritional needs. S1DON stated major medical problems were to be included in the Master Treatment Plan and stated she would have expected the colostomy to be addressed in the treatment plan.
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Patient #5
A review of the closed clinical record for Patient #5 revealed the patient was a 17 year old male admitted to the hospital on 01/02/13 and was discharged from the hospital on 02/18/13. Patient #5's admit diagnoses and discharge diagnoses were Conduct Disorder, Attention Deficit Hyperactivity Disorder, Dysthymic Disorder, Encopresis, Mild Mental Retardation, Chronic Constipation, Glucose-6-Phosphate Dehydrogenase Deficiency with related Anemia and Neutropenia.
A review of Patient #5 Master Treatment Plans during the month of January 2013 and February 2013 revealed no documented evidence the patient's Mental Retardation, Chronic Constipation, Anemia or Neutropenia were included in any of Patient #5 Master Treatment Plans.
In a face-to-face interview on 03/14/13 at 9:55 a.m., S1DON reviewed the clinical record for Patient #5. S1DON verified the Master Treatment Plans for Patient #5 did not include the patient's medical diagnoses of Mental Retardation, Chronic Constipation, Anemia and Neutropenia. S1DON stated medical problems were to be included in the Master Treatment Plan.
Tag No.: A0405
Based on record review and staff interview, the hospital failed to ensure that medications were administered in accordance with the order of the physician and acceptable standards of care for 2 (#4, #7) of 16 (#1-#16) sampled patients. This resulted in 2 medication errors noted during chart review that were not identified by the hospital for Patients #4 and #7. Findings:
Review of the hospital policy titled, "Medication Administration" Policy # NS.5048, effective 01/02/13, provided by S2 Administrator as current, revealed in part the following: Proper procedure for the safe administration of medication will be followed. For Nursing Service, medication is to be administered by authorized RN's or authorized LPN's according to applicable laws and guidelines....C. Medication Administration Times....Stat or "Now" - within 30 minutes of receipt of order (nurse sign-off)....
Patient #7
Review of the active clinical record for Patient #7 revealed the patient was a 45 year old male admitted to the hospital on 03/04/13 with diagnoses of Chronic Paranoid Schizophrenia and Polysubstance Dependence. Review of the psychiatric evaluation dated/timed 03/04/13 at 11:45 p.m., revealed the patient had a Colectomy with a colostomy 4 days ago for adenocarcinoma of the colon, and would probably undergo chemotherapy.
Review of the physician's orders dated/timed 03/04/13 at 10:50 p.m., revealed an order for Quetiapine (Seroquel-antipsychotic medication) 800 mg. PO (By mouth) Q HS (every bedtime) - 1st dose now, and Bentyl (Drug used for irritable bowel syndrome) 20 mg. PO 4 times daily X (times) 5 days - 1st dose now.
Review of the Medication Administration Record (MAR) dated 03/04/13 through 03/10/13 revealed no documented evidence the Quetiapine or the Bentyl was administered on 03/04/13. Further review of the MAR revealed the Bentyl was not administered until 8:00 a.m. on 03/05/13 and the Quetiapine was not administered until 8:00 p.m. on 03/05/13.
In a face-to-face interview on 03/12/13 at 10:50 a.m., S4RN reviewed the physician's orders and MARs for Patient #7. S4RN verified there was no documented evidence that the "now" doses of Quetiapine and Bentyl ordered on 03/04/13 were administered. S4RN verified the first doses of the both medications were not administered until the next day (03/05/13).
In a face-to-face interview on 03/14/13 at 9:55 a.m., S1 Director of Nursing (DON) reviewed the clinical record for Patient #7. S1DON verified there was no documented evidence the "now" doses of Quetiapine and Bentyl ordered on 03/04/13 were administered. S1DON verified the hospital policy to administer stat or now ordered medications within 30 minutes of the nurse sign off time.
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Patient #4
A review of the closed clinical record for Patient #4 revealed the patient was a 33 year old male admitted to the hospital on 01/02/13 and discharged from the hospital on 01/08/13. Patient #4's admit diagnoses were Substance Abuse and Anxiety.
A review of the physician's orders dated 01/04/13 and timed at 9:30 a.m., revealed an order for Inderal LA 60mg po (by mouth) Q day (every day) for anxiety,1st dose NOW.
A review of the Medication Administration Record (MAR) dated 01/02/13 through 01/08/13 revealed the Inderal LA 60mg was documented by the nurse as being administered to Patient #4 on 01/04/13 at 1300 (1:00 p.m.).
In a face-to-face interview on 03/14/13 at 9:55 a.m., S1DON reviewed the clinical record for Patient #4. S1DON verified the Inderal LA 60mg was documented as being given at 1:00 p.m on 01/04/13, 3 and 1/2 hours after it was ordered by the physician. S1DON verified the hospital policy on STAT or NOW medications when ordered by a physician are to be administered within 30 minutes.
Tag No.: A0500
Based on interview and record review, the hospital failed to provide patient safety by controlling and distributing drugs and biologicals with applicable standards of practice as evidenced by failing to ensure that all first doses of non-emergent medications were reviewed by a pharmacist for therapeutic appropriateness, duplication, correct drug, dose, route, and frequency, interactions, allergies, or other contraindications before the first dose was administered. This practice had the potential to affect 49 of 49 patients in the hospital.
Findings:
Review of the "Pharmacy Management Agreement" between the hospital and the contracted Pharmacy service (Pharmacy "a"), dated 12/21/12, revealed in part the following:.... 1.2 Pharmacy "a" shall manage and operate the Pharmacy and provide adequate coverage required in connection with the Service to be furnished to Health Care Facility....1.14 Pharmacy "a" shall provide patient medication profile monitoring at the time of dispensing for medication allergies, drug interactions, therapy duplication, contraindications and safe dosing, with notification provided by the pharmacist to the prescriber of any serious or significant issues.
In a face-to-face interview on 03/12/13 at 10:20 a.m. S21LPN verified she administered medications to the patients on the adult unit. S21LPN stated the pharmacy was open from 8:00 a.m. to 5:00 p.m. When asked how medications ordered after 5:00 p.m. were obtained, S21LPN stated she did an over ride with a witness (another nurse). S21LPN stated if the new medication was not in the Pyxis (on her unit), she did a global search of all the hospital's Pyxis units. S21LPN stated if the medication was not found in any Pyxis unit, she would have to call the Pharmacist. S21LPN stated the Pharmacist did not review new medications ordered after 5:00 p.m.
In a face-to-face interview on 03/12/13 at 11:20 a.m., S3 Director of Pharmacy stated the Pharmacy hours were 8:00 a.m. to 5:00 p.m., Monday through Friday. S3 Director of Pharmacy stated the first dose review for new medications ordered after 5:00 p.m. during the week and anytime on weekends was done by the House Manager who was a Registered Nurse (RN). S3 Director of Pharmacy stated after 5:00 p.m. and on the weekend, the new orders were faxed to the House Manager who reviews the medications for allergies, sensitivities, and interactions. S3 Director of Pharmacy stated the pharmacist reviewed the medications on the next business day when they entered the medications into the profile. She verified new medications ordered on the weekend were not reviewed by the pharmacist until Monday. S3 Director of Pharmacy verified the Pharmacist review of the new medications ordered after pharmacy hours was retroactive. S3 Director of Pharmacy provided a document titled, "Afterhour Medication Orders" as the process the hospital followed for medications ordered after pharmacy hours. Review of the document revealed the following:
The writing of after hour orders for new medications should be limited to urgent medications. For a night time admit, consideration should be given to starting medications with the morning dose. All medication orders written for a new medication must be reviewed for appropriateness prior to removal from Pyxis. Orders written after hours are not reviewed by Pharmacy for appropriateness and are not entered into the client's Pyxis profile with related safe guards/alerts. Therefore, these orders must be reviewed for potential adverse drug interactions....The House Manager will review....
In a face-to-face interview on 03/12/13 at 2:30 p.m., S3 Director of Pharmacy provided documentation of the hospital's overrides for new medications for the last 30 days. S3 Director of Pharmacy verified there were 286 overrides for new medications. S3 Director of Pharmacy verified the pharmacist review of these new medications was retroactive to the first dose administration.
Tag No.: B0120
Based on record review and staff interview, the hospital failed to ensure the written treatment plan included the patient's medical diagnoses/problems that required treatment for 2 (#5, #7 ) of 16 (#1-#16) sampled patients. Findings:
Patient #7
Review of the clinical record for Patient #7 revealed the patient was a 45 year old male admitted to the hospital on 03/04/13 with diagnoses of Chronic Paranoid Schizophrenia and Polysubstance Dependence. Review of the psychiatric evaluation dated/timed 03/04/13 at 11:45 p.m., revealed the patient had a Colectomy with a colostomy 4 days ago for adenocarcinoma of the colon, and would probably undergo chemotherapy. Further review of the psychiatric evaluation revealed the patient had been admitted to the hospital prior to the surgery and was referred to Hospital "a" on 02/21/13 for abdominal pain.
Review of the physician orders dated/timed 03/04/13 at 11:30 p.m. revealed orders for pain medication as needed. Further review of the physician orders dated 03/07/13 at 4:42 p.m. revealed orders for daily ostomy care, vital sign parameters to report to the physician, and wound care instructions. Review of the orders dated 03/12/13 revealed orders for double portions of food and supplements.
Review of the Master Treatment Plan, updated 03/12/13 revealed no documented evidence the patient's surgery, pain management, wound care, colostomy care, or nutritional needs were included in the treatment plan.
In a face-to-face interview on 03/14/13 at 9:55 a.m., S1 Director of Nursing (DON) reviewed the clinical record for Patient #7. S1DON verified the Master Treatment Plan did not include the patient's medical diagnoses of Colectomy with colostomy, Adenocarcinoma of the colon, pain management, or nutritional needs. S1DON stated major medical problems were to be included in the Master Treatment Plan and stated she would have expected the colostomy to be addressed in the treatment plan.
30172
Patient #5
A review of the closed clinical record for Patient #5 revealed the patient was a 17 year old male admitted to the hospital on 01/02/13 and was discharged from the hospital on 02/18/13. Patient #5's admit diagnoses and discharge diagnoses were Conduct Disorder, Attention Deficit Hyperactivity Disorder, Dysthymic Disorder, Encopresis, Mild Mental Retardation, Chronic Constipation, Glucose-6-Phosphate Dehydrogenase Deficiency with related Anemia and Neutropenia.
A review of Patient #5 Master Treatment Plans during the month of January 2013 and February 2013 revealed no documented evidence the patient's Mental Retardation, Chronic Constipation, Anemia or Neutropenia were included in any of Patient #5 Master Treatment Plans.
In a face-to-face interview on 03/14/13 at 9:55 a.m., S1DON reviewed the clinical record for Patient #5. S1DON verified the Master Treatment Plans for Patient #5 did not include the patient's medical diagnoses of Mental Retardation, Chronic Constipation, Anemia and Neutropenia. S1DON stated medical problems were to be included in the Master Treatment Plan.