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Based on record review, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to ensure Patient #3's family member/Medical Power of Attorney was notified of a change in condition which required and x-ray and STAT CT scan.

The hospital's Patient Care Procedure #: 17.03.20: Patient Rights and Responsibilities include: "Patients have the right to receive assistance from a family member, representative, or other individual in understanding, protecting, or exercising their rights...Designate a representative to make decisions about their medical care on their behalf, should patients be unable to make those decisions themselves. Should the patient appoint a representative, the representative will be informed of the patient's rights and will be included in discussions concerning their care...."

Documentation in the clinical record revealed the patient developed abdominal distention and hypoactive bowel sounds during the night of 7/28/2014 and early morning of 7/29/2014. The RN notified the physician and a portable x-ray of the patient's abdomen was ordered and obtained on 7/29/2014 at 12:15 a.m. Based on the results of the x-ray, the physician ordered a "STAT" CT scan of the patient's abdomen and pelvis with intravenous contrast at 5:15 a.m. The patient's family member was not present when these tests occurred and there was no documentation that the family member was notified during the night as to why and when the tests were ordered. The patient died on 07/29/2014 at 8:45 a.m., shortly after the patient's family member arrived to visit.

Staff #5 acknowledged during an interview on 10/1/2014 that the patient's family member was not notified of her change of condition during the night which led to the x-ray and the STAT CT scan.

Based on record review, policy and procedure review, and staff interview, it was determined for Patient #5, the hospital failed to ensure the patient's home medications were transcribed accurately in the electronic health record.

Findings include:

The hospital's Patient Care Procedure #: 17.04.10: Prior to Arrival Medication List and Medication Reconciliation included: "Medication reconciliation is essential in the process to reduce risk of translation and EMR entry errors. It is important to reduce adverse medication events...Definitions...The process of comparing patient's current medications with medication orders to assist in avoiding medication errors such as: omissions, duplication, dosing errors or drug interactions. This is to be completed at every transition of care. . . Pharmacy technicians and pharmacists that have been trained may update the medication list as necessary or as asked to assist...."

A review of Patient #5's ED record revealed he arrived from a skilled nursing facility (SNF) for vomiting and diarrhea. The clinical record included copies of the Medication Administration Records (MAR) from the SNF detailing his current medication regime. The medications included "Quetiapine (Seroquel) 25 mg PO (by mouth) BID prn (2 times a day as needed) aggression..." According to the MAR, the patient had only received one dose of the medication since his admission there at 05/14/2014.

The medication, Quetiapine 25 mg, was entered into the patient's electronic health record as a scheduled two times a day administration rather than as an "as needed" administration and was ordered by the physician as a scheduled administration. The hospital's MAR's revealed the patient was given the medication three times during his stay: 05/23/2014 at 1:37 p.m. and 10 p.m. and on 5/24/2014 at 8:25 a.m.

The Clinical Manager of Pharmaceutical Services acknowledged during an interview on 10/6/2014 that an error was made when the list of medications from the SNF were transcribed into the hospital's electronic health record for the patient by a pharmacy technician.