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Based on policy review, medical record review, and staff and physician interview hospital nursing staff failed to escalate observations and change in assessments for 1 of 6 Behavioral Health patients awaiting placement in the Emergency Department (Patients #5).

The findings included:

Review of the hospital's policy titled, "Assessment and Reassessment, 1PC.ADM.0013", revised 06/28/2021 revealed "... SECTION VI: EMERGENCY DEPARTMENT... B. The priority of data collection is determined by the patient's immediate condition ... E. Reassessment ... Additional assessment/reassessment elements and frequency are based upon patient condition or change in condition ... 2. Exceptions: Patient with a provisional psychiatric diagnosis, including patients presenting with potential harm to self or others, should have vital signs and assessment documented a minimum of once per shift or more frequently if patient experiences changes in behavior ..."

Review of the hospital's policy titled, "Fall Prevention and Post Fall Care Guidelines 1PC.ADM.0004.01", revised 05/2021 revealed, "... High Risk Fall Prevention Algorithm High fall risk patients ... do NOT leave in bathroom unattended! ... Post Fall Care ... Documentation A. Document known details of the fall B. Patient assessment findings and any interventions ... D. Communication with LIP/AP; included orders and interventions E. Communication with family/significant other ..."

Review of the hospital's policy titled, "Patients at Risk for Suicide in Non-Behavioral Health Settings: Identification and Monitoring 1PC.PSY.0102", revised 07/2021 revealed, "... Additional suicide interventions for moderate and high risk ... Staff member accompany the patient to the bathroom and maintains line-of-sight at all times ..."

Review of the hospital's policy titled, "Documentation and Guidelines for Practice, 1NR.NSA.001", last revised 06/28/202 revealed, "... 3. Document significant changes in assessment findings and report them to the LIP/AP [Licensed Independent Practitioner/Advanced Practitioner] as appropriate ..."

Closed record review revealed Patient #5 was a 22-year-old male who presented to the Emergency Department [ED] on 08/25/2021 at 2233 via Law Enforcement, under Involuntary Commitment (IVC). Review of the IVC paperwork revealed the patient was "... assaulting his care workers, headbutting the concrete, and walking into traffic. Respondent has stated that he is suicidal." Review of the "Electronic Physician Orders" revealed, "Suicide Precautions, Camera Obs [observation] (1:1 not indicated)" was ordered by Physician Assistant (PA) #1 at 2236. Review of the "ER Report" by PA #1, dated 08/25/2021 at 2237, revealed the patient's "Problem List/Past Medical History" included Panhypopituitarism (condition in which the pituitary gland stops making most or all hormones). Review of the "Physical Exam" revealed "... Neurological: Alert and oriented to person, place, time, and situation, no gross motor or sensory deficit observed ..." Review of the "ED Triage" RN assessment by RN #7, dated 08/25/2021 at 2256 revealed "...Endocrine Hx [History] ED: Diabetes, Other: hypopituitarism ... ... Morse Fall Risk History of Falling Immediate or Within Last 3 Months: No ... Score: 15 Morse Fall Risk Level: Low Risk ... Problems (Active) ... Panhypopituitarism ... Mental Health Status ... Behavioral Health Emergency: CCSRS [Columbia Suicide Severity Scale: tool used to assess suicide risk] indicates Moderate or High Risk of Harm ... Suicide Risk Assessment ... Suicide Risk Level Score: 8 ... Suicide Risk Level: Moderate Risk..." Review of the lab results at 2258 revealed: Sodium: 139, Potassium: 4.5, Chloride: 101, BUN: 14, Creatinine: 1.32 (H), Calcium: 10.2, Protein: 8.0, Albumin 4.2, ALT: 16, AST: 22, Osmolality: 276. Review of the "Triage Mental Status Exam" nursing assessment by RN #7, dated 08/25/2021 at 2307, revealed the patient was alert and oriented x4, with no communication deficits and cooperative. Review of the nursing assessment by RN #7, on 08/25/2021 at 2117 revealed, Patient #5 was alert and oriented x4, no communication deficits, anxious mood, appropriate thought process, cooperative and well groomed. Review of the "Morse Fall Risk Scale" assessment revealed "Morse Fall Risk Score: 15, Morse Fall Risk Level: Low Risk." Further review of the assessment revealed at 2307, RN #7 noted "Musculoskeletal WDL". Review of the "Triage Mental Status Exam" revealed on 08/26/2021 at 0453, the Licensed Clinical Mental Health Counselor (LCMHC) #1 noted Patient #5 was oriented x4 and "Well Groomed." At 0925, RN #12 noted his mood as "Anxious, Depressed", appropriate thought process, cooperative and "Well Groomed", "Musculoskeletal WDL". At 2117, RN #1 noted his mood as "Anxious, Irritable, Tearful" and "Restless", "Musculoskeletal WDL". Review of a provider "ER Report" note by MD #6, dated 08/27/2021 at 0757 revealed, "...When I went to round on him this morning, he was laying on his stomach he said he could not move his back was hurting. He could not rollover on his own. With the nurse we helped him rollover and then later he was able to sit up. He may have just had some spasm and tightness in his back. He is now sitting up and doing better. I did order some ibuprofen for him ..." Review of the "Electronic Physician Orders" revealed Ibuprofen 800 mg by mouth now was ordered at 0755 and administered at 1132 (3 hours, 37 minutes later). Review of the nursing assessment by RN #11, dated 08/27/2021 at 1134 revealed, the patient was noted as "Anxious, Elated, Irritable, Sad ... Jittery, Pacing, Restless" on the "Triage Mental Status Exam", "Musculoskeletal WDL." At 2025, RN #11 noted "Mood - Anxious, Elated, Irritable, Sad, Tearful, Thought Process ... Impaired Focus/Concentration, Obsessive, Paranoid, Racing Thoughts Behavior ... Jittery, Pacing, Restless, Attention Seeking, Disruptive, Manipulative, Paranoid ... Musculoskeletal WDL." Review of the ED provider and nursing documentation revealed no noted notification of the patient's change in behavior. Review of the medical record revealed there were no documented nursing assessments noted 08/28/2021 and 08/29/2021. Review of the "ER Report" note by MD #5, dated 08/29/2021 at 0028 revealed, "... Over the course of the night he did become slightly agitated and was shouting at nurses. He received oral medications with good effect and rested comfortable over the course of the night." Review of the "Triage Mental Status Exam" nursing assessment by RN #4, dated 08/30/2021 at 0900 revealed Patient #5 was alert and oriented x4 with no communication deficits, Musculoskeletal WDL and "Moves All Extremities Well". Review of the medical record revealed there was no documented nursing assessment for the 7p-7a shift per policy. On 08/31/2021 at 0818, RN #6 noted "Thought Process - Helpless ... Mood - Anxious ... Musculoskeletal WDL ... Morse Fall Risk Score: 15 ...Low Risk ... Broset Numeric Score: 0." Review of the medical record revealed there was no documented nursing assessment for the 7p-7a shift per policy. Review of the "ER Report" revealed on 09/01/2021 at 1006, MD #6 wrote, "... He has no complaints this morning other than his glasses seem dirty and his whole body aches ..." Review of the medical record revealed no noted intervention for the patient's complaint of body aches. Review of the medical record revealed there was no documented nursing assessment noted 09/01/2021 per policy or intervention following the patient's complaint of body aches. Review of the "Triage Mental Status Exam" revealed on 09/02/2021 at 0840, RN #5 noted "Mood - Anxious; Thought Process - Helpless; Behavior - Restless, Attention Seeking, Manipulative, Paranoid ... Musculoskeletal WDL... Broset Numeric Score: 0". Review of the "Morse Fall Risk Scale" assessment by RN #5 on 09/02/2021 at 0900 revealed "Morse Fall Risk Score: 35... Moderate Risk." Review of the "ER Report" revealed at 1013, MD #1 wrote, "... This morning, the patient complains of some calf pain and blurry vision. He says he is uncomfortable when he is sleeping. We will give him Tylenol and ibuprofen. Review of the ED provider and nursing documentation revealed no noted provider notification of the patient's complaint of weakness and pain. At 1548, MD #7 noted, "...He is ambulatory, eating normally during my shift and voices no current complaints other than wanting to leave the ER as he has been here several days ..." Review of the medical record revealed there was no documented nursing assessment noted for the 7p-7a shift per policy. On 09/03/2021 at 0524, MD #8 wrote "... Upon my assessment, he is resting comfortably. He is easily arousable, denies acute complaints. Remains cooperative ..." At 0718, MD #9 wrote, "... He is in stable condition this morning and expresses all needs are being met. He unfortunately stumbled in the bathroom this morning and struck his face. He did not have LOC [loss of consciousness] and has not had any concussion symptoms. No cephalohematoma [accumulation of blood under the scalp], battles [sic] sign or raccoon eyes. He did have minor epistaxis [nosebleed] and sustain [sic] an upper lip hematoma [bruise]. He does not have any facial tenderness, bruising or deformity. Epistaxis was minor from b/l [bilateral] nares and easily controlled with afrin [nasal spray used to treat nasal congestion] and pressure. No septal [area between nostrils] hematoma. No dental injuries noted. No malocclusion [abnormal alignment] or trouble opening jaw. PERRL [Pupils Equal, round, Reactive to Light], EOMI [Extraocular (eyes) Movements Intact]. He is provided tylenol. Review of the "Morse Fall Risk Score" assessment by RN #6, at 0752 revealed "Fall Risk Score: 60 ... High Risk". Review of the medical record revealed there was no noted documentation of known details of the fall, patient assessment findings and interventions, provider, guardian, and supervisor notification, Fall Risk Assessment, or evidence of a "post-fall debrief meeting" by nursing per policy. Review of the nursing assessment by RN #6, dated 09/03/2021 at 0832 revealed, "Triage Mental Status Exam" revealed on 09/03/2021 at 0832, RN #6 noted "Mood - anxious; Thought Process - Helpless; General Appearance - Appropriate", "Musculoskeletal WDL Yes, Except For pain all over, states he feels he is getting weak and having pain from being here so long ... Broset Numeric Score: 0..." Review of a "Mental Health Contact Note" by the Licensed Clinical Social Worker (LCSW), at 1007 revealed, "... Patient appeared groggy and tired. He reported that he had fallen earlier for the third time since his ED admission. Patient stated that he has been feeling weak when he gets up and then falls. Patient had visible blood from his nose and in the corner of his mouth which she [sic] complains resulted from his last fall. Patient stated that because he is not active he gets tired and sluggish. It is unclear at this time patient [sic] has been medicated which is contributing to his grogginess ..." Review of the "ER Report" revealed at 2350, MD #7 wrote, "... Patient had fallen in the bathroom earlier today. On my evaluation he is ambulatory, talking, no active bleeding from bilateral naris [sic] ..." Review of the medical record revealed there was no documented nursing assessment for the 7p-7a shift per policy. Review of the ED provider and nursing documentation revealed no noted provider or nursing notification by the LCSW of the patient's report of multiple falls since admission and noted "grogginess". Review of the nursing assessment by RN #10, dated 09/04/2021 at 0638 revealed, "Triage Mental Status Exam Orientation - Oriented x4, Identifies self, Level of Consciousness - Alert, Awake, Communication - Delayed, Pressured, Stutters ... Musculoskeletal WDL - Yes, Except For: Pt has weak gate [sic] and often stumbles over his own [sic] ... Broset Numeric Score: 1 ... Confused" Review of the ED provider and nursing documentation revealed no noted provider notification of the patient's change in speech, altered gait, change in the Broset score secondary to noted confusion or Fall Risk Assessment per policy. At 0827 on 09/04/2021, MD #9 wrote "... He is in stable condition this morning but says he feels 'weak all over' and he continues to slump onto the floor and require staff to help him back up. He is seen ambulating and performing ADLs [activities of daily living] without any difficulty at other times." Review of the nursing documentation revealed the patient's risk for violence was assessed at 0900 by RN #4, "Broset Numeric Score: 1 ... Confused" Review of the medical record revealed there was no additional documented nursing assessment for the 7a-7p shift or provider notification of the change in the Broset score secondary to confusion. Review of the "Triage Mental Status Exam" assessment by RN #10, on 09/05/2021 at 0236 revealed, "Orientation - Oriented x4, Identifies self, Level of Consciousness - Alert, Awake, Communication - Slurred, Stutters ..." At 0918, RN #6 also noted that Patient #5's "Communication" as "Slurred, Stutters ..." Review of the "ER Report" revealed at 1553 MD #9 wrote, "... He is in stable condition this morning." Review of the ED provider and nursing documentation revealed no noted notification of the patient's change in speech. On 09/06/2021 at 0123, MD #3 wrote "... Patient has been calm and cooperative with staff, no issues. Patient is sleeping on exam tonight." Review of the "Triage Mental Status Exam" nursing assessment by RN #10, on 09/06/2021 at 0406, revealed "Orientation - Oriented x4, Identified self; Level of Consciousness - Alert, Awake; Communication - Slurred; Mood- Anxious; Thought Process - Delayed Associations, Helpless; Behavior - Intrusive, Attention Seeking, Dependent, Limit testing, Self endangering; General Appearance - Disheveled, Poor hygiene" Review of the "ER Report" by MD #10 at 0751 revealed "... Medical Decision Making - Documents reviewed: Emergency department nurses' notes, flowsheet, emergency department records, Psychiatric consultation notes. Reexamination/Reevaluation Course: unchanged. Pain status: unchanged. Assessment: Resting, cooperative, vitals stable. Interventions: awaiting psychiatric disposition." Review of the medical record revealed there was no documented nursing assessment for the 7a-7p shift per policy. Review of the ED provider and nursing documentation revealed no noted notification of the patient's change in thought process, slurred speech, behavior and general appearance. Note: Review of an incident report dated 09/06/2021 at 1030, revealed RN #2 noted the patient was left unattended in the bathroom and fell. Review of the nursing documentation revealed there was no documented nursing assessment for the 7a-7p shift per policy, details of the fall, patient assessment findings and interventions, provider, guardian, and supervisor notification, or evidence of a "post-fall debrief meeting" by nursing per policy. Review of the "ER Report" revealed on 09/07/2021 at 0419, MD #3 wrote, "...No issues throughout the night, patient sleeping on exam." Review of the Vital Signs at 0525 revealed Temperature: 101.0, Heart Rate: 184, Respirations: 48, Blood Pressure: 152/92, SPO2: 97% on room air. Review of the Laboratory results at 0545 revealed: Sodium: >170, Chloride: 142, BUN: 49.0, Creatinine: 2.07, Protein: 8.7, ALT: 131, AST: 305, Troponin: 0.04, Osmolality: >349, Lactic Acid: 4.54. Review of "Nurse Notes" at 0647, revealed RN #7 wrote "Staff went to check patients' blood glucose and observed pt was not talking and felt hot to touch. Upon assessment pt was found to be febrile with increased respirations. Fingertips blue and mottling to all extremities. Pt was moved to a medical room for further evaluation and treatment." At 1028, MD #3 wrote, "I was alerted by nursing staff that the patient had developed a temperature here [at 0551]. Upon assessment patient is febrile and tachycardic [rapid heart rate]. He is tachypneic [rapid breathing] and breathing 40-50 times a minute. He has dry mucous membranes and mottling [blotchy, red-purplish marbling of the skin caused by the heart no longer being able to pump blood effectively] to his upper extremities and lower extremities bilaterally. He will groan occasionally but will not follow commands and will not make any purposeful movements. Febrile, tachy [tachycardic] to 180s Mottled extremities Dry mucus membranes Patient would not follow commands but will moan occasionally Abdominal TTP [Tenderness to Palpate] No leukocytosis [high white blood cell count] at this time however labs appear hemoconcentrated [thickened due to the loss of fluid] so I suspect with fluid resuscitation [correction] he will develop a leukocytosis. He does have an elevated lactate here [caused by impaired tissue oxygenation]. Elevated creatinine [signifies impaired kidney function], hypernatremia [high concentration of sodium in the blood], Transaminitis [elevated liver enzymes], No acute process on CXR [Chest Xray], Covid negative, EKG with sinus tachycardia; elevated trop [troponin: indicative a heart damage], No acute process on CT [CT Scan]. I did attempt to sedate the patient with ketamine [anesthetic] and try to proceed with an LP [lumbar puncture]. I was unable to obtain CSF [Cerebrospinal Fluid] studies [tests used measure chemicals in the spinal fluid]. My colleague pointed out that the patient has not received his DDAVP in [sic] the entire time has been [sic] in the ER which is nearly 300 hours at this time. Explained his elevated sodium and altered mental status. Patient has been covered with broad-spectrum antibiotics to cover for meningitis [inflammation of brain and spinal cord membranes, typically caused by infection] in addition to acyclovir [antibiotic]. CT abdomen is still pending. I have spoken to [Hospital B] direct to help facilitate transfer as I feel that the patient will need ICU [Intensive Care Unit] level of care." Review of the medical record revealed there was no documented nursing assessment noted during the 7a-7p shift per policy. Review revealed Patient #5 was transferred to a higher level of care on 09/21/2021 at 1814.

Review of an incident report, dated 09/03/2021 at 0710, revealed RN #6 noted, "Fall from bed, witnessed by staff [virtual sitter]. Mobility status at time of fall: Ambulatory - Unlimited no Assistance. Time of last fall risk assessment: >1 week. Last fall risk assessment score: Morse score 35 - Moderate Risk. Fall risk assessment score post fall: Morse score 60 - High Risk Fall safety. Precautions in place a time of fall? Yes ... Pt [Patient] states when he went to stand up this morning, his legs were wrapped up in blanket and he fell forward, Pt states he hit his face and now has a nosebleed. Pt [MD #3], made aware [sic]. Afrin spray administered to pt and nose clamp applied to his nose. Bleeding stopped after treatment. [ED Nurse Manager] and [RN #13] house supervisors made aware ... Contributing Factors: Mobility/balance/strength issues Immediate Actions: Phy [physician] Notified, Reinstruction of Family Member/visitor, tx [treatment] provided ... Notified/Witnesses: [Patient Safety Assistant: PSA #1] (Sitter watching cameras when patient fell). [RN #14] Nurse of pt. from night shift checked on pt after fall and notified myself. [MD #9] notified."

Review of an incident report, dated 09/06/2021 at 1030, revealed RN #2 noted, "Fall while standing, Intentional Fall, Unwitnessed. Location: Tub/shower room [bathroom]. Amb. [Ambulatory] limited with assist. Time last fall risk assessment: 12-14 hr. [09/03/2021 at 0752 (72 hours, 38 minutes)] Last fall risk assessment score: 55 [last noted fall risk assessment score was noted as "60"]- High Risk. History falls last month? Yes Fall risk assessment score post-fall .... 55 - High Risk Fall safety precautions in place at time of fall? Yes ... Patient was assisted to the bathroom in the BH [Behavioral Health] unit. I got the patient to the toilet and [sic] the patient sat down. He asked me to stop put [sic] and shut the door. As soon as I closed the door, I heard him scream 'Oh F**k and heard a loud noist [sic]. The patient was found on the floor, on his back, on the other side of the bathroom, with his head towards the wall. Contributing factors: 4 Ps not addressed (paint, potty, position, possessions) [sic], Unattended during toileting. Immediate Actions: Physician Notified. Fall Precautions in place at time of fall: High risk interventions in place. Low risk interventions in place. Other safety precautions in place at time of fall: Gripper socks and assisted to bathroom ... The patient has been doing things like for [sic] the last several days for attention." Review of the incident report revealed nursing staff left the patient unattended in the bathroom and failed to follow hospital policy.

Interview on 10/15/2021 at approximately 0930, with the Interim Chief Nursing Officer (ICNO), Clinical Professional Development Educator and Director of Accreditation, revealed that following discussion of the findings in Patient #5's record review with the State Agency during the onsite investigation and ongoing improvement initiatives, an opportunity had been identified for nursing regarding escalation of concerns and change in patient assessment on 10/14/2021.

Interview on 10/15/2021 at 1605 with RN #2 revealed he was Patient #5's assigned nurse during the 7a-7p shift on 09/06/2021. Interview revealed, "He was still somewhat with it. I noticed some sort of decline. He could still walk but you had to stay with him." Interview revealed RN #2 assisted Patient #5 to the bathroom on 09/06/2021, "stepped out and shut the door", and heard a thump. When the nurse opened the door, Patient #5 was found lying on his back in the floor. RN #2 shared that he assessed Patient #5, got him into a wheelchair, and that he was "fine. It was my first time caring for psych [psychiatric] patients." Interview revealed the off-going nurse reported that Patient #5 was "Kinda going the wrong way ... more lethargic. Would come out onto the hall, was attention seeking. He was sitting in the wheelchair and urinated on himself, but he was following commands." Interview revealed RN #2 got Patient #5 in the shower and helped him bathe. "I made him do it. It took him a while and I helped but I made him do it." Interview revealed RN #2 verbally notified the provider of the patient's fall, "He ask 'How's he look, and I said looks ok. Now, if he rounded on him and checked on him, I guess. They're supposed to check on him." Interview revealed RN #2 did not inform the provider that the patient had urinated on himself or the reported increase in lethargy. Interview revealed, "Nursing assessments are supposed to be done every shift." Interview with RN #2 revealed that a post-fall assessment or physician notification was not recorded in the medical record per policy.

Based on policy review, medical record review and staff interviews, the hospital nursing staff failed to ensure a rejected medication order was reconciled and to notify the LIP/AP or pharmacy per policy resulting in drug omission errors for 1 of 2 Behavioral Health patients with rejected medication orders in the Emergency Department (Patient #5).

The findings included:

Review of the hospital's policy titled, "Medication Orders, 1MM.MED.0012", revised 04/16/2021 revealed "... GENERAL INFORMATION ... F. All medication orders are reviewed independently for appropriateness by a pharmacist and the nurse prior to administration ... Nursing Responsibilities ... The nurse should understand the intention of each medication ... 3. Periodically check for unverified or rejected orders that require clarification and attempt to complete ... ORDER CLARIFICATION A. Nursing Responsibilities ... 1. Identify medication order which needs to be clarified, either via phone or call from Pharmacy, note on a rejected order ... 2. Contact ordering licensed independent practitioner or advance practitioner (LIP/AP) ... 4. When nursing gets a rejected order on eMAR [electronic medication administration record] ... review details for reason for rejection ... 5. Modify the rejected order ..."

Review of the hospital's policy titled., "Medication Errors, 1IM. MED.0010", revised 02/12/2019 revealed, "POLICY: A. All medication errors (as defined below) require completion of a report via [Hospital] online reporting system ... DEFINITIONS ... A. Medication Error: "A medication error is any preventable event that may cause or lead to....Patient harm while the medication is in the control of the health care professional ..."

Closed record review revealed Patient #5 was a 22-year-old male who presented to the Emergency Department [ED] on 08/25/2021 at 2233 via Law Enforcement, under Involuntary Commitment (IVC) for "... assaulting his care workers, headbutting the concrete, and walking into traffic. Respondent has stated that he is suicidal." Review of the "ER Report" by PA #1, dated 08/25/2021 at 2256, revealed the patient's "Problem List/Past Medical History" included Panhypopituitarism (condition in which the pituitary gland stops making most or all hormones) and "Home Medications (16 Active)" included DDAVP (Desmopression) Nasal 10 mcg/inh nasal spray 10 mcg = 1 spray, Alternate Nostrils, BID (used to treat Diabetes Insipidus: condition that causes an imbalance of fluid in the body). Review of the 'Electronic Physician Orders", dated 08/26/2021 at 1552, revealed Desmopressin (DDAVP Nasal) 10 mcg, Nasal Spray, Alternate Nostrils, BID (twice daily) was ordered by the ED Physician Assistant (PA #2). Review of the "Order Comment" revealed at 1558, the order was rejected by the Pharmacist (Pharm #1) following order verification with note stating, "reject reason: non-stock. Please have patient/family bring in and send to pharmacy for identification." Further review of the order history revealed at 1737, another Pharmacist (Pharm #2) modified the "Order Comment" and noted, "reject reason: non-stock. We have injectable despopressin [sic] 4mcg/1ml. May give 1 mcg (1/10th dose of nasal formulation) subcutaneously BID." Review revealed the ordered was reviewed and acknowledged by the Registered Nurse (RN #1) on 08/26/2021 at 2117. Review of the Medication Administration Record (MAR) revealed Desmopressin (DDAVP Nasal) 10 mcg, Nasal Spray, BID was added as a routine scheduled medication on 08/26/2021 at 1552. Review revealed "reject reason: non-stock. We have injectable despopressin [sic] 4mcg/ml. May give 11 mcg (1/10th dose of nasal formulation) subcutaneously BID" was noted on the scheduled medication. Review of the Desmopressin "Admin [Administration] Details" on 08/29/2021 at 2009 RN #3 noted "(Not Given) Medication Unavailable; on 08/30/2021 at 0900, RN #4 noted, (Not Given) Medication Unavailable; on 09/02/2021 at 0824, RN #5 noted, (Not Given) Medication Unavailable; and 09/05/2021 at 0913 and 1050, RN #6 noted "(Not Given) Medication Unavailable". Further review of the MAR revealed no nursing notation on the scheduled Desmopressin 08/26/2021-08/28/2021 (5 scheduled doses with no nursing documentation addressing reason for omission); 08/29/2021 for the 0900 scheduled dose (1 scheduled dose with no nursing documentation addressing reason for omission); 08/30/2021 for the 2100 scheduled dose (1 scheduled dose with no nursing documentation addressing reason for omission); 09/01/2021 (2 scheduled doses with no nursing documentation addressing reason for omission); 09/02/2021 for the 2100 scheduled dose (1 scheduled dose with no nursing documentation addressing reason for omission); 09/03/2021-09/04/2021 (4 missed doses with no nursing documentation addressing reason for omission); 09/05/2021 for the 2100 dose (1 missed dose with no nursing documentation addressing reason for omission); or 09/06/2021 (2 missed doses with no nursing documentation addressing reason for omission). Review revealed 23 scheduled doses of Desmopression were not administered per physician order. Review of nursing progress notes revealed there was no documentation of provider or pharmacy notification of the missed doses or attempts to clarify the rejected order per policy. Review of provider progress notes revealed there was no documentation noting notification from nursing of the missed doses addressing the need for resolution of the rejected order per policy.

Interview on 10/12/2021 at 1510, with the Division Director of Risk, Claims, and Litigation, Interim Chief Nursing Officer (ICNO) Pharmacy Director, Chief Executive Officer (CEO), Clinical Professional Development Educator, Acute Care Team Lead (ACTL) ... revealed following review of the events leading up to 09/07/2021, the ED Medical Director (MD #1) and Risk Management determined a "Serious Safety Event" had occurred. Interview revealed the hospital's accrediting body was notified on 09/29/2021 ... and that a Root Cause Analysis (RCA: analysis conducted to identify the root cause of a problem or event) was conducted 09/16/2021. Interview revealed when an order is rejected, an icon appears "that flags in the MAR summary. The Pharmacist spoke with the patient's nurse [RN #1] and verbalized that alternative recommendations." Interview revealed Pharm #2 attempted to notify the provider first by calling the ED, went to the ED to speak with them directly but was unable to do so, and reported the recommendation to Patient #5's nurse. Interview revealed the provider was not notified of the rejected order and that it was not until 09/07/2021, following a change in condition, that providers became aware that the DDAVP had not been administered in 9 days. The provider reviewed the record and noted the patient [Patient #5] had symptoms of Diabetes Insipidus and Altered Mental Status."

Review of documents presented during a team meeting on 10/12/2021 at 1510, included an "Administrative Timeline", education materials titled, "It Happened Here", summary of the hospital's "Hand off Communication (1PC.ADM.0005)" policy, "Importance of Event Reporting" education.

1. Review of the Administrative Timeline revealed no education to nursing staff of their responsibility in reconciling rejected medications prior to the State Agency onsite investigation.

2. "It Happened Here 10/1/2021 Situation: Pt required intubation and transfer to a higher level of care after home medication was rejected for continued administration while in the ED. Background: Patient was in ED waiting for placement at inpatient psychiatric facility. Medication Reconciliation was completed. However, Desmopressin (DDAVP) was rejected by pharmacy. Patient later required intubation and transfer to higher level of care due to hypernatremia and altered mental status. Assessment: * Medication Reconciliation was completed and order was placed to continue patient's Desmopressin (DDAVP) * Desmopressin (DDAVP) was rejected by pharmacy due to route ordered being unavailable ... *Nursing documentation reflected that medication was not being administered due to medication being unavailable * Nursing unfamiliar with medication and its indications for use. * Variation in review of medications when performing hand off of care to include any rejected medications Recommendation ... * Medications to be reviewed with each hand off of care (RN and MD) ..." Review of the education handout, received on 10/12/2021, revealed no education related to nursing staff's role and responsibility in notifying the provider of a rejected medication order.

3. Review of "Hand off Communication" policy, received on 10/12/2021, revealed no education related to nursing staff's role and responsibility in notifying the provider of a rejected medication order.

4. Review of an RCA Chart, received 10/12/2021, revealed nursing's role and responsibiliy in notifying a provider of a rejected medication order was not identified.

Interview on 10/15/2021 at 1100 with RN #1 revealed she was Patient #5's assigned nurse during the 7p-7a shift on 09/26/2021. Interview revealed, "I remember seeing Pharmacy down there [in the ED] but it's been so long ago, I can't remember what she said." Interview revealed RN #1 could not recall if she notified Pharmacy or the provider of the rejected medication, was not aware of nursing's responsibility to contact the ordering provider of a rejected order and to clarify, if possible, per policy resulting in 23 missed doses of Desmopressin.

Interview on 10/15/2021 at 1605 with RN #2 revealed he was Patient #5's assigned nurse during the 7a-7p shift on 09/06/2021. Interview revealed RN #2 saw Patient #5 had a scheduled dose of Desmopressin on the MAR and asked, "Hey we got this med?" RN #2 could not recall who he asked but shared they replied, 'We don't have it' "so I didn't give it. During the interview, RN #2 was asked if he notified Pharmacy or the provider of the rejected Desmopressin order and number of missed doses and stated, "He [Patient #5] was here 4-5 days before me. What's my reporting going to do for it? I mean, if it wasn't important enough for them [Pharmacy and ED Providers] by then, I didn't think it was a big deal. I didn't know what Desmopressin was for." Interview with RN #2 revealed he was not aware of nursing's responsibility to contact the ordering provider of a rejected order and to clarify, if possible, per policy, resulting in 23 missed doses of Desmopressin.

NC00181680