HospitalInspections.org

The Condition of Participation for Governing Body has not been met.

Based on clinical record reviews, interviews, policy review and review of contracted services, the hospital failed to ensure that contracted physicians (Hospitalists) provided quality care to one of three patients (Patient #44) who had critical laboratory results.

Please see A84

1. Based on clinical record reviews, interviews, policy review and review of contracted services, the hospital failed to ensure that contracted physicians (Hospitalists) provided quality care to one of three patients (Patient #44) who had critical laboratory results. The findings include the following:


a. Patient # 44 was admitted on 1/7/19 with generalized weakness and new onset diarrhea and vomiting. Review of the History & Physical (H&P) dated 1/7/19 indicated that the patient had a three day history of low back pain and abdominal cramps. Laboratory blood work was obtained that indicated a white blood count of 12.5 (normal 4.0-10.5), BUN of 42 (normal 6.0-20.0) and creatinine of 1.4 (normal 0.7-1.2). The H&P indicated that the patient had severe weakness which could be attributed to severe dehydration, and acute gastroenteritis. Blood cultures times 2 were obtained on 1/7/19 at 11:48 AM and 12:36 PM. The record indicated that on 1/8/19 at 1:05 AM laboratory staff called the Charge Nurse with a critical report that identified the patient's blood culture was positive with gram stain which was suggestive of Gram Positive Cocci. The clinical record indicated that RN #4 notified MD #4 at 1:13 AM, the note indicated that MD #4 was made aware and he indicated that he would like to be notified if the patient's temperature was greater than 100.4 and made no changes to the patient's treatment. The record indicated that the Charge Nurse was called on 1/8/19 at 1:31 AM and was notified that the second blood culture was positive with the gram stain which was suggestive of Gram Positive Cocci.

Interview with RN #4 on 1/31/19 at 8:40 AM indicated that she did not call the physician regarding the second blood culture because she felt that when she notified MD #4 earlier he indicated that he was to be called if the patients temperature was greater than 100.4 and at that time the patients temperature was 98.7.



b. Review of Patient #44's clinical record failed to identify that MD #4 documented the results of the preliminary blood culture results and/or his rationale for not initiating additional treatment.

Interview with MD #4 on 2/4/19 at 9:00 AM indicated that he did not receive a sign off from the day shift hospitalist regarding Patient #44 and had to rely on what he was told by nursing and a review of the case on the computer. MD #4 indicated that he was notified of the positive blood culture and informed the RN to notify him if the patient's temperature elevated, however he did not write a note and/or pass this information on to the oncoming shift. MD #4 indicated that even if informed of the second positive blood culture he would not have initiated antibiotics since the results were preliminary and could have been contaminants. MD #4 stated that for anything critical or actionable he would get in touch with the oncoming provider. MD#4 indicated he is responsible for "70-75 patients on the night shift" and "I just report actionable items". MD #4 indicated there were "far more sicker patients" in the hospital that night. MD #4 indicated that the on-coming day shift hospitalist should be reviewing all information that occurred overnight when rounding on the patient.



c. Review of Patient #44's clinical record identified that MD #3's progress note dated 1/8/19 at 10:30 AM failed to reflect that he reviewed all the laboratory data since the previous day and/or that he was aware of the positive blood cultures.

Interview with MD #3 on 1/31/19 at 9:00 AM indicated that he was Patient #44's primary hospitalist and is the Medical Director of the hospitalist program. MD #3 indicated that he would have expected MD #4 to document a note in the record regarding the positive blood cultures. MD #3 stated that in his opinion antibiotics should have been started when the first positive blood culture came back. In addition, MD #3 indicated that in the morning (1/8/19) he did not receive a sign out from MD #4 informing him of the positive blood culture, which resulted in antibiotics not being started. MD #3 indicated that the hospitalist program is a contracted service that had started at the hospital on 1/1/19. MD #3 indicated that the lack of a physician signout process is a weakness that he will be addressing.



d. A nurse's note dated 1/9/19 at 3:34 AM indicated that on 1/8/19 at 10:52 PM Patient #44 was noted to have a temperature of 102.2, pulse of 102 and an oxygen saturation of 84%. A rapid response was called resulting in the intubation and mechanical ventilation of the patient. Zosyn and Vancomycin were administered at approximately 11:30 PM and the patient was transferred to the ICU. Despite life saving measures, Patient #44 expired on 1/9/19 at 12:55 AM.

A discharge summary dated 1/9/19 identified Patient #44's discharge diagnosis as viral myositis.

Interview with the President of Medical Affairs on 2/15/19 stated that the hospitalist group is a contracted service and the Medical Director of the hospitalist program (MD#3) is responsible for staffing based on patient census. The President stated a change in the patient's medical status should be documented in the clinical record.

Review of the contracted programs guidelines indicated in part that hospitalist physicians and providers will abide by the hospitals guidelines for completion of timely documentation for clinical communication and administration services. The guidelines indicated that hospitalist communication with other providers shall have the goal of maintaining continuity of care through the patient's hospital stay.

The Condition of Participation for QAPI has not been met.

Based on review of the hospital's QAPI program, associated documentation and staff interviews, the hospital failed to develop and implement performance measures to include patient safety on the geriatric psychiatric (geri-psych) behavioral health unit.

Please refer to A 286
Cross Reference A 395

Based on review of the hospital's QAPI program, associated documentation and staff interviews, the hospital failed to develop and implement performance measures to include patient safety on the geriatric psychiatric (geri-psych) behavioral health unit. The finding includes:

Cross Reference F 395

Review of the hospital's QAPI program identified that hospital wide performance measures include patient falls, restraint usage and assaultive behaviors. The data collected through performance measures demonstrated that the data was being analyzed, tracked, and included ongoing reviews of the performance measures. However, the geri-psych behavioral health patients were not included in the data collection.

The hospital's QAPI program was reviewed with Quality Specialists # 1 and # 2 on 2/25/19 at 11:50 AM. The QAPI program failed to include patient safety measures specific to the geri-psych behavioral unit to include previously identified safety concerns with fall risk assessments, the use of the seclusion room, safety monitoring and/or implementation of interventions to maintain patient safety.

Although the hospital discussed fall risk patients at a hospital wide safety huddle and education was to be completed with staff regarding the use of 4 point restraints versus seclusion, the hospital failed to analyze the data gathered in the assessments or evaluate the effectiveness of patient safety interventions for patients identified as high fall risk on the geri-psych behavioral health unit.

Based on clinical record reviews, interviews and policy review for three (3) of six (6) patients who underwent invasive procedures (Patients #3, #4 and #7), the hospital failed to ensure that the invasive procedures were completed on the correct location of the body and/or failed to ensure the correct procedure was performed. The findings include the following:


a. Patient #3 was admitted on 10/18/18 for a right sacroiliac and right greater trochanteric bursa injection under fluoroscopy. The consent was completed on 10/11/18. Review of the record identified that the patient went to the OR at 2:30 PM and the procedure was completed at 2:36 PM.

Review of the operative note dictated on 10/18/18 at 2:06 PM with an addendum dated 10/18/18 at 4:34 PM identified that the patient's right ischial bursa was injected, not the right greater trochanteric as was intended.

Interview with MD #6 on 1/31/19 at 12:00 PM stated during the timeout procedure the nurse was holding the consent, the procedure was read out loud and the patient pointed to the area. MD #6 indicated that the patient was marked for laterality but not for the specific site.

Review of the Universal protocol indicated that site markings are required for all procedures involving distinction between sides, surface, multiple structures, or multiple levels. Site markings are the licensed independent practitioner's initials. The time out addresses, in part, the correct patient identity, confirmation that the correct side and site are marked, an accurate procedure consent form, agreement on the procedure being done and correct position.



b. Patient #4 was admitted on 9/14/18 with a right meniscus tear. Review of the consent form dated 8/27/18 identfied a right knee arthroscopy with possible lateral meniscus repair. The H&P completed on 8/27/18 with an addendum on 9/11/18 indicated the plan was to repair the right medial meniscus.

Pre-operative documentation indicated that the RN Circulator prepped the right knee and the timeout was completed on 9/14/18 at 1:52 PM. Review of the operative report indicated that a left knee medial and lateral meniscus tear was repaired.

Interview with the RN Circulator on 1/31/19 at 1:15 PM indicated when he looked at the schedule he thought it was a left knee procedure and that the left leg was prepped in error prior to the procedure.

Interview with MD #5 on 1/31/19 at 10:40 AM indicated that he saw the patient in the pre-operative area and initialed the right leg. MD #5 indicated that upon arrival to the OR the patient was in position, the leg was prepped and draped, and the timeout identified that the "appropriate" procedure was being done. MD #5 identified that he did not have the consent in front of him during the "time out".



c. Patient (P) #7 was admitted to the Interventional Radiology (IR) department on 4/13/18. An original order dated 4/2/18 and signed by the ordering physician indicated P#7 was to have a CT scan of his/her left sternoclavicular (SC) joint. Review of the electronic order generated by Scheduler #1 dated 4/2/18 at 1:00 PM indicated P#7 was to undergo a CT scan of the sacroiliac (SI) joint with injection.

According to a procedure note dated 4/13/18 by Interventional Radiologist (IR) #1, P#7 had been initially scheduled for a left SI joint injection however the original order had been brought to IR#1's attention prior to the patient's arrival because the original order from the ordering physician's office stated SC joint not SI joint. The ordering physician's office was subsequently contacted by Radiology Technician (RT) #1 and the office confirmed that the left SC joint was the correct site.

According to the procedure Universal Checklist completed by RT #1 on 4/13/18, P#7 confirmed the procedure as a left SC joint injection, the consent dated 4/13/18 was signed by P#7 for a left SC joint injection and the left SC joint site was verified and marked by IR #1. In addition a "time out" had been completed prior to the start of the procedure and P#7 agreed the procedure was a steroid injection to the left shoulder.

On 4/13/18 at 12:00 PM P#7 received an injection of Depomedrol and Sensorcaine to the SC joint administered under ultrasound guidance. After P#7 was discharged it was discovered that P#7 should have undergone a CT scan of the left SC joint not an injection. The ordering physician's office and P#7 were notified of the error and P#7 returned to the hospital for a left SC joint CT scan on 4/13/18.

During an interview with RT #1 on 2/27/18 at 11:30 AM he/she indicated prior to the procedure he/she compared the original order, which indicated SC joint with the order entered in the system, which indicated SI joint. Prior to the procedure he/she called the ordering physician's office and clarified if the "injection" was in the SC joint and not the SI joint. The ordering physician's office confirmed a SC joint injection.

During an interview with IR#1 on 2/27/19 at 11:40 AM, IR#1 indicated he/she did visualize the written order and saw SC joint identified however he/she did not see that CT scan was also indicated. IR#1 indicated based on P#1 verifying the SC joint injection several times prior to the procedure and the history P#1 presented with of SC joint pain and swelling with arthritis IR#1 felt the procedure was not out of the ordinary therefore he/she did not question the injection. IR#1 indicated shortly after the injection the ordering physician's office called looking for the CT scan results and that was when the error was identified.

Based on clinical record reviews, policy review and interviews for one (1) of four (4) patients who underwent a procedure (Patient #4), the hospital failed to ensure that physician's followed medical staff bylaws and/or policies. The findings includes the following:


a. Patient #4 was admitted on 9/14/18 with a right meniscus tear. Review of the consent form dated 8/27/18 identfied a right knee arthroscopy with possible lateral meniscus repair. The H&P completed on 8/27/18 with an addendum on 9/11/18 indicated the plan was to repair the right medial meniscus. Pre-operative documentation indicated that the RN Circulator prepped the right knee and the timeout was completed on 9/14/18 at 1:52 PM. Review of the operative report indicated that a left knee medial and lateral meniscus tear was repaired. MD #5 failed to amend the operative report following the identification of the error. Interview with MD #5 on 1/31/19 at 10:40 AM indicated that he did not find out until later in the recovery room about the error and was unsure of what to do and did not document the error in the operative report.


b. Review of Patient #4's clinical record indicated that a consent was completed on 9/14/18 for a right knee cortisone injection. The consent failed to reflect the time it was obtained. Review of the Medical Staff bylaws indicated that it is the responsibility of the practitioner to obtain proper informed consent as a prerequisite to any procedure or treatment. The hospital policy indicated when obtaining informed consent, the consent must contain the minimal element which are in part, date and time the informed consent is signed by the patient or legal representative, and the witness.


c. Interview with MD #5 on 1/31/19 at 10:40 AM indicated that after it was discovered that the meniscus repair was completed on the incorrect knee, the decision was made to inject cortisone into the patient's right knee to help alleviate the patient's discomfort. Review of the clinical record with MD #5 failed to reflect documentation of the procedure.

Review of the bylaws indicated that a brief operative/procedural report must be written in the medical record immediately following the conclusion of the surgery/procedure.

The Condition of Participation for Nursing Services has not been met.

1. Based on facility documentation, clinical record review and staff interview for 2 of 3 sampled patients reviewed for falls, (Patient #6 and Patient # 2), the facility failed to ensure that a patient who required assistance with ambulation was provided that assistance following medication and placement in a seclusion room, resulting in a fall with significant injury and/or failed to remain with a patient identified as a high fall risk while the patient was standing resulting in a fall with injury.

2. Based on clinical record review, interview and policy review for 1 of 3 patients reviewed for medication administration (Patient #12) the hospital failed to ensure that medications were administered as ordered and/or that the efficacy of an intervention was assessed.


3. Based on facility documentation, clinical record review, hospital policy and staff interview for 3 of 4 sampled patients reviewed for controlled substances, (Patient #33, #35 and #36) the hospital failed to ensure controlled substances were discarded appropriately.


Please see A 395 and A 405

1. Based on a review of facility documentation, clinical records, staff interviews, and policy review, for two (2) of three (3) sampled patients reviewed for falls, the facility failed to ensure Patient #6, who required assistance with ambulation, was provided that assistance following administration of psychoactive medication and placement in a seclusion room, resulting in a fall with significant injury and/or for Patient #2, failed to remain with a patient identified as a high fall risk while the patient was standing resulting in a fall with injury. The findings include:


a. Patient #6 was admitted to the inpatient geriatric psychiatric rehabilitation unit on 1/7/19 with agitation and behavioral disturbances including combative behaviors. A fall risk assessment dated 1/17/19 at 10:00 PM identified the patient was a high fall risk and safety interventions included assistance with ambulation and transfers, more frequent monitoring, and constant observation.

Nurse's notes dated 1/17/19 into 1/18/19 identified that between 8:00 PM and 6:00 AM, Patient #6 was intermittently irritable and angry, anxious and restless, combative with care, hitting, elbowing and twisting staff arms and hands and climbing out of bed. Documented interventions identfied that the patient was ambulated in the hallways with assistance of 2 staff, and fluids, snacks and toileting were offered. In this timeframe, Patient #6 received Haldol 2 milligrams (mg) by mouth, and Haldol concentrate 1 mg by mouth with no effect. The physician was notified and directed to administer Haldol 2 mg IM and Ativan 1 mg IM, however the patient continued with verbal/physical aggression towards staff.

On 1/18/19 at 6:05 AM, Patient #6 was placed in a seclusion room with 1 to 1 monitoring with staff standing outside of the seclusion room door. Despite Patient #6 being identified as a high fall risk and requiring assistance with ambulation and transfers, there was no staff in the seclusion room with the patient to provide assistance with ambulation. A nurse's note at 6:55 AM identified the patient was kicking and hitting at the door and fell backwards landing on the floor and hitting his/her head on the wall. The patient was assessed and vital signs were obtained but was uncooperative with neurological checks. The patient was noted with redness to the occipital area of the head and a skin tear to the left elbow. The patient was transferred to a Geri-chair.

Review of a physician progress note dated 1/18/19 at 9:33AM identified a small bump on back of Patient #6's head. The note identified a CT scan will be ordered related to head trauma as the patient was at risk for intracranial hemorrhage given age and dementia.

Review of the CT scan report dated 1/18/19 identified multiple small bilateral hemorrhagic contusions.

Review of the MD progress note dated 1/18/19 at 12:32 PM identified that the CT scan was reviewed with a hospitalist who recommended either to transfer for neurological consult if family wished for aggressive treatment or transfer to medicine for observation and probable palliative care. The note further identified that education was provided to the family regarding the seriousness of the event and the likelihood of death with continued brain bleeding. Patient to be transferred to medicine floor and will request a Hospice consult.

Review of the clinical record identified that between 1/18/19 and 1/25/19, Patient #6 was identified as sedated, lethargic, sleeping, and/or unresponsive, and comfort measures continued to be provided. A physician progress note dated 1/25/19 at 11:43 AM identified Patient #6 was pronounced expired at 11:30 AM.

Interview with RN #4 on 2/5/19 at 11:00 AM stated that on the evening of 1/17/19 into the morning 1/18/19 Patient #6 was restless and agitated throughout the night and was placed on a 1 to 1 intermittently. RN #4 stated that the patient was medicated with his/her scheduled Haldol as well as administering the as needed (prn) Haldol around 3:00 AM for escalating behaviors and trying to climb out of bed. RN # stated the patient's behaviors escalated by grabbing, kicking and punching at staff and twisting a staff' members arm, the physician was notified and the physician directed to administer Haldol and Ativan IM. RN #4 stated that she called the RN Supervisor to the floor who directed to place the patient into the seclusion room to calm the patient down with 1 to 1 monitoring outside the door. RN #4 stated that she was aware the patient required assistance with ambulation due to the patient having an unsteady gait. RN # stated that she was watching the patient on camera and observed the patient kicking and banging at the door and then fell backwards hitting his/her head on the wall. RN #4 stated that she went to the seclusion room and assessed the patient and notified the MD.

Interview with RN #6 on 2/8/19 at 8:35 AM stated that she was called to the unit due to the patient having increased behaviors, hitting and yelling at staff. RN #6 stated that she was aware the patient required assistance with ambulation and transfers but she did not want to place the patient in 4 point restraints because she felt it would be undignified and the day prior the patient was in the seclusion room and was fine. RN #6 further stated that she was unsure where the 4 point restraints were located and if they would be able to apply them because she wasn't sure security was on the floor.

Interview with Quality Specialist #1 on 2/5/19 at 11:15 AM stated that a patient who was requiring assistance for ambulation should not have been left alone in the seclusion room and that receiving Haldol placed the patient in even greater risk for falls. Quality Specialist #1 stated that there are other interventions that could have been used such as a Geri-chair and/or 4 point restraints until the patient's behaviors decreased.

Interview with MD #8 on 2/7/19 at 2:30 PM stated that he reviewed Patient #6's case and the patient's family declined to have a follow up CT scan to see if the bleed had changed. MD #8 stated that the family requested palliative care. MD #8 further stated that it would be hard to tell why the patient died without the follow up CT scan.


Review of the hospitals policy on Restraint and Seclusion identified the use of restraints or seclusion may occur in response to emergent, dangerous behaviors as an adjunct to maximizing a patient's safety and promoting their wellness.

Review of hospital Fall Prevention and Management Protocol identified a patient who is at high risk for falling staff are to assure assistance and stay with the patient during elimination, transfers and ambulation activities.



b. Patient #2 was admitted to the ED on 10/12/18 for increased difficulty swallowing, increased regurgitation and weakness. The patient was admitted for Intravenous (IV) fluids and possible esophageal manometry. Physician orders dated 10/12/18 directed to ambulate the patient with assistance. The fall risk assessment dated 10/25/18 at 12:00 AM identified Patient #2 as a high fall risk. Additional safety interventions included assistance with toileting, transferring and ambulation.

Review of a nurse's note dated 10/25/18 at 7:30 AM identified that at 5:25 AM Patient #2 was heard yelling for help and upon arrival to the room the patient stated he/she needed to get up. The note identified the nurse assisted the patient to the edge of the bed and then to a standing position and assisted the patient to use the urinal. Patient #2 became unsteady and stumbled to the left side. The RN's hands were around the patient's waist, and the patient was assisted to the ground landing on the left hip area. Patient #2 was assessed and complained of left hip pain. The note further identified the MD and RN Supervisor were called to assess the patient and an X-ray was obtained.

Review of the Diagnostic report dated 10/25/18 identified a left intertrochanteric fracture of the left proximal femur.

Review of facility documentation dated 12/25/18 identified as the RN assisted the patient to a standing position to use the urinal, the patient's bed alarm was alarming. The RN let go of the patient to turn off the alarm and the patient began to fall. The documentation further noted that the RN grabbed the patient by the waist in attempt to assist the patient to the floor.

Interview with Quality Specialist #2 on 2/7/19 at 1:15 PM stated that a patient who is a fall risk and requires assistance with ambulation and transferring is not to be left alone. Quality Specialist #2 stated that during the review of the fall, it was identified that the RN let go of the patient to turn off the bed alarm.

Several attempts to contact RN #7 were unsuccessful.




2. Based on clinical record review, facility policy review and staff interview for one (1) of three (3) sampled patients reviewed for safety checks, (Patient #6) the facility failed to ensure that nursing staff monitored and/or accurately documented the patient's behaviors. The finding includes:


Patient #6 was admitted to inpatient geriatric psychiatric rehabilitation on 1/7/19 with agitation and behavioral disturbances including combative behaviors.

Review of Patient #6's Nursing Observation Sheet 15 minute Patient Safety Checks dated 1/17/19 identified that from 12:00 AM thru 5:45 AM the patient was in his/her room and/or hallway. In this timeframe, the patient's behaviors were documented as 1:1 (staff supervision), which was inconsistent with the pre-established list of patient behaviors to choose from. However, according to nursing notes, Patient #6 was placed in the seclusion room on 1/17/19 at 5:15 AM for behaviors of being very agitated, swatting and kicking at staff, exit seeking, yelling and resistive to care, which were not identified on the patient safety check sheet.

According to nursing notes, Patient #6 remained in the seclusion room from 1/17/19 at 5:15 AM until 8:50 AM. Review of the Nursing Observation Sheet 15 minute Patient Safety Checks identified from 5:15 AM through 8:50 AM the patient was isolative with no behaviors identified.

In addition, the Nursing Observation Sheet 15 minute Patient Safety Checks dated 1/17/19 from 9:00 AM through 5:30 PM identified the patient's behaviors as 1:1 (staff supervision), inconsistent with the pre-established list of patient behaviors to choose from.

Review of the Nursing Observation Sheet 15 minute Patient Safety Checks dated 1/17/19 and Interview with Quality Specialist #1 on 2/5/19 at 12:30 PM identified that although the nurse's notes identified the patient was in the seclusion room from 5:15 AM until 8:50 AM, the documentation failed to identify the behaviors the patient was exhibiting during that time. The Quality Specialist stated that the behaviors need to be documented in order for nursing to determine if the intervention is appropriate.

1. Based on clinical record review, interview and policy review for one (1) of three (3) patients reviewed for medication administration (Patient #12) the hospital failed to ensure that medications were administered as ordered and/or that the efficacy was assessed. The findings include the following:

Patient #12 was admitted on 1/15/19 for a total knee replacement. Review of the physician's orders dated 1/14/19 directed Morphine 2 mg IV for severe pain (level 8-10), Oxycodone 5 mg for moderate pain (level 5-7), and Tramadol 50 mg for mild pain (level 1-4).

a. Review of the clinical record on 1/16/19 at 1:30 PM with the Nurse Manager indicated that on 1/15/19 at 9:28 PM the patient indicated a pain level of 8 and 5 mg of Oxycodone was administered. The clinical record indicated that on 1/17/19 at 6:47 AM the patient had a pain level of 9 and 5 mg of Oxycodone was administered, instead of Morphine as directed in the physician order.

b. Review of the clinical record indicated that on 1/17/19 Patient #12 had a pain level of 7 at 1:42 PM and 5 mg of Oxycodone was administered. The record failed to reflect an assessment to determine the efficacy of the medication.

c. Review of the clinical record indicated that on 1/16/19 at 6:45 AM Patient #12 had a pain level of 7 and Tramadol 50 mg was administered instead of Oxycodone as directed in the physician's order.

d. The clinical record indicated that on 1/15/19 at 1:18 PM the patient had a pain level of 7 and Tramadol 50 mg was administered instead of Oxycodone as directed in the physician's order. The record indicated that at 2:15 PM the patient's level of pain was reassessed and was again a 7. The record failed to reflect that this elevated level of pain was addressed and/or failed to identify the rationale of no further interventions.

e. The clinical record indicated that on 1/16/19 at 8:20 AM and 6:45 PM the patient had a pain level of 7 and Tramadol 50 mg was administered instead of Oxycodone as directed in the physician order. The record indicated that at 10:45 AM and 8:00 PM the patient's level of pain was reassessed and was again a 7. The record failed to reflect that the elevated levels of pain was addressed and/or failed to identify the rationale of no further interventions.

Review of the policy for Medication Administration indicated that patients will receive medications per the physician's order. The Pain Assessment policy indicated that it is the responsibility of all clinical staff to assess and reassess the patient for pain and for relief from pain.




2. Based on facility documentation, clinical record review, staff interviews, and hospital policy, for three (3) of four (4) sampled patients reviewed for controlled substances, (Patient #33, #35 and #36) the hospital failed to ensure controlled substances were discarded appropriately. The findings include:

a. Patient #33 was admitted to the Emergency Department (ED) for flu like symptoms. Physician orders dated 2/25/18 at 11:12 PM directed to administer Morphine Sulfate 4 mg Intravenous (IV) now. Review of the medication dispensing system identified RN # 1 pulled Morphine 10 mg for Patient #33, but failed to document the time and who witnessed the remaining 6 mg of Morphine being discarded.

b. Patient #35 was admitted to ED on 2/25/18 with complaints of abdominal pain, cough and body aches. Physician orders dated 2/25/18 at 2:50 PM directed to administer Ativan 10mg IV now. Review of the medication dispensing system identified RN #1 pulled Ativan 2 mg vial at 2:43 PM and wasted 1 mg of Ativan at 5:52 PM without the benefit of a witness.

c. Patient #36 was admitted to the ED on 2/25/18 with complaints of left hip pain. Physician orders dated 2/25/18 at 2:26 PM directed to administer Dilaudid 10mg IV now. Review of the medication dispensing system identified RN #1 pulled Dilaudid 2 mg at 2:29 PM, but failed to document the time and who witnessed the other 1 mg of Dilaudid being discarded.

Interview with the Director of Pharmacy on 2/5/19 at 1:45 PM stated discrepancy reports are generated from the pharmacy each day and on the report it identifies if mediations were wasted appropriately according to hospital policy. The Director of Pharmacy further stated that he reviews those reports and saw that RN #1 had pulled a larger amount of controlled medications then what was ordered but did not waste the medications with another nurse according to hospital policy.

Interview with Quality Specialist #1 on 2/7/19 at 10:15 AM stated that when controlled substances need to be wasted another nurse is to be present and the medication is to be put into the sharps container and the witness enters their password to complete the transaction. In the case of RN #1, this process did not occur.