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Based on record review and interview the facility failed to protect patient from harm by administering a double dose of psychiatric medications not ordered by the provider in 1 of 10 records reviewed (Patient (Pt) #2) in a total sample of 10 medical records reviewed.

Findings include:


Staff failed to protect patient from harm by administering a double dose of psychiatric medications not ordered by the provider. See tag A-0144

Staff failed to analyze the cause and implement preventative action plan for medication errors. See tag A-286

Based on record review and interview the facility failed to protect patients from harm by administering a double dose of psychiatric medications not ordered by the provider. in 1 of 10 records reviewed (Patient (Pt) #2) in a total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure titled, "Medication Orders Policy" last revised on 10/24/2022 revealed the following:
-All medications must be administered pursuant to a provider order recorded in the EMR (electronic medical record).
-The primary attending provider or another practitioner who is responsible for the care of the patient must authenticate the order within 48 hours of receipt.
-When verbal/telephone orders are received, orders shall be read-back to verify the correctness of the order.

Review of policy and procedure titled, "Medication Errors Policy" last revised on 08/16/2022 revealed the following:
-Medication error reported via Incident Reporting System are reviewed by manager/supervisor of the location, Medication Safety, Patient Safety and/or Risk Management. Patient Safety and/or Risk Management will determine when medications errors that are not sentinel events require a RCA (root cause analysis).

Review of Pt # 2's medical record revealed that Pt #2 was admitted to the hospital on 10/11/2022 for falls. Pt #2 was currently an inpatient at the time of record review on 11/09/2022 beginning at 2:00 pm (29 days in the hospital). Per review of Pt #2's History and Physical (H & P) dated 10/11/2022 at 1:51 pm, Pt #2 has a history of schizophrenia and cognitive impairment and presented to the ED (emergency department) from a group home with weakness and 3 unwitnessed falls. Per Pt #2's H & P, "(Pt #2) is noted to be weak, tired, lethargic, and drowsy since (Pt #2) arrived...(Pt #2) is verbal, but difficult to understand at baseline." Per Pt #2's H & P, Pt #2 "...uses a walker for ambulation and is a 1 person assist...(Pt #2) uses bathroom for urination and for bowel movements on (his/her) own with 1 person assist."

Review of Pt #2's "Home" medications listed on the H & P revealed Pt #2 was on Lithium 300 mg (milligram) (mood stabilizer to treat mania) oral tablets extended release, 2 tablets (600 mg total) daily at bedtime.

Review of Pt #2's medical record revealed a "Verbal order with Read Back" order by Medical Doctor (MD) J, and "entered and electronically signed" by Pharmacist H on 10/11/2022 at 6:53 pm for Lithium 600 mg Daily at bedtime. Per review of the Lithium medication order, "Special Instructions" revealed, "Dose from tomorrow please. (Pt #2) already received 600 today." Review of the Lithium medication orders revealed no evidence of MD J authenticating (signing) off this verbal order.

Review of Pt #2's medication administration record revealed Pt #2 received Lithium 600 mg (BID) twice daily (1200 mg total dose) scheduled for 9:00 am and 9:00 pm on 10/12/2022 through 10/18/2022 (7 days), this was inconsistent with the original inpatient Lithium MD verbal order of 600 mg daily at bedtime and Pt #2's home medication Lithium dose on the H & P.

Per interview with Director of Quality B and RN F on 11/09/2022 at 4:00 pm during Pt #2's medical record review, Director B and RN F stated that they were unable to find an MD order documented for Lithium 600 mg BID.

Per review of Pt #2's Lithium blood test, Pt #2's lithium levels increased from 0.67 on 10/06/2022 to 1.27 on 10/18/2022 (normal levels are 0.6 to 1.2).

Review of Pt #2's Physician Progress Notes revealed the following:
-10/13/2022 at 7:39 am: "Patient evaluated this morning sitting comfortably on recliner, eating breakfast.

-10/17/2022 at 2:20 pm : "Per RN (registered nurse) patient appears withdrawn, not participating, and still very weak. Per RN (Pt #2) having trouble with swallowing solid food." Per physician progress note, "...will change diet to mechanical soft, and will consult speech for swallow evaluation and further diet recommendations."

-10/19/2022 at 8:55 am: "Patient continues to be withdrawn, and as per RN report [sic] floppy and has muscle twitching. (Pt #2) also continues to remain drowsy and sleepy." Per physician progress note, "...Based on lithium levels (outpatient psychiatrist) also reported that the primary psychiatrist would like the levels to remain below 1, and recommended to decrease (Pt #2's) lithium dosing to (Pt #2's) prior dose at bedtime." Physician progress note, revealed that Pt #2 had been on 600 mg BID since 10/12/2022 which was double Pt #2's prior dose at previous discharge (inpatient 10/6/22-10/10/22) of 600 mg at bedtime. Per review of physician progress note, Pt #2 was exhibiting signs and symptoms of lithium toxicity (confusion, agitation, neuromuscular excitability); the physician's plan revealed to discontinue lithium 600 mg BID, obtain repeat lithium levels within 3 days, and reinitiate the prior dosing of 600 mg at bedtime.

Per interview with Pharmacist H on 11/10/2022 beginning at 10:00 am, Pharmacist H confirmed that he/she was the Pharmacist who received the verbal order from Physician J in regards to Pt #2's Lithium order. Pharmacist H stated that there is an issue with how the electronic system processes patient's home medications and that some medications are not recognized by the system, so this requires the pharmacist to "resolve" (fix) the original medication order. Per Pharmacist H, sometimes the original order must be deleted and then transcribed by the Pharmacist. Pharmacist H stated that this ongoing issue was submitted to Cerner (electronic computer system) but it was never fixed. Per Pharmacist H, he/she transcribed Pt #2's original order of lithium 300 mg tab BID and changed it to 600 mg daily at bedtime. Per Pharmacist H the system automatically defaulted to BID even though at bedtime was entered; Pharmacist H stated this happened twice. Pharmacist H stated that he/she missed that the lithium order was for BID instead of daily and the patient was given a double dose of lithium for 7 days. Per Pharmacist H, he/she was not sure if the physician ever authenticated or verified the transcribed order to ensure it was accurate.

Per interview with Lead Pharmacist I on 11/10/2022 beginning at 10:13 am, Pharmacist I stated that there was no root cause analysis done for this incident because it was not considered a sentinel event. Pharmacist I stated that there was no documented evidence of staff implementing an action plan to address this incident. Pharmacist I stated that Patient Safety/Risk Management has not reviewed this incident.

Based on record review and interview the facility failed to analyze the cause and implement preventative action plans for a medication error that harmed a patient in 1 of 10 records reviewed (Patient (Pt) #2), in a total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure titled, "Medication Errors Policy" last revised on 08/16/2022 revealed the following:
-Medication error reported via Incident Reporting System are reviewed by manager/supervisor of the location, Medication Safety, Patient Safety and/or Risk Management. Patient Safety and/or Risk Management will determine when medications errors that are not sentinel events require a RCA (root cause analysis).

Review of policy and procedure titled, "Incident Reporting System Policy" last revised 04/26/2022 revealed the following:
-All reported incidents are investigated
-Incident investigations are meant to look for systemic and process improvement opportunities...

Review of Pt # 2's medical record revealed that Pt #2 was admitted to the hospital on 10/11/2022 for falls, Pt #2 was currently an inpatient at the time of record review on 11/09/2022 beginning at 2:00 pm (29 days in the hospital). Per review of Pt #2's History and Physical (H & P) dated 10/11/2022 at 1:51 pm, Pt #2 has a history of schizophrenia and cognitive impairment and presented to the ED (emergency department) from a group home with weakness and 3 unwitnessed falls. Per Pt #2's H & P, "(Pt #2) is noted to be weak, tired, lethargic, and drowsy since (Pt #2) arrived...(Pt #2) is verbal, but difficult to understand at baseline." Per Pt #2's H & P, Pt #2 "...uses a walker for ambulation and is a 1 person assist...(Pt #2) uses bathroom for urination and for bowel movements on (his/her) own with 1 person assist."

Review of Pt #2's "Home" medications listed on the H & P revealed Pt #2 was on Lithium 300 mg (milligram) (mood stabilizer to treat mania) oral tablets extended release, 2 tablets (600 mg total) daily at bedtime.

Review of Pt #2's medical record revealed a "Verbal order with Read Back" order by Medical Doctor (MD) J, and "entered and electronically signed" by Pharmacist H on 10/11/2022 at 6:53 pm for Lithium 600 mg Daily at bedtime. Per review of the Lithium medication order, "Special Instructions" revealed, "Dose from tomorrow please. (Pt #2) already received 600 today." Review of the Lithium medication orders revealed no evidence of MD J authenticating (signing) off this verbal order.

Review of Pt #2's medication administration record revealed Pt #2 received Lithium 600 mg (BID) twice daily (1200 mg total dose) scheduled for 9:00 am and 9:00 pm on 10/12/2022 through 10/18/2022 (7 days), this was inconsistent with the original inpatient Lithium MD verbal order of 600 mg daily at bedtime and Pt #2's home medication Lithium dose on the H & P.

Per interview with Director of Quality B and RN F on 11/09/2022 at 4:00 pm during Pt #2's medical record review, Director B and RN F stated that they were unable to find an MD order documented for Lithium 600 mg BID.

Per interview with Pharmacist H on 11/10/2022 beginning at 10:00 am, Pharmacist H confirmed that he/she was the Pharmacist who received the verbal order from Physician J in regards to Pt #2's Lithium order. Pharmacist H stated that there is an issue with how the electronic system processes patient's home medications and that some medications are not recognized by the system, so this requires the pharmacist to "resolve" (fix) the original medication order. Per Pharmacist H, sometimes the original order must be deleted and then transcribed by the Pharmacist. Pharmacist H stated that this ongoing issue was submitted to Cerner (electronic computer system) but it was never fixed. Per Pharmacist H, he/she transcribed Pt #2's original order of lithium 300 mg tab BID and changed it to 600 mg daily at bedtime. Per Pharmacist H the system automatically defaulted to BID even though at bedtime was entered; Pharmacist H stated this happened twice. Pharmacist H stated that he/she missed that the lithium order was for BID instead of daily and the patient was given a double dose of lithium for 7 days. Per Pharmacist H, he/she was not sure if the physician ever authenticated or verified the transcribed order to ensure it was accurate.

Per interview with Lead Pharmacist I on 11/10/2022 beginning at 10:13 am, Pharmacist I stated that there was no root cause analysis done for this incident because it was not considered a sentinel event. Pharmacist I stated that there was no documented evidence of staff implementing an action plan to address this incident. Pharmacist I stated that Patient Safety/Risk Management has not reviewed this incident.