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Based on observation, record review, and interview it was determined the facility failed to ensure patients had the rights to receive care in a safe setting and services provided met acceptable standards of practice as evidenced by failing to accurately administer medications for 1 of 12 (patient #21) current patients selected for review; failing to follow physician orders for administering medications for 1 of 12 (patient #20) current patients selected for review; and failing to ensure non-licensed personnel were denied access to a medication room.

Findings:

1. Observation of medication pass for patient #21, on 07/07/10 at 8:45 AM on North Wing, revealed that Prednisone 30 milligrams (mg.) was administered at 9:05 AM.

During reconciliation of medications administered it was noted, in the Medication Administratrion Record (MAR), that the medication was not provided as the physician had prescribed it. Further review of the MAR, revealed the physician actually ordered on 07/01/10, Prednisone 30 mg. to be administered every day (QD) at 9:00 AM for 3 days starting on 07/02/10. Further review of this order revealed the order stated to decreased the Prednisone to 20 mg. QD at 9:00 AM starting on 07/05/10, and then decrease to Prednisone 10 mg QD at 9:00 AM starting on 07/08/10.

Interview with the medication nurse #1 on North Wing on 07/07/10 at 10:30 AM, confirmed that she had administered Prednisone 30 mg. instead of Prednisone 20 mg., as ordered to be given at 9:00 AM.

2. Review of the medical record of patient #20, revealed this patient receives hemodialysis treatments on-site 3 days a week at 9:00 AM.
Review of patient #20's MARs revealed several blank areas on various medications entries. The missing medication entries had initials with an explanation as to why it was not given.
Review of the July 2010 MARs and the Physician orders revealed the following:
a. Cardizem 120 mg. three times daily at 9:00 AM, a medication prescribed for management of variant angina or chronic stable angina pectoris, for the following dates of 07/05/10 and 07/07/10 at 9:00 AM, was circled on the MAR with an explanation as this medication was not administered because the patient was in dialysis.
b. Morphine Sulfate CR 30 mg twice a day at 9:00 AM and 9:00 PM, a pain medication prescribed for severe pain, for the following date 07/07/10 at 9:00 AM, was circled on the MAR with an explanation as this medication was not administered because the patient was in dialysis.

3. During the tour of the facility on 07/06/10 at 10:00 AM when entering the medication room on the North Wing, an unlicensed personnel found alone and unsupervised in the medication room. When asked how they had entered the medication room, the response was "she had received the code from another staff member and enter by myself." When asked what her job title was, the response was "medical records personnel". Visible hanging on the wall was Intravenous (IV) antibiotics, combivent inhalers, and in the cabinets were needles and syringes.

Review of the facility's personnel records revealed that this medical records staff member had been hired on 05/26/10 with a job description of medical records technician.

Interview on 07/07/10 at 2:00 PM with the Risk Manager revealed that this medical records staff person was a new employee and was still in training.

Review of the facility's policy and procedures entitled Security of Medication Storage areas,", with a last revised date of 1/2008, revealed an attachment #1, which indicates the, "Approval of 'Authorized [Personnel]". Further review of this attachment failed to reveal that a person from medical records has approval to access the medication storage area.

Based on observation, record review and interview, the facility failed for one of twelve (patient #21) current patients selected for review, to administer medications as prescribed by the physician. Failure to administer medications as prescribed has the potential for adverse drug reactions.

Findings:

Observation of medication pass for patient #21, on 07/07/10 at 8:45 AM on North Wing, revealed that Prednisone 30 milligrams (mg.) was administered at 9:05 AM.

During reconciliation of medications administered it was noted, in the Medication Administratrion Record (MAR), that the medication was not provided as the physician had prescribed it. Further review of the MAR, revealed the physician actually ordered on 07/01/10, Prednisone 30 mg. to be administered every day (QD) at 9:00 AM for 3 days starting on 07/02/10. Further review of this order revealed the order stated to decreased the Prednisone to 20 mg. QD at 9:00 AM starting on 07/05/10, and then decrease to Prednisone 10 mg QD at 9:00 AM starting on 07/08/10.

Interview with the medication nurse #1 on North Wing on 07/07/10 at 10:30 AM, confirmed that she had administered Prednisone 30 mg. instead of Prednisone 20 mg., as ordered to be given at 9:00 AM.