HospitalInspections.org

Based on interviews and document review the nursing staff failed to ensure medications were administered in accordance with physician orders for one (1) of two (2) complaint patients included in the survey sample. (Patient #12)

The findings included:

An interview and electronic medical records (EMR) review was conducted on 11/15/2017 at 8:40 a.m., with Staff Member #8. The review of Patient #12's EMR included tracking the documentation of medications administered during the patient's hospitalization from 02/27/2017 through discharge on 03/15/2017. Staff Member #8 verified according to the physician's order, Patient #12 was to receive Pulmicort twice a day.

The review revealed nursing staff failed to ensure Patient #12 had received his/her Pulmicort (Budesonide) inhalation medication twice a day on the following days and times: 03/04/2017 at 8:00 a.m., 03/09/2017 at 8:00 a.m., 03/10/2017 at 8:00 p.m., and both doses 8:00 a.m. and 8:00 p.m. on 03/14/2017.

The missed administration of the Pulmicort on 03/04/2017, 03/10/2017 and the 8:00 p.m. dose on 03/14/2017 staff documented the medication was not available from the pharmacy. The missed administration of Pulmicort on 03/09/2017 and the 8:00 a.m. dose on 03/14/2017 staff failed to document a reason why the medication was not administered.

Staff Member #8 could not find documentation in Patient #12's EMR that the pharmacy had been notified regarding the Pulmicort not being available. Staff Member #8 could not find documentation the physician was notified that Patient #12 did not receiver his/her ordered medication.

An interview was conducted on 11/15/2017 from 11:30 a.m. through 12:20 p.m., with Staff Members #17 and #18. The surveyor inquired regarding the Pharmacy's inability to ensure the Pulmicort was available for administration to Patient #12. Staff Member #18 reviewed the dates and times Patient #12 was not administered Pulmicort. Staff Member #18 was able to provide electronic documentation that Patient #12's Pulmicort dose had been delivered to the unit and was available for administration on the dates the medication had not been administered. Staff Member #17 reported he/she would contact [Staff Member #34's name] to determine why staff had documented the medication was not available.

An interview was conducted on 11/15/2017 at 12:20 p.m., with Staff Member #15, a physician. The surveyor inquired regarding expectations if an ordered medication could not be administered to his/her patient. Staff Member #15 reported if an ordered medication was "not administered or held for any reason, generally the nurses would notify" him/her.

An interview was conducted on 11/15/2017 at 1:42 p.m., with Staff Member #34. Staff Member #34 reported Patient #12's physician had ordered a combination of respiratory medications Duo-Neb and Pulmicort that was equivalent to the medication Advair, which the patent received at home. Staff Member #34 reported he/she had reviewed the missed administration of Pulmicort. Staff Member #34 stated, "The physician ordered a pediatric dose for [Patient #12]. The pediatric dose is not always kept in the main pyxis (automated medication dispensing system). Staff would have to hit override and type in a [specific word] then the door to the tower or refrigerator will open. They would have to look for the patient's name and room number in order to pull the meds (medications)." Staff Member #34 reported the five (5) missed doses of Pulmicort "had not been held but were just not given, because staff didn't know where to find it." Staff Member #34 reported the staff had not documented correctly by indicating it was not available. Staff Member #34 verified staff should have contacted pharmacy to determine why the medication could not be found. Staff Member #34 acknowledged staff did not document or administer attempting to provide the Pulmicort as a late medication. Staff Member #34 verified staff failed to administer Patient #12's medication ordered by the physician.

Review of the facility's policy titled "Medication Administration with Barcoding and IV Addendum" read in part: "Areas Affected: All Patient Care Areas ... 2. b. Non-time-critical scheduled medications are scheduled medications for which a longer or shorter interval of time since the prior does dose not significantly change the medication's therapeutic effect or otherwise cause harm. Greater flexibility in the timing of these medications is permissible. These include: ii. Medications prescribed more frequently that daily but no more frequently than every 4 hours: these medications may be administered within 1 hour before or after the scheduled dosing time for a total window that does not exceed 2 hours. Scheduled medications meeting these criteria, but given outside of the 2-hour window will be considered early or late. 3. Missed or late administration of medications: When necessary to administered medication(s) outside of the scheduled administration time ... This includes doses which may have been missed due to the patient being temporarily away from the nursing unit, patient refusal, patient inability to take the medication as prescribed, problems related to medication availability, or any other reason resulting in a missed or late does administration. Based on clinical judgement, some medications may require subsequent administration schedule changes which must be performed by a pharmacist. The nurse will contact pharmacy to retime these doses ..."