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Based on staff interview, patient medical record review and review of the facility's policies and procedures, the facility failed to implement their discharge policy for 1 of 5 discharge records reviewed, Patient #1. The responsible party was not notified when Patient # 1 was discharged from the licensed hospital to a separately licensed facility on the campus.

The findings include:

An electronic medical record review was completed for Patient #1, admitted into the facility under a BA-52 for delusions. During the patient's admission, the Admission Discharge Coordinator (ADC) progress notes revealed the patient's wife was granted temporary guardianship and requested placement for the patient in a skilled nursing facility. The patient's wife was also informed of an upcoming court date. ADC and psychiatric records identified that the patient has remained confused during his hospital stay, no behaviors exhibited. ADC efforts on finding long term care placement for the patient was well documented in the record.

A review of the physician orders dated, 11/05/2018 at 8:55am indicates "Transfer to PATH," which is the Crisis Stabilization Unit. There was no discharge order.

On 11/05/2018, documented at 4:07pm by the ADC - "..ADC received a call from client's wife - stating that her friend told her about (Name of ALF) and that they have an open male bed available." ADC documented the patient's wife was informed of the cost and that the wife would need to review with her attorney. Same entry then documented - that "ADC attempted to call client's wife to inform her that court is on Thursday ..... There was no answer and ADC was unable to leave a message. ADC will continue to monitor." There was no indication that the wife was informed that the client was being transferred/discharged to a separately licensed facility on the hospital campus.

A review of progress notes completed by the Registered Nurse on 11/05/2018 at 4:21PM indicates "Client will be discharged to SRT today. Handwritten instructions will be given. Will continue to monitor behavior and safety." The note did not indicate if the guardian was provided instructions.

Review of MD/ Psychiatrist notes, entered on 11/07/2018 at 4:47pm, for 11/05/2018, indicates ... client still confused, unsteady gate. Mobilizes with a walker and is not fully capable to care for himself. Patient does not understand some information that is presented to him. Presented tired this morning with a soft tone and low energy. Indicates Patient will be transferring to SRT (Short Term Residential Treatment) due to insurance not covering anymore days. Patient's ADC (Admission Discharge Coordinator) will be following with placement options."

On 12/05/2018 at approximately 2:15pm an interview was conducted with Staff E, the Admission Discharge Coordinator. Staff E stated that if a patient is being discharged to a nursing home, she would coordinate the time that the nursing home can come to pick up the patient. If they transport the patient, she makes sures everything is ready and that the patient has all their prescriptions. Staff E stated would make sure the family knows they are going and review the discharge instructions. Staff E reviewed Patient #1 medical record, and confirmed the family was not notified of the patient's discharge to another facility (Short Term Residential Treatment Facility.) Staff E stated she tried to call the Patient's wife, but there was no answer and she was not able to leave a message.

A review of the facility's policy and procedure entitled "Inpatient Services - Discharge Procedure," last revised April 2015 indicated "A. Physician writes the order for discharge following input from Nursing and Social Services. B. Nurse reviews and signs off on the discharge order and communicates with the Admission/Discharge Coordinator regarding the details of the discharge, including what time the discharge will occur and who will be picking up the client. .......I. The nurse shall conduct "teach back" with the client or caregiver regarding instructions/plan, to ensure an understanding of the instructions. Provision of the "teach back" shall be documented on the Discharge Instruction/Continuing Care Plan. ...... N. A client may not leave the unit until the nurse and Admission/Discharge Coordinator communicate and insure that all discharge arrangements have been made, including contacting family and arranging transportation. .... Q. To ensure client safety, clients awaiting pick-up are to remain on the unit until their designated transportation arrives unless otherwise approved by the Program Director. Client will be notified that he/she will be required to remain on unit until his/her designated ride arrives. ... The Admission/Discharge Coordinator will notify client's care manager of discharge. Family/Guardian significant others will be notified as appropriate."

A review of the facility's policy and procedure entitled "Discharge Planning," last revised April 2015, indicates under section "B. Implementation," that "2. Client's families' involvement in the discharge planning process, and their understanding and approval of the final discharge plan must be reflected in the progress notes. - - a. Attempts must be made to contact and involve family and/or significant others to discuss client's previous history and treatment, baseline behavior/functioning, previous suicidal/homicidal aggressive behaviors, and to discuss/verify discharge plans. ... ... ...6. Any additions or revisions of the patient's discharge plan must be entered in the progress notes explaining reasons for additional or revisions to the discharge plan. 7. Any changes in discharge plans must also be verbally communicated to all team members (M.D., Nursing, M.H.A.) and to Case Management/F.A.C.T. immediately and the communication noted in the chart."

QA
Citation Text for Tag 0205, Regulation XPFJ

Ball, Debra

Based on observation, staff interview and record review, the facility's Quality Assurance Performance Improvement program failed to ensure a systematic process for collecting data that included administration of medications in accordance with physician orders. As part of the quality assurance process, the facility failed to evaluate medication administration accuracy at the point of care. This failure resulted in not collecting data to determine priorities for improvement and actions to improve performance for safe, quality care. During a medication pass observation, 10 medication administration errors were identified for 3 of 7 patients (#4, #6 #10) observed during medication administration.

Findings:

On 12/05/18 beginning at 09:33, medication administration was observed with Licensed Practical Nurse (LPN), Staff D. Medication errors of wrong dosage were identified for patient #6 and both wrong dosage and medication omission errors were identified for patient #10. On 12/06/2018 beginning at 9:02am, medication administration was again observed with Staff D. Medication errors of medication omissions were identified for patient #4 and medication omission errors were again identified for patient #10. Please see evidence under A395 and A405.

A review of the facility's incident reports for the last 6 months, identified only 2 incident reports related to errors in medication administration.

Review of the facility policy on medication administration, last revised March 2018, showed drugs were to be administered in accordance with written orders of the attending physician. Review of the facility policy for medication records stated, "If for any reason the patient does not receive the medication ordered, the nurse must initial and circle dose omitted. On the back side, under nurse's medication notes, the nurse must document reason why the medication was not given. A corresponding progress note as to why medication not given must be entered in the patient record."

Review of the facility's Quality Assurance Performance Improvement (QAPI) program revealed the performance indicators being tracked and trended for medication administration included the following: (1) verbal orders signed and dated within 24 hours (2) verbal orders include date and name of staff given, receiving, recording and implementing the order (3)clients discharged on 2 or more antipsychotic medications (4) number of incidents for medication preparation and dispensing (5) use of 2 patient identifiers and (6) current medication consent completed prior to prescribing and signed by ARNP and MD.

In interview conducted with the Risk Manager on 12/6/18 at 2:10pm, she stated the indicator for medication preparation and dispensing is specifically looking at pharmacy related errors to ensure right medication is being sent from the pharmacy. She further stated the QAPI indicator for receiving, recording and implementing the order applies to verbal orders as relates to person receiving order, person giving order, nurse writing the order and checking the transcription of medication onto the MAR. She further stated these indicators were based on Joint Commission survey findings conducted in September 2018. The RM stated the Nurse Manager would be responsible for the oversight.

On 12/04/2018 at approximately 2:00pm an interview was conducted with the Consultant Pharmacist. The Consultant Pharmacist stated she does not observe medication administration as part of the facility's Quality Assurance process. She does get notified of any medication errors.

In interview conducted with the Nurse Manager on 12/6/18 at approximately 2:30pm, she stated she does not randomly perform medication administration observations and does not review patient Medication Administration Records (MAR) to ensure physician ordered medications are documented onto the MAR. She further stated she was not aware of medications not being administered in accordance with the physician orders.

Based on observation, record review and interview, the facility failed to ensure a registered nurse was supervising and evaluating medication administration procedures to ensure accurate medication services were provided for 3 of 7 patients (#4, #6 #10) in accordance with facility policy.

The findings Include:

On 12/05/18 at 09:33, medication administration was observed with Licensed Practical Nurse (LPN), Staff D. The Staff nurse had already gathered each individually packaged medication into a cup on a tray labeled with each patient's name. The medications that were inside each patient's cup were recorded, prior to administration as part of the observation process. Prior to administration, the number of medications recorded was compared with what the nurse was to administer. As the patient came to the medication room door, the nurse would appropriately identify the patient, tell the patient what medication she was providing, open the medications in front of the patient and place them in the medication cup for the patient to take.

Patient #6. Review of physician orders documented an order to administer Aripiprazole 300mg - Give three 100mg tablets daily. On 12/05/18 at approximately 9:33am, medication administration for Patient #6 was observed. LPN Staff D was asked to count the number of pills in the cup to compare to what had been recorded on the MAR; and the count was not correct. Staff D identified she had placed four Aripiprazole 100 mg tablets in the medication cup instead of the ordered three 100mg tablets. This error was diverted before the medication was administered.

Patient #10: On 12/05/18 at approximately 9:55am, the number of medications dispensed in the medication cup and recorded on the MAR cup was (4) four. This was confirmed with Staff D. Patient #10 received one Citalopram 20mg tablet, two Vitamin D 1000 IU (international unit) tablets, and one multi-vitamin. The medications given were compared to the Medication Administration Record (MAR). The MAR documented to give Citalopram 10mg every morning. The patient received double the ordered dosage. The MAR documented to administer Vitamin D 1000 IU, give 1 tablet by mouth every other day (on odd days). The patient received two 1000 IU tablets for a total of 2,000 IU, double the dosage ordered. Additionally, the MAR documented patient #10 was also scheduled to receive the following medications during the medication pass: Calcium 500mg chewable tablet, Ranitidine 150mg for acid reflux and an antipsychotic medication, Zyprexa 5mg (Olanzapine). Staff D failed to administer these 3 medications. Further review of the MAR for Zyprexa revealed the 9:00am dose had not been signed as given for the entire preceding days of December. Staff D stated that patient #10 has been sedated so she had been withholding that dose. There was no documentation on the MAR that the medication was withheld, no indication in the nurse's notes that the medication had been withheld, no indication that the physician had been informed, and no documentation that the patient has been sedated.

Review of physician orders, dated 10/17/2018, documented Citalopram 10mg daily, Zyprexa 5mg give 2 times a day, Ranitidine 150mg give two times a day, Calcium 500mg every day and Vitamin D3 1,000 IU tablets give 1 tablet every other day.


33394

Patient #4
On 12/06/2018 beginning at 9:02am, medication administration was observed with facility Licensed Practical Nurse (LPN) Staff D. The nurse had gathered individually packaged medications into cups on a tray labeled with each patient's name. As the patient came to the medication room door, the nurse would appropriately identify the patient, tell the patient what medications she was providing, open the medications in front of the patient and place them in a paper cup for the patient to take.

Review of the medications in the cup for patient #4 showed he was getting an antibiotic, vitamin D3, dementia medication and medications for high blood pressure and high cholesterol. Comparison of the medications prepared for administration and the medication administration record (MAR) for patient #4 showed he was also to receive Seroquel, an antipsychotic and Proscar for benign prostatic hyperplasia, but neither of these medications were observed in the medication cup for patient #4.

Staff D was then asked why neither of these medications were in the cup for the patient, and stated they could not give antipsychotics without consent and consent had not yet been obtained for the administration of Seroquel. She further stated that the hospital did not have Proscar so she couldn't give it.

Review of the medical record for patient #4 confirmed that the patient had a physician's order, dated 12/02/2018, for Proscar 5mg by mouth daily and for Seroquel 50mg every morning and every evening.

On 12/6/18 at 11:40am, an interview was conducted with Staff B (charge nurse) and Staff A (nurse manager) concerning procedures for obtaining medications for patients not available through their pharmacy and obtaining consent for antipsychotic medications. Charge nurse, Staff B, stated if a patient was admitted to the hospital on a medication not available in the hospital pharmacy, they would call the family or facility the patient came from and have them bring the medication to the hospital for administration. When asked about the Proscar for patient #4, she stated she just found out they were missing the Proscar that morning and that the facility he came from was coming to reassess that day and maybe take him back on 12/7/18. Staff A, nurse manager, stated the hospital had to have consent for the administration of all psychotropic medications and stated the order for Seroquel for patient #4 had been missed when the medication consent form had been filled out and thus was not presented to the patient's wife for consent when they obtained consent for his other medications. She further stated that patient #4 should not even be taking Seroquel due to his dementia and stated she had gotten an order for the physician to discontinue the medication.

Patient #10

Continued observation of morning medication administration on 12/06/2018 with LPN Staff D revealed a cup of medications for patient #10 that contained a multivitamin, an acid reflux medication and an antidepressant. Review of the MAR for patient #10 showed he was also to receive calcium 500mg chewable tablet and Zyprexa 5 mg, but these medications were not observed to be in the medication cup for patient #10.

Review of the medical record for patient #10 showed a physician order, dated 10/17/18, for calcium 500mg by mouth daily and Zyprexa 5mg twice daily.

LPN Staff D was asked why the patient's Zyprexa was on the MAR but not being administered, she stated it had been held because it made the patient too sedated.

Continued review of the medical record for patient #10 showed no documentation about sedation or medication side effects, and also contained no documentation the ordering physician had been notified of the patient's Zyprexa being held.

In interview conducted with the Nurse Manager on 12/6/18 at approximately 2:30pm, she stated she does not randomly perform medication administration observations and does not review patient Medication Administration Records (MAR) to ensure physician ordered medications are documented onto the MAR. She further stated she was not aware of medications not being administered in accordance with the physician orders.

Review of the facility policy on medication administration, last revised March 2018, showed drugs were to be administered in accordance with written orders of the attending physician. It confirmed that the nurse would ensure the client or guardian had signed a consent form for controlled medications and psychotropic medications after receiving medication information from the physician, and stated that if the nurse had any concerns or questions about the medication, the nurse manager or psychiatrist must be contacted to discuss those concerns prior to administration of the medication in question. The policy went on to state that medication orders would be put on the patient's MAR and that if a medication was not immediately available when it was time to give to the patient, the nurse would contact the pharmacist to resolve the issue. The policy also stated that in extenuating circumstances, on a case by case basis, the physician can consult with the pharmacist to arrange for the use of personal medications. In such cases, the pharmacist must visually evaluate the medication's integrity.

Review of the facility policy for medication records stated, "If for any reason the patient does not receive the medication ordered, the nurse must initial and circle dose omitted. On the back side, under nurse's medication notes, the nurse must document reason why the medication was not given. A corresponding progress note as to why medication not given must be entered in the patient record."

Based on observation, record review and staff interview, the facility failed to ensure medications were administered in accordance with physician orders, accepted standards of practice, and facility policy for 3 of 7 patients (#4, #6 and #10) observed during medication administration.

The Findings Include:

Patient #6: On 12/05/18 at approximately 9:33am, medication administration for Patient #6 was observed. Licensed Practical Nurse (LPN) Staff D had already gathered each individually packaged medication into a cup on a tray labeled with the patient's name. The medications inside the cup were recorded, prior to administration, as part of the observation process. Prior to administration, the number of medications recorded on the Medication Administration Record (MAR) was compared with what the nurse was administering. Staff D was asked to count the number of pills in the cup to compare to what had been recorded on the MAR; and the count was not correct. Staff D identified she had placed Aripiprazole 400mg - four 100 mg tablets instead of the ordered three 100mg tablets in the medication cup. This error was diverted before the medication was administered. Review of physician orders documented an order to administer Aripiprazole 300mg - three (3) 100mg tablets daily.

Patient #10: On 12/05/18 at approximately 9:55am, the number of medications dispensed in the medication cup and recorded on the MAR cup was (4) four. This was confirmed with Staff D. Patient #10 received one Citalopram 20mg tablet, two Vitamin D 1000 IU (international unit) tablets, and one multi-vitamin. The medications given were compared to the Medication Administration Record (MAR). The MAR documented to give Citalopram 10mg every morning. The patient received double the ordered dosage. The MAR documented to administer Vitamin D 1000 IU, give 1 tablet by mouth every other day (on odd days). The patient received two 1000 IU tablets for a total of 2,000 IU, double the dosage ordered. Additionally, the MAR documented patient #10 was also scheduled to receive the following medications during the medication pass: Calcium 500mg chewable tablet, Ranitidine 150mg for acid reflux and an antipsychotic medication, Zyprexa 5mg (Olanzapine). Staff D failed to administer these 3 medications. Further review of the MAR for Zyprexa revealed the 9:00am dose had not been signed as given for the entire preceding days of December. Staff D stated that patient #10 has been sedated so she had been withholding that dose. There was no documentation on the MAR that the medication was withheld, no indication in the nurse's notes that the medication had been withheld, no indication that the physician had been informed, and no documentation that the patient has been sedated.

Review of physician orders, dated 10/17/2018, documented Citalopram 10mg daily, Zyprexa 5mg give 2 times a day, Ranitidine 150mg give two times a day, Calcium 500mg every day and Vitamin D3 1,000 IU tablets give 1 tablet every other day.


33394


Patient #4
On 12/06/2018 beginning at 9:02am, medication administration was observed with facility Licensed Practical Nurse (LPN) Staff D. The nurse had gathered individually packaged medications into cups on a tray labeled with each patient's name. As the patient came to the medication room door, the nurse would appropriately identify the patient, tell the patient what medications she was providing, open the medications in front of the patient and place them in a paper cup for the patient to take.

Review of the medications in the cup for patient #4 showed he was getting an antibiotic, vitamin D3, dementia medication and medications for high blood pressure and high cholesterol. Comparison of the medications prepared for administration and the medication administration record (MAR) for patient #4 showed he was also to receive Seroquel, an antipsychotic and Proscar for benign prostatic hyperplasia, but neither of these medications were observed in the medication cup for patient #4.

Staff D was then asked why neither of these medications were in the cup for the patient, and stated they could not give antipsychotics without consent and consent had not yet been obtained for the administration of Seroquel. She further stated that the hospital did not have Proscar so she couldn't give it.

Review of the medical record for patient #4 confirmed that the patient had a physician's order, dated 12/02/2018, for Proscar 5mg by mouth daily and for Seroquel 50mg every morning and every evening.

On 12/6/18 at 11:40am, an interview was conducted with Staff B (charge nurse) and Staff A (nurse manager) concerning procedures for obtaining medications for patients not available through their pharmacy and obtaining consent for antipsychotic medications. Charge nurse, Staff B, stated if a patient was admitted to the hospital on a medication not available in the hospital pharmacy, they would call the family or facility the patient came from and have them bring the medication to the hospital for administration. When asked about the Proscar for patient #4, she stated she just found out they were missing the Proscar that morning and that the facility he came from was coming to reassess that day and maybe take him back on 12/7/18. Staff A, nurse manager, stated the hospital had to have consent for the administration of all psychotropic medications and stated the order for Seroquel for patient #4 had been missed when the medication consent form had been filled out and thus was not presented to the patient's wife for consent when they obtained consent for his other medications. She further stated that patient #4 should not even be taking Seroquel due to his dementia and stated she had gotten an order for the physician to discontinue the medication.

Patient #10

Continued observation of morning medication administration on 12/06/2018 with LPN Staff D revealed a cup of medications for patient #10 that contained a multivitamin, an acid reflux medication and an antidepressant. Review of the MAR for patient #10 showed he was also to receive calcium 500mg chewable tablet and Zyprexa 5 mg, but these medications were not observed to be in the medication cup for patient #10.

Review of the medical record for patient #10 showed a physician order, dated 10/17/18, for calcium 500mg by mouth daily and Zyprexa 5mg twice daily.

LPN Staff D was asked why the patient's Zyprexa was on the MAR but not being administered, she stated it had been held because it made the patient too sedated.

Continued review of the medical record for patient #10 showed no documentation about sedation or medication side effects, and also contained no documentation the ordering physician had been notified of the patient's Zyprexa being held.

On 12/04/2018 at approximately 2:00pm an interview was conducted with the Consultant Pharmacist. The Consultant Pharmacist stated she does not observe medication administration as part of the facility's Quality Assurance process. She does get notified of any medication errors.

In interview conducted with the Nurse Manager on 12/6/18 at approximately 2:30pm, she stated she does not randomly perform medication administration observations and does not review patient Medication Administration Records (MAR) to ensure physician ordered medications are documented onto the MAR. She further stated she was not aware of medications not being administered in accordance with the physician orders.

Review of the facility policy on medication administration, last revised March 2018, showed drugs were to be administered in accordance with written orders of the attending physician. It confirmed that the nurse would ensure the client or guardian had signed a consent form for controlled medications and psychotropic medications after receiving medication information from the physician, and stated that if the nurse had any concerns or questions about the medication, the nurse manager or psychiatrist must be contacted to discuss those concerns prior to administration of the medication in question. The policy went on to state that medication orders would be put on the patient's MAR and that if a medication was not immediately available when it was time to give to the patient, the nurse would contact the pharmacist to resolve the issue. The policy also stated that in extenuating circumstances, on a case by case basis, the physician can consult with the pharmacist to arrange for the use of personal medications. In such cases, the pharmacist must visually evaluate the medication's integrity.

Review of the facility policy for medication records stated, "If for any reason the patient does not receive the medication ordered, the nurse must initial and circle dose omitted. On the back side, under nurse's medication notes, the nurse must document reason why the medication was not given. A corresponding progress note as to why medication not given must be entered in the patient record."

Based on electronic medical record reviews and review of the facility "Bylaws, Rules and Regulations of the Clinical Staff," the facility failed to ensure the patient's electronic medical record contained a discharge summary for 4 of 5 closed medical records reviewed. (Patient #1, #3, #7 and #8).

The findings include:

On 12/04 - 12/06/2018 a total of five (5) closed medical records were reviewed for discharge planning.

Patient #1, discharged on 11/05/2018 from the facility, failed to have a discharge summary in the medical record.
Patient #3, discharged on 11/13/2018 from the facility, failed to have a discharge summary in the medical record.
Patient #7, discharged on 06/21/2018 from the facility, failed to have a discharge summary in the medical record.
Patient #8, discharged on 05/05/2018 from the facility, failed to have a discharge summary in the medical record.

A review of the facility's "Bylaws, Rules and Regulations of the Clinical Staff," dated, June 2018 - under "Article VIII - Rules and Regulations of Inpatient Services" indicates "30. Within fifteen (15) days of inpatient unit discharge, a Discharge Summary must be dictated, or entered into the Electronic Health Record, by the attending practitioner for EPH patients."