HospitalInspections.org

Based on observation, interview and record review the facility failed to:
A. ensure psychotropics, narcotics and anesthetic/sedatives were used in a manner to enhance patient's health and well being.
*The facility failed to have complete physician orders and clear protocols for anesthetic/sedatives being administered.
*The facility failed to ensure staff followed physician orders when administering anesthetic/sedatives.
*They failed to use pychotropics and anesthetic/sedative agents as clinically indicated.
*They failed to ensure less restrictive alternatives were tried before administration of psychotropics and sedatives.
This deficient practice was found in 2 of 2 patients (Patient #s 10 and 11) and posed an Immediate Jeopardy to patient health and safety. This deficient practice placed all patients at risk for the likelihood of harm, serious injury, impairment and or subsequent death.
Refer to tag A0160 for additional information.


B. ensure patient grievances were investigated and responded to in a timely manner in 4 of 4 patients (Patient #s' 11, 13, 14, and 15).
Refer to tag A0122 for additional information.

Based on interview and record review, the facility failed to ensure patient grievances were investigated and responded to in a timely manner in 4 of 4 grievances (Patient #s 11, 13, 14, and 15).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of facility grievance reports and investigations revealed the following:
*On 07/03/2014, a grievance was received about Patient #11's care. One of the allegations was the cause of death (for her mother) was suffocation due to the patient's dentures being lodged in her throat. The complainant reported that at approximately 0300-0400 on the morning of admission, a "male nurse" called her and said, "Because of the stuff we gave her (Patient #11) we need to intubate her" ...
On 07/24/2014, the complainant called and wanted to know what was discovered regarding the investigation of her mother's care while in the hospital. She was told that the internal investigation was ongoing.
On 08/03/2015, the facility received another complaint regarding the death of Patient #11 and the care given by staff from the same complainant.
During an interview on 08/12/2015, after 3:50 p.m., Staff #2 confirmed the dates of the grievances. Staff #2 reported they had not sent the initial response letter of acknowledgement of the complaints. Resolution letter had not been sent either because the complainant told them not to send it.
*On 07/27/2015, the facility received a report from Patient #14s' family member about pain management being inadequate on 07/24/2014. There was documentation of the initial response letter of acknowledgement of the complaint being sent.
*On 06/23/2015, the facility received a report an assessment, test and diagnosis of Patient #15 being incorrect on a 06/18/2015 visit. According to the records Patient #15 was sent a response letter on 07/20/2015 (almost a month later).
*On 06/02/2015, the facility received a complaint concerning inadequate treatment and care. Patient #13's family made a complaint that staff was "rude and disrespectful". Resolution was met with the complainant being able to share her concerns with the ED director. According to the form the case was closed on 06/02/2015. On 07/01/2015 a physician review was performed.
According to the report the complainant reported "Nurse in back and Dr. were 'rude and disrespectful". No follow through with rechecking temperature and child had "brown stuff" draining out of ear. Nurses did not check on her or child while in the room. The doctor told her they needed to wait 24-48 hours to see if there was an ear infection. Patient #13 saw a doctor who put the patient on an antibiotic for an ear infection.
The following was written underneath the doctor's comments on the case:
"3y/o F, L ear pain w/brown drainage; likely AOM w/perforated TM. Reasonable to have prescribed antibiotics, either otic drops or oral. Read through nurses notes, doubt that they were rude/disrespectful. Appears that patient's mother was upset due to significant____ (visit?), which is reasonable. No further action required.
The complaint was not resolved on 06/02/2015 because further investigation was performed on 07/01/2015. There was no documentation of staff being talked to about the rude and disrespectful treatment.
During an interview on 08/12/2015 after 5:00 p.m., Staff #2 confirmed no response letter was sent on the grievances for Patient #14. The initial letter was sent late on Patient #15. Staff #2 confirmed no letter was sent on Patient #13 because they felt it was resolved on 06/02/2015. The complaint required additional investigation into the record and staff members had not been talked to.

Review of a facility policy named "GRIEVANCE/COMPLAINT PROCESS" revised 11/2013 revealed the following:
III. DEFINITIONS:
Patient grievances: A formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding:
The patient's care (when the complaint is not resolved at the time of the complaint by staff present*)
Abuse or neglect
Issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs)
A Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489.^
"Staff present" includes any hospital staff present at the time of the complaint or who can quickly be at the patient's location (i.e., nursing, administration, nursing supervisors, patient advocates, etc.) to resolve the patient's complaint.
If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and /or requires further actions for resolution, then the complaint is a grievance. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf.
C. Grievance Process begins with receipt of the grievance):
3. A written notice of resolution to the patient or the patient's representative shall be sent within seven (7) days of the receipt of the grievance. The letter will contain the name of the contact person at HCMH, steps taken on the behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. If the grievance is unable to be resolved in seven (7) days of receipt, the patient or patient's representative will be notified of the continuing investigation.
4. "A complaint is considered resolved when the patient is satisfied with the actions taken on their half."

Based on observation, interview and record review the facility failed to ensure psychotropics, narcotics and anesthetic/sedatives were used in a manner to enhance patient's health and well being.
*The facility failed to have complete physician orders and clear protocols for anesthetic/sedatives being administered.
*The facility failed to ensure staff followed physician orders when administering anesthetic/sedatives.
*They failed to use psychotropic and anesthetic/sedative agents as clinically indicated.
*They failed to ensure less restrictive alternatives were tried before administration of psychotropics and sedatives.
This deficient practice was found in 2 of 2 patients (Patient #s' 10 and 11) and posed an Immediate Jeopardy to patient health and safety. This deficient practice placed all patients at risk for the likelihood of harm, serious injury, impairment and or subsequent death.
Findings include:

Review of the record on Patient #10 revealed he was a 64 year old male who presented to the ED at 0945 a.m. on 08/08/2015. Patient #10 presented with chief complaints of increased agitation and not taking meds, food and fluids in 2 days. There was also documentation that Patient #10 had increased agitation, muscle rigidity and combativeness for the past 12 hours. According to documentation Patient #10 was uncooperative with vital signs assessment and monitor placement. The vital signs at 9:45 a.m. was a pulse of 120 (RR 60-120), respiration rate 24(RR 12-24), blood pressure 151/? and oxygen saturation of 99 percent (RR 90-100).
At 9:55 a.m., the ER physician assessment revealed Patient #10 diagnoses were AMS (altered mental status), rigidity, Delirium and possible NMS (neuroleptic malignant syndrome).
Neuroleptic malignant syndrome is a life-threatening neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs. NMS typically consists of muscle rigidity, fever, autonomic instability, and cognitive changes such as delirium, and is associated with elevated plasma creatine phosphokinase (CPK).
Review of a physician history and physical dated 08/08/2015 revealed Patient #10 had severe Alzheimer's dementia.
At 10:10 a.m., the anti-anxiety agent Ativan 1 mg was administered IM to Patient #10. There was no documentation of what less restrictive measure was tried prior to administration of the medication. There was no documentation of what current behavior warranted the usage of the medication.
At 10:15 a.m.(5 minutes later), the anti-psychotic agent Geodon 10 mg was administered IM. There was no documentation of what less restrictive measure was tried prior to administration of the medication. There was no documentation of what current behavior warranted the usage of the medication.
At 11:10 a..m., Patient #10 was started on the anti-convulsant Dilantin 1 gram IVPB in 100 ml of normal saline.
At 12:21 p.m., there was documentation the remaining Ativan 1 mg was administered for agitation. There was no documentation of what less restrictive measure was tried prior to administration of the medication.
At 1:07 p.m., the anti-anxiety agent Ativan 1 mg was administered for agitation. There was no documentation of what less restrictive measure was tried prior to administration of the medication. The vital signs at 1:07 p.m. was a pulse of 87, respiration rate 22, blood pressure 98/55 and oxygen saturation 98 percent.
At 3:27 p.m., the vital signs were documented as a pulse of 87, respiration of 22, no documented blood pressure and oxygen saturation of 98 percent.
At 3:28 p.m., report was given to Staff nurse #7 on the medical surgical unit.
At 3:29 p.m., Patient #10 was admitted to the Medical/surgical unit from the ED.
At 3:55 p.m., the vital signs on the Medical/Surgical unit were documented as being pulse of 83, respirations 22, blood pressure 100/68 and oxygen saturation of 98 percent.
At 5:30 p.m.(1.5 hours later), the nurse was called to the room by a CNA."BP 79/54, BP rechecked via electronic cuff, 81/55. BP checked via manual cuff to left arm BP72/50, charge nurse made aware, MD made aware, n/o to bolus LR, HR reg., r&r, no s/sx of distress, Pt continues to not respond to verbal, touch, or pain stimulus. Will remain at bedside and continue to monitor."
At 5:40 p.m., "BP rechecked, Pt hooked up to continuous monitor, BP 106/69, Pt now snoring loudly, no s/sx of distress.
At 6:01 p.m. lab results showed an elevated total creatine kinase of 1240 with reference ranges being (RR of 55-170)."
At 9:01 p.m. shift assessment complete. "Pt non verbal, hits when you touch him, bed alarm on for safety."
At 10:00 p.m., Received Pt to 400B via bed from third floor (Medical/surgical unit)." Pt accompanied by nursing staff. Pt nonresponsive verbally. Limbs drawn up and rigid. He has pulled out his IV. Pt appears very agitated."
Dr. #16 from the ER here for intubation of pt per Dr. #17's orders. IV started to left hand with 20 gauge ...Second IV started to RFA ....."Pt struggling against staff trying to hold him in bed. Rocuronium (sedative agent) 100mg administered with 20 mg Etomidate (sedative agent) to RFA. Difficult intubation due to pt's rigidity. Successful with 6.5 ET tube. Secured @ 24 cm at the lip."
At 10:22 p.m., Patient #10 was noted to be anxious severely rigid and shaking, attempted to give Ativan IV but could not because Pt pulled out IV. Not able to get new IV access. Dr. #17 to bedside and ordered to move Pt to ICU STAT. Last B/P was 90/70 .... Dr. #17 spoke with son who is POA on the phone to inform him of changes.
At 10:45 p.m., a physician order was written for the anesthetic/sedative "Diprovan (Propofol) 10mg/ml, 100 ml @0 mls/hr Tritate PRN IV" (to be used while on ventilator if needed). The order made no reference to what parameters or protocol to use to adjust the medication.
There was documentaion of the Patient #10 receiving Propofol at different rates while in ICU.
On 08/10/2015 (2 days later) at 2:59 p.m., Patient #10 was extubated and placed on 3 Liters of oxygen per nasal cannula. There was documentation of the Diprovan order being discontinued on 08/10/2015 at 3:24 p.m.
Review of the neurologist notes dated 08/10/2015 revealed Patient #10 had a past medical history of early onset Alzheimer's disease. In the nursing home approximately three weeks ago the patient was noted be progressively more anxious, agitated and his mental status was more altered. The patient had been having progressive problems with his memory and speech, however, still would occasionally joke around and had good verbal output. However, the son, who is at the bedside and provided most of the history, has stated that the patient recently has been only mumbling and has been nonverbal completely. The patient has been referred to be progressively more rigid, and at times, unresponsive. The patient has been getting Geodon (ziprasidone) and Ativan to treat his anxiety. The patient first received Geodon medication approximately four weeks ago. Per nursing home documentation available the patient was also on Namenda 10 mg twice daily, Lexapro 10 mg, Exelon 4.6 mgg patch, Baclofen 20 mg every 5 hours and risperidal, as well as Depakote 250 twice daily and the Geodon as mentioned ...
Creatine kinase is 1240 which had been decreasing with hydration.
ASSESSMENT/PLAN
1.The patient's altered mental status appears to be related to medication effect. The patient recently started atypical anti psychotics and therefore there is concern for neuroleptic malignant syndrome. The patient has mildly elevated CK. However, this has been decreasing with hydration. The patient's mental status appears to be mildly improving. We will continue to monitor the patient clinically and all atypical antipsychotics should be held at this time. There is also a possibility of serotonin syndrome as the patient was on Lexapro 10 mg in the nursing home and therefore we should also hold any serotonin containing medication ...
2. Rhabdomylosis (breakdown of muscle tissue). Continue to treat with hydration and monitor CK levels.

During an interview on 08/13/2015 after 4:00 p.m., Staff #9 confirmed the problems with the way the psychotropics were administered to Patient #10. Staff #9 confirmed there were no parameters or reference made on the Propofol orders. Staff #9 reported she was the charge nurse that was called in to check on the Patient #10 when he declined. Staff #9 reported Patient #10 was so sedated when he was transferred to them a sternal rub would not arouse him. They do not have the staff to watch that type of patient. They usually have 5 or 6 patients to 1 nurse on the Medical/Surgical unit.
During an interview on 08/14/2015 after 1:00 p.m., Staff #7 confirmed being the nurse who received Patient #10 onto the Medical/surgical unit on 08/08/2015. When Patient #10 came to the floor he was in a deep sleep and he would not respond to pressure to his finger nor a sternal rub. Staff #7 reported Patient #10 was so stiff she had to press his arm down to get the blood pressure cuff down. Staff #7 reported Patient #10's son was worried about dehydration since the patient had not eaten in the last 2 days. After the assessment Staff #7 reported this information to Dr. #17 when he was coming out of another patient's room. Dr. #17 wanted fluids (lactated ringers) started immediately and as CPK ordered. Staff #7 reported at 6:00 p.m. the nurse aide took vitals and they were low. Staff #7 reported she got the charge nurse into the room (Staff #9) who took over and said the decline was from a side effect from the medications given in the ED.
During an observation on 08/14/2015 after 9:00 a.m., Patient #10 was observed on the Medical/surgical unit. Three out of four of the siderails were up on his bed. Patient #10 had scooted down in the bed, tilted sideways with his legs hanging off the side of the bed into the bottom siderail. Patient #10 was totally dependent in ADLs, lower legs were rigid and contracted at the knees, and had a dressing over his coccyx area.
According to the Federal Drug Administration, "Geodon for injection is indicated for the treatment of acute agitation in schizophrenic patients for whom treatment with ziprasidone is appropriate and who need intramuscular (IM) antipsychotic medication for rapid control of the agitation.
Geodon for injection is associated with a number of serious risks, some of which are potentially fatal. The PI (product labeling) for Geodon for injection includes a black box warming concerning increased mortality in elderly patients with dementia-related psychosis. The Pl also include warnings for neuroleptic malignant syndrome, tardive dyskinesia, and hyperglycemia and diabetes mellitus, as well as a number of precaution including rash, orthostatic hypotension, and seizures.


Review of the record on Patient # 11 revealed she was a 94 year old female who presented to the ED with chief complaints of Altered mental status and low blood sugar on 06/26/2014 at 9:38 p.m. According to the triage assessment at 9:38 p.m. Patient #11 vital signs was a blood pressure of 159/106, pulse 70, respirations 16 and oxygen saturation of 96 percent. There was no documentation indicating if the oxygen saturation was on room air or not. Respirations were normal, even, unlabored and breath sounds clear. Patient #11 was classified as being urgent. Patient #11 was also described as conscious and confused.
At 10:10 p.m. there was documentation the nurse was called to CT by a tech. Patient would not remain still for CT. The anti-anxiety agent Ativan 1 mg IVP was given. Patient attempted to move off stretcher. The doctor was notified and Ativan 1 mg was repeated. Patient secured with straps to board. Patient moving against straps. Dr. notified and new orders received ... The anesthetic/sedative agent Versed 3 mg was administered IVP. There was no documentation of what less restrictive measure was tried prior to administration of the medication. There was no documentation of what current behavior warranted the usage of the medication.
Review of a Radiology report dated 06/26/2014 revealed Patient #11 had congestive heart failure with mild pulmonary edema.
According to Drugs.com the following information was provided on Versed (same as midazolam):
"Geriatric Use: Because geriatric patients may have altered drug distribution and diminished hepatic and/or renal function, reduced doses of midazolam are recommended. Intravenous and intramuscular doses of midazolam should be decreased for elderly and for debilitated patients over 70 years of age may be particularly sensitive. These patients will also probably take longer to recover completely after midazolam administration for the induction of anesthesia. Administration of IM and IV midazolam to elderly and/or high risk surgical patients has been associated with rare reports of death under circumstances compatible with cardiorespiratory depression. In most cases, the patients also received other central nervous system depressants capable of depressing respiration, especially narcotics.
Patients Ago 60 or Older, and Debilitated or Chronically Ill Patients; Because the danger of hypoventilation, airway obstruction, or apnea is greater in elderly patients and those with chronic disease states or decreased pulmonary reserve, and because the peak effect may take longer in these patients increments should be smaller and the rate of injection slower. Titrate slowly to the desired effect (e.g. the initiation of slurred speech). Some patients may respond to as little as 1 mg. No more than 1.5 mg should be given over of period of no less than 2 minutes. Wait an additional 2 or more minutes to fully evaluation the sedative effect. If additional titration is necessary it should be given at a rate of no more than 1 mg over a period of 2 minutes wafting an additional 2 or more minutes each time to fully evaluate the sedative effect. Total doses greater than 3.5 mg are not usually necessary."
According the facility record the following was revealed:
At 11:10 p.m., lab results revealed, Patient #11 had a BNP of 1040 (RR being 5-100). The level of BNP in the blood increases when heart failure symptoms worsen, and decreases when the heart failure condition is stable.
At 12:03 a.m., Patient #11 remained confused and saying "help me". Patient pulling at tubes and cords. Patient positioned, but continues to move around bed.
At 12:20 a.m., Patient #11 was given the diuretic Lasix IVP. Patient pulling at Foley and attempting to climb out of bed. Ativan 1 mg IVP was given. Oxygen saturation was 80 percent on oxygen at 2 liters. It was increased to 4 liters. Dr at bedside to reassess and oxygen saturation up to 91 percent. There was no documentation of what less restrictive measure was tried prior to administration of the Ativan.
At 12:45 a.m. , Patient #11 had an oxygen saturation of 70 percent, fingers purple, generalized mottling noted. Patient repositioned and Dr. aware. Oxygen saturation up to 89 percent. Patient moved to Trauma 1 for intubation.
At 1:20 a.m, Patient #11 was intubated by the doctor.
At 1:35 a.m., a Propofol 50 mg bolus IVP and drip started at 15 micrograms. Review of the ED physician orders revealed an order for a Propofol drip 20 mcg, but there was no order written on the sheet for a bolus.
Review of a physician's history and physical dated 06/27/2014 revealed the following documentation:
"The patient is a 94 year old white female who presented to the hospital and was noted to have altered level of consciousness and she was apparently uncontrollable in the Emergency Room. She was therefore sedated, paralyzed and intubated for airway protection and moved to the Intensive Care Unit."
At 2:39 a.m., Patient #11 was received to ICU and there was documentation of restraints being on.
Review of ventilation protocol orders dated 06/27/2014 at 2:39 a.m. revealed the following:
Optional Propofol: For further sedation, may titrate Propofol from 0(zero) to 50 (fifty micrograms/kilograms/minutes in order to keep Systolic Blood Pressure >90 mmHg while receiving Propofol.
Optional Versed:-0.05-0.2mg/kg/hour titrated for sedation. May increase 25-50 percent based on sedation level.

06/27/2014
At 1:10 p.m. Patient #11 was documented as being extremely agitated while attempting to draw labs. The pain agent Morphine 2 mg IVP was administered.
Review of the physician orders revealed the Morphine was ordered for pain not agitation.
At 3:30 p.m.,Patient #11 had a blood pressure of 74/53 and Propofol was at 20 mcg.
At 4:00 pm., Patient #11 had a blood pressure of 74/62 and Propofol was still at 20 mcg.
The nurses failed to follow the physician order to keep the Systolic blood pressure above 90.
At 4:30 p.m., Patient #11 had a blood pressure of 88/54 and Propofol was at 10 mcg (an hour later).
At 4:35 p.m., there was documentation Patient #11 was becoming hypotensive. Will decrease Propofol and monitor closely. Repositioned for comfort.
At 5:45 p.m., there was documentation the MD was paged in response to low blood pressure. Orders for 500cc of NS. Will monitor.
At 6:00 p.m., blood pressure was documented as being 85/33 and Propofol at 10 mcg.
At 6:10 p.m., Patient #11 was bucking in bed, attempted to take ETT tube out, Re-restrained. ETT advanced by respiratory. Sedation changed to Versed and initiated ....
At 6:55 p.m. and 8:43 p.m. there was documentation that Patient #11 was receiving Versed and Propofol. Nursing staff added addendums were on 06/28/2013 at 6:20 a.m. and 6:21 a.m. saying the Propofol was off at those times (6:55 p.m. and 8:43 p.m.).

On 06/28/2014 the following was found:
At 2:30 p.m., physician orders were written to discontinue Versed and administer sedative agent Precedex drip.
At 3:49 p.m., Initiated Precedex per MD orders. Will titrate Versed down as patients calms down.
At 4:00 p.m., Patient #11 had a blood pressure of 145/62, HR of 71 and was on the sedatives Versed and Precedex.
At 5:00 p.m., Patient #11 had a blood pressure of 116/65, HR of 61 and was on the sedatives Versed and Precedex.
At 6:00 p.m., Patient #11 had a blood pressure of 114/56, HR of 54 and was on the sedatives Versed and Precedex.
Three and half hours after receiving the order to discontinue the Versed it was still infusing.
At 6:06 p.m., Patient #11 had a blood pressure of 87/52 and a HR of 51. There was documentation that Patient #11 had a low BP and oxygen saturations were declining. Dr. still at bedside finishing central line placement. Fiox turned up to 100 percent, Dopamine initiated. MD remained at bedside until oxygen saturation improved as well at BP and heart rthym. Dopamine discontinued and fluid bolus continues to infuse. Will continue to monitor closely. The Versed was off.
At 6:20 p.m., an order was written to resume Versed drip at this time (IVPB). Titrate for sedation
At 7:00 p.m. Patient #11 had a heart rhythm of sinus brady with PVC, to pauses and had a first degree block. Heart rate ranging from 30 to 58 bpm and blood pressure okay. Bilateral wrist restraints were on. There was documentation that when patient is not sedated she tries to pull tube out. Breath sounds clear and vent settings changed.
Untimed physician orders were written to hold all sedations. The pharmacy was notified at 7:08 p.m. about the orders and the orders were signed off by nursing at 7:30 p.m.
At 7:30 p.m., nursing documented they turned sedation back on Versed and Dexmedetomidine (Precedex). No order could be found on the chart for this.
At 9:55 p.m., Patient #11 was having PVC's and several pauses. Defib pads in place. Will continue to monitor.
At 10:33 p.m. documentation showed the two sedations were still infusing at 10:33 p.m. At this time there was documentation of Patient #11 having a blood pressure of 59/16 and pulse of 46.
At 11:00 p.m. Patient reassessment completed at this time. "Patient remains on vent and no changes since the beginning of shift. Patient HR has been as low as 31 to as high as 60 per monitor. Pt has received potassium replacements. Versed off at this time as directed by the Dr."
There was no documentation that nursing followed the physician order to stop the sedations at 7:30 p.m..

On 06/29/2014 at 1:25 p.m., Patient #11 was extubated and placed on 4 Liters of oxygen per nasal cannula.
At 4:30 p.m. physicians orders were written placing Patient #11 on comfort care.
At 6:35 p.m. the patient had no heart tones or visible respirations and the physician was called to pronounce.

During an interview on 08/14/2014 after 9:00 a.m., Staff #4 confirmed there was no documentation of alternatives being tried prior to administration of the medications in the emergency room. Staff #4 reported they did not have a policy which addressed chemical restraints and usage of psychotropic medications. Staff #4 confirmed the condition of the physician orders for Propofol written in the Emergency room.
During an interview on 08/14/2015 after 10:00 a.m., Staff #6 confirmed she gave the Ativan and Versed in the emergency room to Patient #11. Staff #6 confirmed no alternatives were tried prior to administration of the medication and there was no documentation of behaviors that warranted the usage of the medication.

During an interview on 08/13/2015 after 3:00 p.m., Staff #11 reported she started the Propofol drops at 50 mcg when using the prn orders. It just depends on the patient because for some that is not enough. Staff #11 confirmed the missing information in the notes, low vital signs and continuation of the drips.
During an interview on 08/13/2015 after 6:00 p.m., Staff #12 reported she starts Propofol at 10 mcg when using the prn orders. Staff #12 confirmed the missing information in the nurses notes, low vital signs and continuation of the drips.
During an interview on 08/13/2015 after 7:00 p.m., Staff #5 reported she titrates by patient comfort from 5 mcg-200 mcg. Staff #5 confirmed she administered the Morphine and the order she used was the one that was for pain.
During an interview on 08/14/2015 after 1:50 p.m., Dr. #8 reported the nurses were instructed to go by the scale on the protocols for sedation.
Review of the facility undated Diprivan/Propofol protocol revealed the following instructions:
INDICATIONS AND ACTIONS: ANESTHETIC SEDATIVE-HYPNOTIC:USED FOR VENT PATIENTS
USUAL DOSE:5-50MCG/KG/MIN. START @5 MCG/KG/MINUTE FOR 5 MINUTES THEN INCREASE BY 5-10 MCG/KG/MINUTE UNTIL PATIENT IS SEDATED.
DILUTION:PREMIXED 1000 MG/100 CC, THIS IS A LIPID
WATCH FOR :HYPOTENSION, BRADYCARDIA, APNEA, DYSTONIC MOVEMENT
THINGS TO KNOW:CHANGE TUBING Q12 HOURS,
VITAL SIGNS Q 15 MINUTES @ FIRST
URINE MIGHT TURN GREEN
STOP DRUG GRADUALLY
There was also a hand written directive that read "per 12/19/14 ICU meeting note MAX now 200 mcg". There was no documentation of who added the information to the protocol. This protocol was totally different from the Ventilator order protocol for usage of Propofol.
Review of the Versed protocol revealed directions hand written in on a sheet of paper and read as follows:
"Versed gtt
Remove 10 ml from 100 ml bag NS
Add Versed (50 mg/10mlvial)10 ml to bag
Normal Infusion 0.05-0.2 mg/kg/HR
(We give in non weight base 1-7mg/hr)
50mg in 100 ml"
There was no indication as to when and who initiated the protocol. The protocol was written in two different pens and had mark outs. There was no way to tell who had made changes to the protocol.

Based on observation, interview and record review the facility failed to:

A. ensure nursing staff administered psychotropics, narcotics and anesthetic/sedatives in a manner to enhance patient's health and well being.
*The facility failed to have complete physician orders and clear protocols for anesthetic/sedatives being administered.
*The facility failed to ensure staff followed physician orders when administering anesthetic/sedatives.
*They failed to use pychotropics and anesthetic/sedative agents as clinically indicated.
*They failed to ensure less restrictive alternatives were tried before administration of psychotropics and sedatives.
This deficient practice was found in 2 of 2 patients (Patient #s' 10 and 11) and posed an Immediate Jeopardy to patient health and safety. This deficient practice placed all patients at risk for the likelihood of harm, serious injury, impairment and or subsequent death.
Refer to tag A0392 for additional information.

Based on observation, interview and record review the facility failed to ensure nursing staff administered psychotropics, narcotics and anesthetic/sedatives in a manner to enhance patient's health and well being.
*The facility failed to have complete physician orders and clear protocols for anesthetic/sedatives being administered.
*The facility failed to ensure staff followed physician orders when administering anesthetic/sedatives.
*They failed to use psychotropic and anesthetic/sedative agents as clinically indicated.
*They failed to ensure less restrictive alternatives were tried before administration of psychotropics and sedatives.
This deficient practice was found in 2 of 2 patients (Patient #s' 10 and 11) and posed an Immediate Jeopardy to patient health and safety. This deficient practice placed all patients at risk for the likelihood of harm, serious injury, impairment and or subsequent death.
Findings include:

Review of the record on Patient #10 revealed he was a 64 year old male who presented to the ED at 0945 a.m. on 08/08/2015. Patient #10 presented with chief complaints of increased agitation and not taking meds, food and fluids in 2 days. There was also documentation that Patient #10 had increased agitation, muscle rigidity and combativeness for the past 12 hours. According to documentation Patient #10 was uncooperative with vital signs assessment and monitor placement. The vital signs at 9:45 a.m. was a pulse of 120 (RR 60-120), respiration rate 24(RR 12-24), blood pressure 151/? and oxygen saturation of 99 percent (RR 90-100).
At 9:55 a.m., the ER physician assessment revealed Patient #10 diagnoses were AMS (altered mental status), rigidity, Delirium and possible NMS (neuroleptic malignant syndrome).
Neuroleptic malignant syndrome is a life-threatening neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs. NMS typically consists of muscle rigidity, fever, autonomic instability, and cognitive changes such as delirium, and is associated with elevated plasma creatine phosphokinase (CPK).
Review of a physician history and physical dated 08/08/2015 revealed Patient #10 had severe Alzheimer's dementia.
At 10:10 a.m., the anti-anxiety agent Ativan 1 mg was administered IM to Patient #10. There was no documentation of what less restrictive measure was tried prior to administration of the medication. There was no documentation of what current behavior warranted the usage of the medication.
At 10:15 a.m.(5 minutes later), the anti-psychotic agent Geodon 10 mg was administered IM. There was no documentation of what less restrictive measure was tried prior to administration of the medication. There was no documentation of what current behavior warranted the usage of the medication.
At 11:10 a..m., Patient #10 was started on the anti-convulsant Dilantin 1 gram IVPB in 100 ml of normal saline.
At 12:21 p.m., there was documentation the remaining Ativan 1 mg was administered for agitation. There was no documentation of what less restrictive measure was tried prior to administration of the medication.
At 1:07 p.m., the anti-anxiety agent Ativan 1 mg was administered for agitation. There was no documentation of what less restrictive measure was tried prior to administration of the medication. The vital signs at 1:07 p.m. was a pulse of 87, respiration rate 22, blood pressure 98/55 and oxygen saturation 98 percent.
At 3:27 p.m., the vital signs were documented as a pulse of 87, respiration of 22, no documented blood pressure and oxygen saturation of 98 percent.
At 3:28 p.m., report was given to Staff nurse #7 on the medical surgical unit.
At 3:29 p.m., Patient #10 was admitted to the Medical/surgical unit from the ED.
At 3:55 p.m., the vital signs on the Medical/Surgical unit were documented as being pulse of 83, respirations 22, blood pressure 100/68 and oxygen saturation of 98 percent.
At 5:30 p.m.(1.5 hours later), the nurse was called to the room by a CNA."BP 79/54, BP rechecked via electronic cuff, 81/55. BP checked via manual cuff to left arm BP72/50, charge nurse made aware, MD made aware, n/o to bolus LR, HR reg., r&r, no s/sx of distress, Pt continues to not respond to verbal, touch, or pain stimulus. Will remain at bedside and continue to monitor."
At 5:40 p.m., "BP rechecked, Pt hooked up to continuous monitor, BP 106/69, Pt now snoring loudly, no s/sx of distress.
At 6:01 p.m. lab results showed an elevated total creatine kinase of 1240 with reference ranges being (RR of 55-170)."
At 9:01 p.m. shift assessment complete. "Pt non verbal, hits when you touch him, bed alarm on for safety."
At 10:00 p.m., Received Pt to 400B via bed from third floor (Medical/surgical unit)." Pt accompanied by nursing staff. Pt nonresponsive verbally. Limbs drawn up and rigid. He has pulled out his IV. Pt appears very agitated."
Dr. #16 from the ER here for intubation of pt per Dr. #17's orders. IV started to left hand with 20 gauge ...Second IV started to RFA ....."Pt struggling against staff trying to hold him in bed. Rocuronium (sedative agent) 100mg administered with 20 mg Etomidate (sedative agent) to RFA. Difficult intubation due to pt's rigidity. Successful with 6.5 ET tube. Secured @ 24 cm at the lip."
At 10:22 p.m., Patient #10 was noted to be anxious severely rigid and shaking, attempted to give Ativan IV but could not because Pt pulled out IV. Not able to get new IV access. Dr. #17 to bedside and ordered to move Pt to ICU STAT. Last B/P was 90/70 .... Dr. #17 spoke with son who is POA on the phone to inform him of changes.
At 10:45 p.m., a physician order was written for the anesthetic/sedative "Diprovan (Propofol) 10mg/ml, 100 ml @0 mls/hr Tritate PRN IV" (to be used while on ventilator if needed). The order made no reference to what parameters or protocol to use to adjust the medication.
There was documentaion of the Patient #10 receiving Propofol at different rates while in ICU.
On 08/10/2015 (2 days later) at 2:59 p.m., Patient #10 was extubated and placed on 3 Liters of oxygen per nasal cannula. There was documentation of the Diprovan order being discontinued on 08/10/2015 at 3:24 p.m.
Review of the neurologist notes dated 08/10/2015 revealed Patient #10 had a past medical history of early onset Alzheimer's disease. In the nursing home approximately three weeks ago the patient was noted be progressively more anxious, agitated and his mental status was more altered. The patient had been having progressive problems with his memory and speech, however, still would occasionally joke around and had good verbal output. However, the son, who is at the bedside and provided most of the history, has stated that the patient recently has been only mumbling and has been nonverbal completely. The patient has been referred to be progressively more rigid, and at times, unresponsive. The patient has been getting Geodon (ziprasidone) and Ativan to treat his anxiety. The patient first received Geodon medication approximately four weeks ago. Per nursing home documentation available the patient was also on Namenda 10 mg twice daily, Lexapro 10 mg, Exelon 4.6 mgg patch, Baclofen 20 mg every 5 hours and risperidal, as well as Depakote 250 twice daily and the Geodon as mentioned ...
Creatine kinase is 1240 which had been decreasing with hydration.
ASSESSMENT/PLAN
1.The patient's altered mental status appears to be related to medication effect. The patient recently started atypical anti psychotics and therefore there is concern for neuroleptic malignant syndrome. The patient has mildly elevated CK. However, this has been decreasing with hydration. The patient's mental status appears to be mildly improving. We will continue to monitor the patient clinically and all atypical antipsychotics should be held at this time. There is also a possibility of serotonin syndrome as the patient was on Lexapro 10 mg in the nursing home and therefore we should also hold any serotonin containing medication ...
2. Rhabdomylosis (breakdown of muscle tissue). Continue to treat with hydration and monitor CK levels.

During an interview on 08/13/2015 after 4:00 p.m., Staff #9 confirmed the problems with the way the psychotropics were administered to Patient #10. Staff #9 confirmed there were no parameters or reference made on the Propofol orders. Staff #9 reported she was the charge nurse that was called in to check on the Patient #10 when he declined. Staff #9 reported Patient #10 was so sedated when he was transferred to them a sternal rub would not arouse him. They do not have the staff to watch that type of patient. They usually have 5 or 6 patients to 1 nurse on the Medical/Surgical unit.
During an interview on 08/14/2015 after 1:00 p.m., Staff #7 confirmed being the nurse who received Patient #10 onto the Medical/surgical unit on 08/08/2015. When Patient #10 came to the floor he was in a deep sleep and he would not respond to pressure to his finger nor a sternal rub. Staff #7 reported Patient #10 was so stiff she had to press his arm down to get the blood pressure cuff down. Staff #7 reported Patient #10's son was worried about dehydration since the patient had not eaten in the last 2 days. After the assessment Staff #7 reported this information to Dr. #17 when he was coming out of another patient's room. Dr. #17 wanted fluids (lactated ringers) started immediately and as CPK ordered. Staff #7 reported at 6:00 p.m. the nurse aide took vitals and they were low. Staff #7 reported she got the charge nurse into the room (Staff #9) who took over and said the decline was from a side effect from the medications given in the ED.
During an observation on 08/14/2015 after 9:00 a.m., Patient #10 was observed on the Medical/surgical unit. Three out of four of the siderails were up on his bed. Patient #10 had scooted down in the bed, tilted sideways with his legs hanging off the side of the bed into the bottom siderail. Patient #10 was totally dependent in ADLs, lower legs were rigid and contracted at the knees, and had a dressing over his coccyx area.
According to the Federal Drug Administration, "Geodon for injection is indicated for the treatment of acute agitation in schizophrenic patients for whom treatment with ziprasidone is appropriate and who need intramuscular (IM) antipsychotic medication for rapid control of the agitation.
Geodon for injection is associated with a number of serious risks, some of which are potentially fatal. The PI (product labeling) for Geodon for injection includes a black box warming concerning increased mortality in elderly patients with dementia-related psychosis. The Pl also include warnings for neuroleptic malignant syndrome, tardive dyskinesia, and hyperglycemia and diabetes mellitus, as well as a number of precaution including rash, orthostatic hypotension, and seizures.


Review of the record on Patient # 11 revealed she was a 94 year old female who presented to the ED with chief complaints of Altered mental status and low blood sugar on 06/26/2014 at 9:38 p.m. According to the triage assessment at 9:38 p.m. Patient #11 vital signs was a blood pressure of 159/106, pulse 70, respirations 16 and oxygen saturation of 96 percent. There was no documentation indicating if the oxygen saturation was on room air or not. Respirations were normal, even, unlabored and breath sounds clear. Patient #11 was classified as being urgent. Patient #11 was also described as conscious and confused.
At 10:10 p.m. there was documentation the nurse was called to CT by a tech. Patient would not remain still for CT. The anti-anxiety agent Ativan 1 mg IVP was given. Patient attempted to move off stretcher. The doctor was notified and Ativan 1 mg was repeated. Patient secured with straps to board. Patient moving against straps. Dr. notified and new orders received ... The anesthetic/sedative agent Versed 3 mg was administered IVP. There was no documentation of what less restrictive measure was tried prior to administration of the medication. There was no documentation of what current behavior warranted the usage of the medication.
Review of a Radiology report dated 06/26/2014 revealed Patient #11 had congestive heart failure with mild pulmonary edema.
According to Drugs.com the following information was provided on Versed (same as midazolam):
"Geriatric Use: Because geriatric patients may have altered drug distribution and diminished hepatic and/or renal function, reduced doses of midazolam are recommended. Intravenous and intramuscular doses of midazolam should be decreased for elderly and for debilitated patients over 70 years of age may be particularly sensitive. These patients will also probably take longer to recover completely after midazolam administration for the induction of anesthesia. Administration of IM and IV midazolam to elderly and/or high risk surgical patients has been associated with rare reports of death under circumstances compatible with cardiorespiratory depression. In most cases, the patients also received other central nervous system depressants capable of depressing respiration, especially narcotics.
Patients Ago 60 or Older, and Debilitated or Chronically Ill Patients; Because the danger of hypoventilation, airway obstruction, or apnea is greater in elderly patients and those with chronic disease states or decreased pulmonary reserve, and because the peak effect may take longer in these patients increments should be smaller and the rate of injection slower. Titrate slowly to the desired effect (e.g. the initiation of slurred speech). Some patients may respond to as little as 1 mg. No more than 1.5 mg should be given over of period of no less than 2 minutes. Wait an additional 2 or more minutes to fully evaluation the sedative effect. If additional titration is necessary it should be given at a rate of no more than 1 mg over a period of 2 minutes wafting an additional 2 or more minutes each time to fully evaluate the sedative effect. Total doses greater than 3.5 mg are not usually necessary."
According the facility record the following was revealed:
At 11:10 p.m., lab results revealed, Patient #11 had a BNP of 1040 (RR being 5-100). The level of BNP in the blood increases when heart failure symptoms worsen, and decreases when the heart failure condition is stable.
At 12:03 a.m., Patient #11 remained confused and saying "help me". Patient pulling at tubes and cords. Patient positioned, but continues to move around bed.
At 12:20 a.m., Patient #11 was given the diuretic Lasix IVP. Patient pulling at Foley and attempting to climb out of bed. Ativan 1 mg IVP was given. Oxygen saturation was 80 percent on oxygen at 2 liters. It was increased to 4 liters. Dr at bedside to reassess and oxygen saturation up to 91 percent. There was no documentation of what less restrictive measure was tried prior to administration of the Ativan.
At 12:45 a.m. , Patient #11 had an oxygen saturation of 70 percent, fingers purple, generalized mottling noted. Patient repositioned and Dr. aware. Oxygen saturation up to 89 percent. Patient moved to Trauma 1 for intubation.
At 1:20 a.m, Patient #11 was intubated by the doctor.
At 1:35 a.m., a Propofol 50 mg bolus IVP and drip started at 15 micrograms. Review of the ED physician orders revealed an order for a Propofol drip 20 mcg, but there was no order written on the sheet for a bolus.
Review of a physician's history and physical dated 06/27/2014 revealed the following documentation:
"The patient is a 94 year old white female who presented to the hospital and was noted to have altered level of consciousness and she was apparently uncontrollable in the Emergency Room. She was therefore sedated, paralyzed and intubated for airway protection and moved to the Intensive Care Unit."
At 2:39 a.m., Patient #11 was received to ICU and there was documentation of restraints being on.
Review of ventilation protocol orders dated 06/27/2014 at 2:39 a.m. revealed the following:
Optional Propofol: For further sedation, may titrate Propofol from 0(zero) to 50 (fifty micrograms/kilograms/minutes in order to keep Systolic Blood Pressure >90 mmHg while receiving Propofol.
Optional Versed:-0.05-0.2mg/kg/hour titrated for sedation. May increase 25-50 percent based on sedation level.

06/27/2014
At 1:10 p.m. Patient #11 was documented as being extremely agitated while attempting to draw labs. The pain agent Morphine 2 mg IVP was administered.
Review of the physician orders revealed the Morphine was ordered for pain not agitation.
At 3:30 p.m.,Patient #11 had a blood pressure of 74/53 and Propofol was at 20 mcg.
At 4:00 pm., Patient #11 had a blood pressure of 74/62 and Propofol was still at 20 mcg.
The nurses failed to follow the physician order to keep the Systolic blood pressure above 90.
At 4:30 p.m., Patient #11 had a blood pressure of 88/54 and Propofol was at 10 mcg (an hour later).
At 4:35 p.m., there was documentation Patient #11 was becoming hypotensive. Will decrease Propofol and monitor closely. Repositioned for comfort.
At 5:45 p.m., there was documentation the MD was paged in response to low blood pressure. Orders for 500cc of NS. Will monitor.
At 6:00 p.m., blood pressure was documented as being 85/33 and Propofol at 10 mcg.
At 6:10 p.m., Patient #11 was bucking in bed, attempted to take ETT tube out, Re-restrained. ETT advanced by respiratory. Sedation changed to Versed and initiated ....
At 6:55 p.m. and 8:43 p.m. there was documentation that Patient #11 was receiving Versed and Propofol. Nursing staff added addendums were on 06/28/2013 at 6:20 a.m. and 6:21 a.m. saying the Propofol was off at those times (6:55 p.m. and 8:43 p.m.).

On 06/28/2014 the following was found:
At 2:30 p.m., physician orders were written to discontinue Versed and administer sedative agent Precedex drip.
At 3:49 p.m., Initiated Precedex per MD orders. Will titrate Versed down as patients calms down.
At 4:00 p.m., Patient #11 had a blood pressure of 145/62, HR of 71 and was on the sedatives Versed and Precedex.
At 5:00 p.m., Patient #11 had a blood pressure of 116/65, HR of 61 and was on the sedatives Versed and Precedex.
At 6:00 p.m., Patient #11 had a blood pressure of 114/56, HR of 54 and was on the sedatives Versed and Precedex.
Three and half hours after receiving the order to discontinue the Versed it was still infusing.
At 6:06 p.m., Patient #11 had a blood pressure of 87/52 and a HR of 51. There was documentation that Patient #11 had a low BP and oxygen saturations were declining. Dr. still at bedside finishing central line placement. Fiox turned up to 100 percent, Dopamine initiated. MD remained at bedside until oxygen saturation improved as well at BP and heart rthym. Dopamine discontinued and fluid bolus continues to infuse. Will continue to monitor closely. The Versed was off.
At 6:20 p.m., an order was written to resume Versed drip at this time (IVPB). Titrate for sedation
At 7:00 p.m. Patient #11 had a heart rhythm of sinus brady with PVC, to pauses and had a first degree block. Heart rate ranging from 30 to 58 bpm and blood pressure okay. Bilateral wrist restraints were on. There was documentation that when patient is not sedated she tries to pull tube out. Breath sounds clear and vent settings changed.
Untimed physician orders were written to hold all sedations. The pharmacy was notified at 7:08 p.m. about the orders and the orders were signed off by nursing at 7:30 p.m.
At 7:30 p.m., nursing documented they turned sedation back on Versed and Dexmedetomidine (Precedex). No order could be found on the chart for this.
At 9:55 p.m., Patient #11 was having PVC's and several pauses. Defib pads in place. Will continue to monitor.
At 10:33 p.m. documentation showed the two sedations were still infusing at 10:33 p.m. At this time there was documentation of Patient #11 having a blood pressure of 59/16 and pulse of 46.
At 11:00 p.m. Patient reassessment completed at this time. "Patient remains on vent and no changes since the beginning of shift. Patient HR has been as low as 31 to as high as 60 per monitor. Pt has received potassium replacements. Versed off at this time as directed by the Dr."
There was no documentation that nursing followed the physician order to stop the sedations at 7:30 p.m..

On 06/29/2014 at 1:25 p.m., Patient #11 was extubated and placed on 4 Liters of oxygen per nasal cannula.
At 4:30 p.m. physicians orders were written placing Patient #11 on comfort care.
At 6:35 p.m. the patient had no heart tones or visible respirations and the physician was called to pronounce.

During an interview on 08/14/2014 after 9:00 a.m., Staff #4 confirmed there was no documentation of alternatives being tried prior to administration of the medications in the emergency room. Staff #4 reported they did not have a policy which addressed chemical restraints and usage of psychotropic medications. Staff #4 confirmed the condition of the physician orders for Propofol written in the Emergency room.
During an interview on 08/14/2015 after 10:00 a.m., Staff #6 confirmed she gave the Ativan and Versed in the emergency room to Patient #11. Staff #6 confirmed no alternatives were tried prior to administration of the medication and there was no documentation of behaviors that warranted the usage of the medication.

During an interview on 08/13/2015 after 3:00 p.m., Staff #11 reported she started the Propofol drops at 50 mcg when using the prn orders. It just depends on the patient because for some that is not enough. Staff #11 confirmed the missing information in the notes, low vital signs and continuation of the drips.
During an interview on 08/13/2015 after 6:00 p.m., Staff #12 reported she starts Propofol at 10 mcg when using the prn orders. Staff #12 confirmed the missing information in the nurses notes, low vital signs and continuation of the drips.
During an interview on 08/13/2015 after 7:00 p.m., Staff #5 reported she titrates by patient comfort from 5 mcg-200 mcg. Staff #5 confirmed she administered the Morphine and the order she used was the one that was for pain.
During an interview on 08/14/2015 after 1:50 p.m., Dr. #8 reported the nurses were instructed to go by the scale on the protocols for sedation.
Review of the facility undated Diprivan/Propofol protocol revealed the following instructions:
INDICATIONS AND ACTIONS: ANESTHETIC SEDATIVE-HYPNOTIC:USED FOR VENT PATIENTS
USUAL DOSE:5-50MCG/KG/MIN. START @5 MCG/KG/MINUTE FOR 5 MINUTES THEN INCREASE BY 5-10 MCG/KG/MINUTE UNTIL PATIENT IS SEDATED.
DILUTION:PREMIXED 1000 MG/100 CC, THIS IS A LIPID
WATCH FOR :HYPOTENSION, BRADYCARDIA, APNEA, DYSTONIC MOVEMENT
THINGS TO KNOW:CHANGE TUBING Q12 HOURS,
VITAL SIGNS Q 15 MINUTES @ FIRST
URINE MIGHT TURN GREEN
STOP DRUG GRADUALLY
There was also a hand written directive that read "per 12/19/14 ICU meeting note MAX now 200 mcg". There was no documentation of who added the information to the protocol. This protocol was totally different from the Ventilator order protocol for usage of Propofol.
Review of the Versed protocol revealed directions hand written in on a sheet of paper and read as follows:
"Versed gtt
Remove 10 ml from 100 ml bag NS
Add Versed (50 mg/10mlvial)10 ml to bag
Normal Infusion 0.05-0.2 mg/kg/HR
(We give in non weight base 1-7mg/hr)
50mg in 100 ml"
There was no indication as to when and who initiated the protocol. The protocol was written in two different pens and had mark outs. There was no way to tell who had made changes to the protocol.

Based on interview and record review the facility failed to ensure physician orders were complete and accurate in 8 of 8 patients (Patient #s' 1,2,4,6,9,10,11 and 12)reviewed.
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of the record on Patient #11 revealed she was a 94 year old female who presented to the ED with chief complaints of Altered mental status and low blood sugar on 06/26/2014.
Review of an ED "Physician Order Sheet" revealed orders for labs, x-rays and medications which were not timed. There were medication orders for psychotropic and anesthetic/sedative medications IVP which did not include the frequency. There was an order for the sedative drip Propofol which did not include parameters or reference to protocols to use. Some of the medications on the list were marked through and there was no way to tell who marked through them nor when. There was documentation of Patient #11 being admitted to the Medical/Surgical unit at the bottom of the page of orders. The physician signed off on the order set, but left the area for date/time blank.
Another order set named "Congestive heart failure" revealed Patient #11 was being admitted to ICU. The order set was signed and dated by the physician,but were not timed.
Another protocol named "DVT/PE PROPHYLAXIS ORDERS" (for deep vein thrombosis/pulmonary embolism) revealed nursing signed off Patient #11 was at risk and wrote SCD (sequential compression devices). Nursing signed off on 06/28/2014. The physician signed off on the orders over a month later on 08/01/2014.
Review of the clinical record on Patient #12 revealed she was a 72 year old female who presented to the ED on 06/26/2014 with a chief complaint of trouble breathing and coughing.
Review of an ED "Physician Order Sheet " revealed orders for labs and x-rays which were not timed. There was an order for a respiratory treatment which was not timed nor was it complete with the dosage or frequency for administration.
Another set of physician orders was signed off by the physician, but were not timed or dated.

Review of the clinical record on Patient #6 revealed he was a 62 year old male who presented to the ED on 08/08/2015 with diagnoses which included shortness of breath and epigastric/chest pain.
Review of an ED "Physician Order Set" revealed orders written for IV access and a medication which were not timed. The physician signed off on the order set, but left the area for date/time blank.

Review of the clinical record of Patient #10 revealed he was a 64 year old male who presented to ED on 08/08/2015 with chief complaints of increased agitation.
Review of an ED "Physician Order Set" revealed orders were written for psychotropic medications which were not timed nor did they include the frequency of administration.
The physician signed off on the order set, but left the area for the time blank.

Review of the clinical record on Patient #1 revealed she was a 10 year old female who presented to the ED on 08/09/2015 with a chief complaint of abdominal pain.
Review of an ED "Physician Order Set" revealed orders for a medication. The computerized dosage for the ordered medication was marked through and another dosage amount written over it. There was no indication as to if this was a one time order or what the frequency should be. The order was not timed. The physician signed off on the order set, but left the area for date/time blank.

Review of the clinical record on Patient #9 revealed she was a 72 year old female who presented to the ED on 08/09/2015 with a chief complaint of unresponsiveness. Diagnoses given on admit were diabetic ketoacidosis and respiratory failure.
Review of an ED "Physician Order Set" revealed orders for sedatives IVP but did not include the frequency. There was an order which was written as "Restraints" which did not include what type, reason for them or parameters. There was an order for an insulin drip which was not timed nor did it include parameters for nursing to follow on how to titrate. The physician signed off on the order set, but left the area for date/time blank.

Review of the clinical record on Patient #2 revealed he was a 49 year old male who presented to the ED on 08/10/2015 with a chief complaint of right shoulder pain.
Review of an ED "Physician Order Set" revealed an order for the pain medication Dilaudid, but there was no indication as to how often to give it nor was it timed. The physician signed off on the order set, but left the area for date/time blank.

Review of the clinical record on Patient #4 revealed he was a 71 year old male who presented to the ED on 08/10/2015 with a chief complaint of shortness of breath, dizziness, unsteady gait and chest tightness.
Review of an ED "Physician Order Set" revealed orders for medications. The medications included respiratory medications and antibiotic therapy. There was no indication as to if these were one time orders or what the frequency should be. The orders were not complete with the dosage or routes. The physician signed off on the order set, but left the area for date/time blank.
During an interview on 08/13/2015 after 9:00 a.m., Staff #9 confirmed the problems with the physician orders.
During an interview on 08/14/2015 after 9:00 a.m., Staff #4 confirmed the problems with the physician orders.

Review of the Medical Staff Rules and Regulations dated 2013 revealed the following:
Physician orders
Physician will follow(hospital name) policy on orders. A practitioner's routine orders, when applicable to a given patient, shall become a part of the patient's record, dated and signed by the practitioner.
Timeliness of Entries
Entries should be made as soon as possible after an event or observation is made. An entry should never be made in advance..
F.MEDICAL RECORDS
The attending practitioner shall be responsible for the preparation of a complete and legible medical record on each patient. It's contents shall be pertinent and current.