HospitalInspections.org

Based on record review and interview the hospital failed to ensure the grievance policy was followed as evidenced by 1 (#3) of 12 (#1-#12) sampled patients filing a grievance and not receiving a written response. Findings:
Review of a document typed by S2PI/Risk Mgmt. revealed patient # 3 made numerous phone calls to Acadia Vermillion Hospital between 08/08/12 and 08/21/12. Statements not pertinent were omitted as not relevant to the complaint.
The following items from the narrative report created by S2PI/Risk Management were relevant to Acadia Vermillion Hospital:

"I've been trying to get in touch with somebody there about the fact that ya'll [sp?] injured my spine in February. A young man named (patient #11), (patient #11), lives with his grandmother in Abbeville. Back injury.

And I was watching people be assaulted in your hospital. And poor (patient #11), a man called him a nigger, and he still didn't cause a physical altercation. And I've been trying to find out if ya'll [sp?] still had the video for six months.

Instructed me to contact a former patient, (patient #11).

Stated she was trying to save my hospital from going bankrupt, because "ya'll [sp?] paralyzed me." Whenever I attempted to clarify what (patient #3) meant, she stated "everyone in ya'll [sp?] whole hospital jumped on-top of me, I was slightly paralyzed before, now it's even worse."

Informed me we were liable for her medical problems...I then attempted to redirect (patient #3) and inquired why employees would jump on-top of her; she asked if I could mail her the "video tape" of her stay here. I informed (patient #3) that the surveillance footage from the time she was in treatment would not still be saved, due to the fact her hospitalization was in February, and footage is not saved for that long of a timeframe. (Patient #3) then asked if I "erased it because you knew I was calling."

This is (patient #3), my number is (number). Ya'll [sp?] need to be aware of how damaged my spine was going into ya'll [sp?] hospital, because I'm in the process of having MRI's (Magnetic Resonance Imaging) caused by the damage to my spine on February 13th of this year. Thank you very much."

In an interview on 09/12/12 at 2:00 p.m. with S2PI/Risk Management he stated he had not conducted any investigation into the allegations made by patient #3. He further stated there had been no written response to patient #3 per the hospital's grievance policy.

Review of a hospital policy titled Grievance - Procedure Patient and Family, number RI-005, original date of issue 05/06, last revised 03/11, read in part: "Purpose: To establish consistent guidelines for addressing patient/family concerns/complaints/grievances in a timely manner. Policy: Acadia Vermillion Hospital will provide an effective mechanism for handling patient/family grievances as an important part of providing quality care and service to our patients...Definition: A "patient grievance"is a formal or informal written or verbal complaint that is made to the hospital by a patient...7.0 The Risk Manager will attempt to respond in writing to all grievances within seven (7) calendar days of receipt of the grievance. Due to the nature and complexity of the grievance, if a written response cannot be made within seven (7) calendar days, the Patient Advocate will inform the patient or his/her representative that the hospital is still working to resolve the grievance and that a written response will be made within thirty (30) calendar days of receipt of the grievance..."

Based on record review and interview the hospital failed to identify and reduce medical errors as evidenced by:

a)failing to complete an Incident Report for 3 missed medication administrations of Campral, Naltrexone and Robitussin DM on 09/05/12 as per the "Incident Reporting", policy number RM-002 and "Medication Management/Medication Misadventures", Policy Number: MM-6.20-01 for one (R5) of 6 random sampled patients (R1 through R6) focused reviewed for medication errors and 0 of 13 sampled patients (#1 through #13)

b) failing to have accurate medication error data collected and reported to PI from February through September of 2012.

Findings:

a)
Review of the "Physician's Orders" dated/timed 09/05/12 at 5:40 a.m. read, "Campral 333 (mg-milligrams) two (ii) tablets oral (po) three times a day (tid) and Naltrexone 50 milligrams (mgs) one (i) tablet po every morning (q am)". Review of the Medication Reconciliation Form, Home Medication Lists" dated/timed 09/04/12 at 7:05 a.m. revealed R5 was to continue taking "Robitussin DM 1 (one) tsp (teaspoon) Q6 (every six hours) X (times) 3 days" in the hospital on 09/05/12.

Review of the "Medication Administration Record" (MAR) from 09/05/12 at 7:00 a.m. through 09/06/12 at 6:59 a.m. revealed the following hand written medication orders, "Campral 333 mg ii po TID, Naltrexone 50 mg po q am, and Robitussin DM 1 (one) tsp (teaspoon) Q6 (every six hours) X (times) 3 days". Further review revealed there were circles drawn around the 6:00 a.m. medication administration for Robitussin on 09/05/12 and around the 9:00 a.m. medication administrations for Campral and Naltrexone on 09/05/12.

The "Incident Reports" for September, 2012 revealed there were no "Incident Reports" completed for the 3 missed medication administrations of Campral, Naltrexone, and/or Robitussin DM for Random Patient R5 on 09/05/12 presented during the survey conducted from 09/10/12 through 09/13/12.

Review of the monthly "Medication Variances" reports from February through September of 2012 revealed there was no "Incident Reports" completed for the 3 missing medication administrations/medication errors of Robitussin, Campral and/or Naltrexone medications on 09/05/12.

During an interview on 09/13/12 at 12:30 p.m., S7Rph (registered pharmacist), contracted pharmacy confirmed Robitussin DM, Campral, and Naltrexone medications were not administered to R5 as ordered by the physician on 09/05/12. S7Rph verified there were three (3) missed medication administrations/medication errors for R5. The contracted pharmacist, S7Rph indicated there should be 3 "Incident Reports" completed by the nursing staff for the missed medication administrations/medication errors of Robitussin, Campral and Naltrexone for R5 on 09/05/12 as per policy. The contracted pharmacist, S7 denied knowledge of what the medication error rate was for September of 2012 as of 09/13/12.

In interviews on 09/13/12 at 12:45 pm. and at 1:00 p.m., the Director of Nursing, S3 confirmed the medication administration times circled on 09/05/12 indicated the patient (R5) was not administered the Robitussin DM at 6:00 a.m. and/or Campral and Naltrexone at 9:00 a.m. as ordered by the physician. S3DON indicated there were 3 missed medication administrations/medication errors for Robitussin, Campral, and Naltrexone that required the nursing staff to complete an "Incident Report" for each of the 3 missed medication administrations/medication errors for R5 on 09/05/12 as per policy. The DON, S3 verified there were no "Incident Reports" completed for the 3 missed medication administrations/medication errors of Robitussin at 6:00 a.m. Campral at 9:00 a.m. and/or Naltrexone at 9:00 a.m. on 09/05/12 by the nursing staff as per policy. S3DON denied knowledge of what the medication error rate was for September of 2012 as of 09/13/12.

The policy titled, "Medication Administration Times", Policy Number: MM-001, Original Date of Issue on 05/06, Revised date on 03/11, with no last reviewed date, read, its "Purpose was to establish uniform times for the administration of medications based on the frequency of administration stated in the medication order...Medication administration will be in accordance with the time schedule below...Military time is used...Medication administration times: Daily-0900; bid-0900 and 2100; tid-0900, 1300, 2100; qid-0900, 1300, 1700, 2100; hs-2200 or 2100 - 2200; ac-30 minutes before scheduled meal;...q6h-0600, 1200, 1800, 2400;...Documentation administration of medication. If the medication was not given at the specified time, the specific time will be circled; the time the medication was given will be entered along with the reason...Medication can be given 1 hour prior to routine time or 1 hour after routine time and be considered within the time frame. There is a 1 hour window of time before and after the routine time to give the medication...".

Review of the "Medication Management/Medication Misadventures", Policy Number: MM-6.20-01, Effective date on 07/24/2006, Revision date on 08/01/2008, with no last reviewed date revealed it is hospital policy for drugs doses omitted to be reported and reviewed in accordance with policy. A medication error is defined as any deviation during the dispensing and administering of a drug. The types of medication errors is the wrong patient, wrong drug, drug not ordered, wrong time, and/or omission of a drug. The person who discovers the error (or other person designated by the individual in charge) shall prepare a written drug administration error report. All copies of the written drug administration error reports shall be distributed as specified by the facility's policy. Reports shall be available to the responsible physician and the Director of Nursing. Pharmacy-related reports shall be available to the Director of Pharmacy.

b)
Interviews conducted on 09/13/12 at 8:35 a.m., at 1:50 p.m., and at 1:55 p.m., S2PI/Risk Management indicated there were no "Incident Reports" completed for the 3 missed medication administrations/medication errors of Robitussin, Campral and/or Naltrexone medications on 09/05/12 as per policy. The PI/Risk Management, S2 further indicated there is inaccurate data collected in order to track, trend, monitor and evaluate medication errors from February through September of 2012.

The policy titled, "Incident Reporting", Policy Number: RM-002, Original Date of Issue on 05/06, Revised date on 03/11, with no last reviewed date, read, "The responsibility of any staff member who witnesses, or discovers any happening not consistent with the routine care and/or operation of the facility which may place the facility at increased risk for liability to complete an Incident Report. The Incident Report is a risk management tool that notifies the facility of potential areas of loss and enables the facility to take corrective action, reducing the losses and improving the quality of health care in the facility. It is hospital procedure for any staff member who witnesses, discovers, or has direct knowledge of an incident to complete an Incident Report as soon as practical after the incident is witnessed or discovered, before the end of the shift/work day. An Incident Report should be filed for any incident including but not limited to: ...2.5 an event occurs which, by standards, appears unexpected and/or unintended (i.e. medication error)...2:19...Medication Error...

Review of the policy titled, "Medication Errors", Policy Number: MM-011, Original Date of Issue on 05/06, Revised date on 03/11, with no last reviewed date, revealed it is hospital policy to insure that medication errors are documented and reported with follow-up action take to protect the patient. The hospital is committed to patient safety and promotes an open and supportive environment for reporting medication errors. A Medication Error Form is completed including an incident report, copy of the order and a copy of the MAR and forwarded to the Chief Nursing Officer and Pharmacist, who will review, investigate as needed, take any immediate corrective actions indicated, and incorporate into quality improvement data, observing for any trends or patterns.

Based on record review and interview, the Registered Nurse failed to supervise and evaluate the nursing care for each patient as evidenced by failing to ensure there were physician's orders written prior to:

1) performing blood sugar checks (CBG) from 04/08/12 through 04/17/12 for one (#6) of 12 sampled patients (#1 through #12), and

2) administering Acamprosate Calcium (Campral) and Naltrexone Hydrochloride (Naltrexone) medications on 09/05/12 at 9:00 a.m. for one (#8) of 12 sampled patients (#1 through #12).

Findings:

1)
Patient #6:
Review of the medical record for #6 revealed the patient was admitted with the diagnosis of Schizophrenia on 04/08/12. Review of the "Psychiatric Admission Orders" dated/timed 04/08/12 at 5:00 p.m. revealed there was no documented evidence Patient #6 had diabetes mellitus on admission.

Review of the "Nursing Assessment-Part Two" dated 04/08/12 revealed the section titled, "Critical Diagnosis Includes" Diabetes was checked and circled by the admitting nurse during her initial assessment of Patient #6. Review of the "Multidisciplinary Notes Clinical Services" revealed Patient #6 was admitted on 04/08/12 at 10:40 p.m.

Review of the "Medication Reconciliation Form" dated 04/09/12 at 4:30 a.m.the same night the patient was admitted revealed the patient (#6) was taking the following home medications and was to continue taking the following medications: Metformin 500 mg (milligrams) oral (po) tablet daily and Glyburide/Metformin 5/500mg po tablet daily-diabetic medications. Review of the "Psychiatric Admission Orders" revealed no order addressing Patient #6's diabetic medication administrations ordered. Further review of the Physician' Orders dated/timed 04/09/12 at 9:25 a.m. -the next morning revealed there were the following medication orders for Patient #6: Glyburide 5mg one (i) po daily and Metformin 500mg po daily. There were no physician orders written addressing the patient's (#6's) diabetes from time of admission on 04/08/12 through 04/17/12-for 9 days. Further review revealed there were "Physician's Orders" dated/timed 04/17/12 at 1:10 a.m. read CBG monitoring QAC (before meals) and hs (at bedtime)-9 days after the patient (#6) was admitted.

The "Psychiatric Evaluation-Part Five" dated/timed 04/05/12 at 7:00 a.m. 3 days prior to admission revealed Patient #6 had a past medical history of diabetes.

The "Multidisciplinary Treatment Plan" dated 04/08/12-same day of admission revealed Patient #6 was admitted with Diabetes Melititis (DM) diagnosis recorded on Axis III.

Review of the "History and Physical Examination" dated/timed 04/09/12 at 2:15 p.m. revealed Patient #6 had a past medical history of DM.

The "Medication Administration Records" from 04/08/12 through 04/17/12 revealed Patient #6 was administered diabetic medications, (Glyburide and Metformin) daily as ordered by the attending physician.

Review of the "Medication Administration Records" and/or "Glucose Monitoring" sheets revealed Patient #6's blood sugar was checked four times a day at 7:30 a.m., at 11:30 a.m. at 4:30 p.m. and at 9:00 p.m. by the nursing staff. Further review revealed there was no physician orders written for the blood sugar checks (CBGs) from 04/08/12 through 04/17/12 for 9 days.

In an interview on 09/11/12 at 1:40 p.m., the S3DON, (Director of Nursing) verified Patient #6 was diagnosed and admitted with the diagnosis of diabetes mellititus on 04/08/12. S3DON further verified the nursing staff performed blood sugar checks on Patient #6 from 04/08/12 to 04/17/12 with no physician orders for 9 days. The S3DON, indicated blood sugar checks (CBGs) require a physician's order as per policy. S3DON further indicated the Registered Nurses failed to get a physician's order for Patient #6's blood sugar (CBGs) checks from 04/08/12 through 04/17/12 as per policy.

The policy titled, "Diabetic Care", Policy Number: CTS-084, Original Date of Issue on 05/06, Revised date on 03/11, with no date of approval and/or last reviewed dates, revealed blood glucose levels will be tested at the frequency ordered by the physician.

2)
Patient #8:
The "Incident Report Form" dated/timed revealed a medication error occurred in the medication room with the incorrect medication administered to Patient #8 on 09/05/12 at 9:00 a.m. The section titled, "Facts Summary of Event" read in part, "An order was written on the patient's MAR (Medication Administration Record) for the wrong patient. The order was written for Campral and Naltrexone on the patient's MAR but there was no order written for these medications".

Review of the Medication Administration Record (MAR) revealed Patient #8 was administered Campral 333mgs ii (2) tablets oral and Naltrexone 50mgs i (1) tablet oral by the nurse on 09/05/12 at 9:00 a.m.

The "MedDispense Override Report for 09/04/12 at 10:0 a.m. through 09/05/12 at 10:00 a.m." revealed the Registered Nurse, S16 had to override the medications, Campral and Naltrexone, in order to administer them to Patient #8 on 09/05/12 at 9:00 a.m.

Review of the medical record revealed Patient #8 was admitted for Major Depression on 09/01/12. Further review revealed no documented evidence there were physician orders written for Campral 333 milligrams two (ii) po (oral) tid (three times a day) and/or Naltrexone 50 mgs one (i) oral every morning (QA.M.) medications administered to Patient #8 on 09/05/12 at 9:00 a.m Review of the "Medication Reconciliation Form" and/or "Physician Orders" revealed there was no documented evidence the patient (#8) was taking Campral and/or Naltrexone at home prior to admission on 09/01/12 at 11:00 p.m. and/or prior to being administered the medications, Campral and Naltrexone, on 09/05/12 at 9:00 a.m.

During interviews on 09/10/12 from 2:40 p.m. through at 2:55 p.m., on 09/12/12 from 2:15 p.m. through 2:30 p.m., and on 09/13/12 at 9:15 a.m., at 9:35 a.m., at 12:45 p.m., and at 1:00 p.m., S3DON, confirmed Patient #8 was administered Campral and Naltrexone medications by S16RN on 09/05/12 at 9:00 a.m.with no physician's order as per policy.

Review of the policy titled, "Medication Administration Guidelines", Policy Number: MM-010, Original Date of Issue on 05/06, Revised date on 03/11, with no last reviewed date, revealed medications will only be administered to patients to whom they have been prescribed. Medications are not given without a physician's order.

The policy titled, "Medication Management/Administration", Policy Number: MM-5.10-01, Effective date of 7/24/2006, Revision date of 08/01/2008, with no last reviewed and/or revised dates, revealed the individuals who dispense and administer drugs shall do so only upon the order of a practitioner.

Based on record review and interview, the hospital failed to ensure the drugs and biologicals were administered in accordance with the orders of the practitioner or practitioners responsible for the patient's care and in accordance with the approved policies and procedures as evidenced by failing to ensure there were physician's orders written prior to performing blood sugar checks (CBG) from 04/08/12 through 04/17/12 for one (#6) of 12 (#1 - #12) sampled patients as per the "Diabetic Care", Policy Number: CTS-084, and administering Acamprosate Calcium (Campral) and Naltrexone Hydrochloride (Naltrexone) medications on 09/05/12 at 9:00 a.m. (0900) for one (#8) of 12 (#1 - #12) sampled patients as per the "Medication Administration Guidelines", Policy Number: MM-010, and "Medication Management/Administration", Policy Number: MM-5.10-01. Findings:

Patient #6:
Review of the medical record for #6 revealed the patient was admitted with the diagnosis of Schizophrenia on 04/08/12. Review of the "Psychiatric Admission Orders" dated/timed 04/08/12 at 5:00 p.m. (1700) revealed there was no documented evidence Patient #6 had diabetes mellitus on admission.

Review of the "Nursing Assessment-Part Two" dated 04/08/12 revealed the section titled, "Critical Diagnosis Includes" Diabetes was checked and circled by the admitting nurse during her initial assessment of Patient #6. Review of the "Multidisciplinary Notes Clinical Services" revealed Patient #6 was admitted on 04/08/12 at 10:40 p.m. (2240).

Review of the "Medication Reconciliation Form" dated 04/09/12 at 4:30 a.m. (0430)-the same night the patient was admitted revealed the patient (#6) was taking the following home medications and was to continue taking the following medications: Metformin 500 mg (milligrams) oral (po) tablet daily and Glyburide/Metformin 5/500mg po tablet daily-diabetic medications. Review of the "Psychiatric Admission Orders" revealed no order addressing Patient #6's diabetic medications. Further review of the Physician' Orders dated/timed 04/09/12 at 9:25 a.m. (0925)-the next morning revealed there were the following medication orders for Patient #6: Glyburide 5mg one (i) po daily and Metformin 500mg po daily. There were no physician orders written addressing the patient's (#6's) diabetes from the time of admission on 04/08/12 through 04/17/12-for nine (9) days. Further review revealed there were "Physician's Orders" dated/timed 04/17/12 at 1:10 a.m. (0110) read CBG monitoring QAC (before meals) & (and) hs (at bedtime)-nine (9) days after the patient (#6) was admitted.

The "Psychiatric Evaluation-Part Five" dated/timed 04/05/12 at 7:00 a.m. (0700)-three (3) days prior to admission revealed Patient #6 had a past medical history of diabetes.

The "Multidisciplinary Treatment Plan" dated 04/08/12-same day of admission revealed Patient #6 was admitted with Diabetes Mellitus (DM) diagnosis recorded on Axis III.

Review of the "History and Physical Examination" dated/timed 04/09/12 at 2:15 p.m. (1415) revealed Patient #6 had a past medical history of DM.

The "Medication Administration Records" from 04/08/12 through 04/17/12 revealed Patient #6 was administered diabetic medications, (Glyburide and Metformin) daily as ordered by the attending physician.

Review of the "Medication Administration Records" and/or "Glucose Monitoring" sheets revealed Patient #6's blood sugar was checked four times a day at 7:30 a.m. (0730), at 11:30 a.m. (1130), at 4:30 p.m. (1630) and at 9:00 p.m. (2100) by the nursing staff. Further review revealed there was no physician orders written for the blood sugar checks (CBGs) performed by the nursing staff from 04/08/12 through 04/17/12 for nine (9) days.

In an interview on 09/11/12 at 1:40 p.m., the Director of Nursing (DON), S3 verified Patient #6 was diagnosed and admitted with the diagnosis of diabetes mellitus on 04/08/12. S3DON further verified the nursing staff performed blood sugar checks on Patient #6 from 04/08/12 to 04/17/12 with no physician orders for nine (9) days. The DON, S3 indicated blood sugar checks (CBGs) require a physician's order as per policy. S3DON further indicated the Registered Nurses failed to get a physician's order for Patient #6's blood sugar (CBGs) checks from 04/08/12 through 04/17/12 as per policy.

The policy titled, "Diabetic Care", Policy Number: CTS-084, Original Date of Issue on 05/06, Revised date on 03/11, with no date of approval and/or last reviewed dates, revealed blood glucose levels will be tested at the frequency ordered by the physician.

Patient #8:
The "Incident Report Form" dated/timed revealed a medication error occurred in the medication room with the incorrect medication administered to Patient #8 on 09/05/12 at 9:00 a.m. (0900). The section titled, "Facts Summary of Event" read in part, "An order was written on the patient's MAR (Medication Administration Record) for the wrong patient. The order was written for Campral and Naltrexone on the patient's MAR but there was no order written for these medications".

Review of the Medication Administration Record (MAR) revealed Patient #8 was administered Campral 333mgs ii (2) tablets oral and Naltrexone 50mgs i (1) tablet oral by the nurse on 09/05/12 at 9:00 a.m. (0900).

The "MedDispense Override Report for 09/04/12 1001 (10:01 a.m.) through 09/05/12 10:00 (10:00 a.m.)" revealed the Registered Nurse, S16 had to override the medications, Campral and Naltrexone, in order to administer them to Patient #8 on 09/05/12 at 9:00 a.m. (0900).

Review of the medical record revealed Patient #8 was admitted for Major Depression on 09/01/12. Further review revealed no documented evidence there were physician orders written for Campral 333 milligrams two (ii) po (oral) tid (three times a day) and/or Naltrexone 50 mgs one (i) oral every morning (QA.M.) medications administered to Patient #8 on 09/05/12 at 9:00 a.m. (0900). Review of the "Medication Reconciliation Form" and/or "Physician Orders" revealed there was no documented evidence the patient (#8) was taking Campral and/or Naltrexone at home prior to admission on 09/01/12 at 11:00 p.m. (2300) and/or prior to being administered the medications, Campral and Naltrexone, on 09/05/12 at 9:00 a.m. (0900).

During interviews on 09/10/12 from 2:40 p.m. through at 2:55 p.m., on 09/12/12 from 2:15 p.m. through 2:30 p.m., and on 09/13/12 at 9:15 a.m., at 9:35 a.m., at 12:45 p.m., and at 1:00 p.m., the Director of Nursing (DON), S3 confirmed Patient #8 was administered Campral and Naltrexone medications by S16RN (registered nurse) on 09/05/12 at 9:00 a.m. (0900) with no physician's order as per policy.

Review of the policy titled, "Medication Administration Guidelines", Policy Number: MM-010, Original Date of Issue on 05/06, Revised date on 03/11, with no last reviewed date, revealed medications will only be administered to patients to whom they have been prescribed. Medications are not given without a physician's order.

The policy titled, "Medication Management/Administration", Policy Number: MM-5.10-01, Effective date of 7/24/2006, Revision date of 08/01/2008, with no last reviewed and/or revised dates, revealed the individuals who dispense and administer drugs shall do so only upon the order of a practitioner.

Based on record review and interview the hospital failed to ensure the hospital procedure for medication errors was reported, implemented and regularly monitored through the hospital's QAPI program as evidenced by failing to complete an Incident Report for three (3) missed medication administrations of Campral, Naltrexone and Robitussin DM on 09/05/12 as per the "Incident Reporting", policy number RM-002 and "Medication Management/Medication Misadventures", Policy Number: MM-6.20-01 for one (#R5) of 6 random sampled patients (#R1 through #R6) focused reviewed for medication errors and 0 of 12 sampled patients (#1 through #12) and failing to have accurate medication error data collected and reported to PI from February through September of 2012. Findings:

Review of the "Physician's Orders" dated/timed 09/05/12 at 5:40 a.m. (0540) read, "Campral 333 (mg-milligrams) two (ii) tablets oral (po) three times a day (tid) and Naltrexone 50 milligrams (mgs) one (i) tablet po every morning (q am)". Review of the Medication Reconciliation Form, Home Medication Lists" dated/timed 09/04/12 at 7:05 a.m. (0705) revealed R5 was to continue taking "Robitussin DM 1 (one) tsp (teaspoon) Q6 (every six hours) X (times) three (3) days" in the hospital on 09/05/12.

Review of the "Medication Administration Record" (MAR) from 09/05/12 at 7:00 a.m. (0700) through 09/06/12 at 6:59 a.m. (0659) revealed the following hand written medication orders, "Campral 333 mg ii po TID, Naltrexone 50 mg po q am, and Robitussin DM 1 (one) tsp (teaspoon) Q6 (every six hours) X (times) three (3) days". Further review revealed there were circles drawn around the 6:00 a.m. (0600) medication administration for Robitussin on 09/05/12 and around the 9:00 a.m. (0900) medication administrations for Campral and Naltrexone on 09/05/12.

The "Incident Reports" for September, 2012 reveled there were no "Incident Reports" completed for the three (3) missed medication administrations of Campral, Naltrexone, and/or Robitussin DM for Random Patient #5 (R5) on 09/05/12 presented during the survey conducted from 09/10/12 through 09/13/12.

Review of the monthly "Medication Variances" reports from February through September of 2012 revealed there was no "Incident Reports" completed for the three (3) missing medication administrations/medication errors of Robitussin, Campral and/or Naltrexone medications on 09/05/12.

During an interview on 09/13/12 at 12:30 p.m., S7Rph (registered pharmacist), contracted pharmacy confirmed Robitussin DM, Campral, and Naltrexone medications were not administered to R5 as ordered by the physician on 09/05/12. S7Rph verified there were three (3) missed medication administrations/medication errors for R5. The contracted pharmacist, S7Rph indicated there should be three (3) "Incident Reports" completed by the nursing staff for the missed medication administrations/medication errors of Robitussin, Campral and Naltrexone for R5 on 09/05/12 as per policy. The contracted pharmacist, S7 denied knowledge of what the medication error rate was for September of 2012 as of 09/13/12.

In interviews on 09/13/12 at 12:45 pm. and at 1:00 p.m., the Director of Nursing, S3 confirmed the medication administration times circled on 09/05/12 indicated the patient (R5) was not administered the Robitussin DM at 6:00 a.m. (0600) and/or Campral and Naltrexone at 9:00 a.m. (0900) as ordered by the physician. S3DON indicated there were three (3) missed medication administrations/medication errors for Robitussin, Campral, and Naltrexone that required the nursing staff to complete an "Incident Report" for each of the three (3) missed medication administrations/medication errors for R5 on 09/05/12 as per policy. The DON, S3 verified there were no "Incident Reports" completed for the three (3) missed medication administrations/medication errors of Robitussin at 6:00 a.m. (0600), Campral at 9:00 a.m. (0900) and/or Naltrexone at 9:00 a.m. (0900) on 09/05/12 by the nursing staff as per policy. S3DON denied knowledge of what the medication error rate was for September of 2012 as of 09/13/12.

Interviews conducted on 09/13/12 at 8:35 a.m., at 1:50 p.m., and at 1:55 p.m., S2PI/Risk Management indicated there were no "Incident Reports" completed for the three (3) missed medication administrations/medication errors of Robitussin, Campral and/or Naltrexone medications on 09/05/12 as per policy. The PI/Risk Management, S2 further indicated there is inaccurate data collected in order to track, trend, monitor and evaluate medication errors from February through September of 2012.

Review of the "Medication Management/Medication Misadventures", Policy Number: MM-6.20-01, Effective date on 07/24/2006, Revision date on 08/01/2008, with no last reviewed date revealed it is hospital policy for drugs doses omitted to be reported and reviewed in accordance with policy. A medication error is defined as any deviation during the dispensing and administering of a drug. The types of medication errors is the wrong patient, wrong drug, drug not ordered, wrong time, and/or omission of a drug. The person who discovers the error (or other person designated by the individual in charge) shall prepare a written drug administration error report. All copies of the written drug administration error reports shall be distributed as specified by the facility's policy. Reports shall be available to the responsible physician and the Director of Nursing. Pharmacy-related reports shall be available to the Director of Pharmacy.

The policy titled, "Incident Reporting", Policy Number: RM-002, Original Date of Issue on 05/06, Revised date on 03/11, with no last reviewed date, read, "The responsibility of any staff member who witnesses, or discovers any happening not consistent with the routine care and/or operation of the facility which may place the facility at increased risk for liability to complete an Incident Report. The Incident Report is a risk management tool that notifies the facility of potential areas of loss and enables the facility to take corrective action, reducing the losses and improving the quality of health care in the facility. It is hospital procedure for any staff member who witnesses, discovers, or has direct knowledge of an incident to complete an Incident Report as soon as practical after the incident is witnessed or discovered, before the end of the shift/work day. An Incident Report should be filed for any incident including but not limited to: ...2.5 an event occurs which, by standards, appears unexpected and/or unintended (i.e. medication error)...2:19...Medication Error...

Review of the policy titled, "Medication Errors", Policy Number: MM-011, Original Date of Issue on 05/06, Revised date on 03/11, with no last reviewed date, revealed it is hospital policy to insure that medication errors are documented and reported with follow-up action take to protect the patient. The hospital is committed to patient safety and promotes an open and supportive environment for reporting mediation errors. A Medication Error Form is completed including an incident report, copy of the order and a copy of the MAR and forwarded to the Chief Nursing Officer and Pharmacist, who will review, investigate as needed, take any immediate corrective actions indicated, and incorporate into quality improvement data, observing for any trends or patterns.

The policy titled, "Medication Administration Times", Policy Number: MM-001, Original Date of Issue on 05/06, Revised date on 03/11, with no last reviewed date, read, its "Purpose was to establish uniform times for the administration of medications based on the frequency of administration stated in the medication order...Medication administration will be in accordance with the time schedule below...Military time is used...Medication administration times: Daily-0900; bid-0900 and 2100; tid-0900, 1300, 2100; qid-0900, 1300, 1700, 2100; hs-2200 or 2100 - 2200; ac-30 minutes before scheduled meal;...q6h-0600, 1200, 1800, 2400;...Documentation administration of medication. If the medication was not given at the specified time, the specific time will be circled; the time the medication was given will be entered along with the reason...Medication can be given 1 hour prior to routine time or 1 hour after routine time and be considered within the time frame. There is a 1 hour window of time before and after the routine time to give the medication...".

Based on record review and interview the hospital failed to ensure that medication allergies were accurately recorded for 1 (#3) of 12 (#1-#12) sampled patients as evidenced by pharmacy issued Medication Administration Records (MAR) having Geodon listed as a medication allergy and a PRN (as needed) medication. Findings:

Review of the MAR for 02/10/12 through 02/14/12 revealed the pharmacy issued MAR for patient #3 listed Ziprasidone (Geodon) as an allergy for 5 consecutive pharmacy issued MAR's. Review of the same 5 MAR's revealed Geodon was listed as a prn medication.

In an interview on 09/10/12 at 2:10 p.m. S7RpH confirmed that Geodon was listed as an allergy on 02/10/12, 02/11/12, 02/12/12, 02/13/12, and 02/14/12. S7RpH stated she entered the Geodon as an allergy on 02/09/12 at 8:50 a.m. Review of a computer generated profile for patient #3 confirmed the medication was listed as an allergy on 02/09/12 at 8:50 a.m. S7RpH stated she was unaware of why she nor the computer system did not catch the fact that the Geodon was listed as both an allergy and a prn medication.

Review of a hospital policy titled Pharmacy Policy and Procedures, policy number LD-01, effective 01/05/06, last revision 08/01/2008, revealed in part: "Pharmacy Policies and Procedures. The Department of Pharmacy is responsible for: (1) The procurement, distribution, and control of all pharmaceuticals used within the institution...(3) the monitoring, evaluation, and assurance of the quality of drug use...Scope of Pharmacy Policies and Procedures...2. Drug Distribution and Control - the Department of Pharmacy is responsible for the procurement, distribution, and control of drugs used within the institution...Pharmacy Employees:..d. Maintain and use an up-to-date medication profile for all patients..."