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Based on record review and staff interview, it has been determined that the hospital failed to meet the Condition of Participation relative to Nursing Services for Patient ID #1 relative to the administration of medication resulting in Immediate Jeopardy. Additionally, the hospital failed to meet the Condition of Participation relative to Nursing Services for Patient ID #3 relative to medication administration.

Findings are as follows:

1. The hospital failed to provide nursing care in accordance with the hospital policy for "Safe Medication Administration Practices, General" for Patient ID #'s 1 and 3, resulting in both patients requiring transfer to an acute care hospital for treatment. (refer to A-0405)

Based on record review, policy review and staff interview, it has been determined that the hospital failed to follow their own policy regarding safe medication administration which resulted in medication errors necessitating higher levels of care for 2 of 2 sample patients (Patient ID #'s 1 and 3).

Findings are as follows:

The hospital's policy, "Safe Medication Administration Practices, General", last revised in November 2020, states, in part,

" ...Identifying the patient ...Confirm the patient's identity using at least two patient identifiers ...compare the information with the MAR (medication administration record) or EMAR (electronic medication administration record). Explain the name and purpose of each medication and when and how the patient will take it" ...

" ...Administering high-alert medications ...before administering a high-alert medication, ask another nurse to perform an independent double-check to verify the patient's identity and confirm that the right medication in the prescribed strength ...is on hand."

The Institute of Safe Medication Practice's (ISMP's) "List of High -Alert Medications in the Acute Care Setting", published in 2018, states, in part, "All forms of insulin ...are considered a class of high-alert medications"

1. Patient ID #1 presented to the hospital in March 2021 with a psychiatric history of depression and hypersexual behavior. While inpatient, on 3/26/2021, Patient ID #1 was administered medications prepared for another patient, Patient ID #2. The medications incorrectly administered to Patient ID #1 included Keppra (an anticonvulsant), metoprolol (treats high blood pressure and angina), tamsulosin (decreases the size of the prostrate and helps with urination), fenofibrate (treats high cholesterol) and digoxin (treats heart failure and/or irregular heartbeat). Additionally, Patient ID #1 also received 16 times his/her normal dose of the medication lisinopril (treats high blood pressure).

A Nursing Progress Note dated 3/26/2021 states that at approximately 11:15 AM a Physician's Assistant was in Patient ID #1's room and noticed s/he was having labored breathing (struggling to breathe) with his/her eyes closed. Vital signs were assessed and Patient ID #1's oxygen level was low, his/her pulse was 65, and staff were unable to obtain a blood pressure by machine or by auscultation (listening when manually taking a blood pressure). Patient ID #1 was placed on 6 liters (L) of oxygen. Upon further assessment Patient ID #1's blood pressure was now in the 50's systolic (the top number) and his/her heart rate, which was in the 60's, decreased to the 30's with the patient's oxygen level dropping even lower. Patient ID #1 was subsequently transferred to an acute care hospital via EMS (Emergency Medical Services) for evaluation.

While in the acute care hospital Emergency Department (ED), Atropine (a medication to treat a slow heart rate) and Epinephrine (a medicine that relaxes the airway muscles and tightens the blood vessels) intravenous drips were administered and a central line (a larger catheter in a centrally located veins) was placed. Patient ID #1 was subsequently admitted to the Intensive Care Unit for further management of his/her "shock secondary to toxic ingestion."

During an interview with the Director of Nursing Education on 4/1/2021 at 12:50 PM, she explained that after the nursing staff retrieve a patient's medications from the Pyxis machine (a machine that dispenses medication), they are to print the list of medications from the machine, write the patient's date of birth on the list, and take the Pyxis list with them to compare the patient's identification band to the Pyxis list, which is considered the EMAR, for patient verification.

On 3/30/2021 at 11:00 AM, surveyor interviewed the Registered Nurse who administered the incorrect medications to Patient ID #1, Staff A. Staff A stated she prepared the medications for Patient ID #2, and, when she went to his/her bedside to administer the medications, the patient refused them. She further explained that she returned to the Medication Room and placed Patient ID #2's medications on the counter, instead of placing them in the medication lock box, as per protocol. Next, she began preparing the medications for Patient ID #1. Once prepared and the medications were ready to be dispensed, Staff A stated she then placed the medications down, donned her gloves, and proceeded to leave the Medication Room to administer the medications to Patient ID #1. When in Patient ID #1's room she acknowledged that she did not compare the Pyxis generated medication slip with the patient's ID. She further acknowledged that she did not review the medications administered to Patient ID #1 with him/her. She stated that it was not until she was ready to administer eye drops to Patient ID #1 that she realized that the name on the bottle was not Patient ID #1's.

During an interview with the Director of Risk Management on 3/30/2021 at 10:00 AM, she explained that all Medication Rooms are equiped with a clear "medication lock box."

Surveyor reviewed the criteria for lock box use, which was posted on the wall near the lock box on each unit. This document revealed that the lock boxes were installed to provide an increased level of security for nurses, if the nurse must leave the medication room while preparing medications. The guideline for use includes, " ...These boxes are intended to be used in the following manner: ...Situations that might require the lock box would be any time a medication might otherwise be placed on the counter..."

2. Patient ID #3 was admitted to the hospital in March 2021 with a psychiatric history of bipolar disorder and increased disorganization. Patient ID #3's medical history includes, but is not limited to, insulin dependent diabetes.

Patient ID #3 had provider orders for two types and doses of insulin:
a. Insulin glargine (a long acting type of insulin; also known as Lantus insulin), 45 units (0.45 milliliters), subcutaneous (SC, under the skin) daily
b. Insulin Lispro (a fast-acting insulin), sliding scale doses (the dose is dependent on the patient's blood sugar level), SC, twice daily (morning and night)

A Doctor On Call (DOC) note from 3/31/2021 at 6:27 AM states, "Called to evaluate patient after 45 units [of] lispro [was] administered in place of 45 units [of] Lantus. Current blood glucose is 189 .... Will send patient out to medical hospital for closer monitoring ..."

Review of the record from the acute care hospital revealed that Patient ID #3 presented to the ED via ambulance, and, upon arrival, his/her blood sugar was 89, which necessitated the administration of a bolus of intravenous dextrose (glucose; sugar). Poison Control was notified, and the hospital was advised to observe the patient for 10 hours to monitor for hypoglycemia (low blood sugar). After observation, the patient was returned to Butler Hospital for ongoing psychiatric care.

On 4/1/2021 at 2:03 PM, the surveyor conducted a telephone interview with the Registered Nurse, Staff B, who administered the incorrect insulin to Patient ID #3. Staff B stated that he removed the bottle of insulin from the patient's medication drawer; he then recalled drawing up 45 units of the medication he thought was Lantus insulin. Next, he stated, he proceeded to bring the bottle of insulin and the syringe with him to another RN, Staff C, to have the medication witnessed. He stated that after Staff C observed the bottle and syringe, which was his witnessing of the medication, Staff B went to Patient ID # 3's room and administered the insulin. He further stated that once he returned to the Medication Room to put the insulin back in the patient's medication drawer, he realized there was another bottle of insulin in the drawer and the insulin error was identified. Staff B acknowledged that he did not read the name of the medication on the bottle of insulin prior to preparing to administer, or at any time prior to administering. He also acknowledged that he did not compare the medication bottle to the EMAR prior to drawing the insulin into the syringe.

On 4/1/2021 at 2:30 PM, the surveyor conducted a telephone interview with the Registered Nurse, Staff C, who witnessed the insulin for Staff B. Staff C stated that he was in the process of providing report to the day shift doctor in another area when Staff B approached him with a vial and a syringe and asked him to witness the medication. He further stated he witnessed the medication and syringe and recalled that Staff B notified him that he was administering 45 units of Lantus insulin. Although Staff C denied he witnessed the incorrect insulin, he acknowledged that he did not perform an independent double-check to verify the patient's identity and confirm that the right medication in the prescribed strength was being administered.

Based on record review and staff interview it has been determined that the hospital medical record failed to contain sufficient nursing information to justify the care, treatment, and services required by Patient ID #3 after she/he received an incorrect dose of insulin.

Surveyor review of the medical record for Patient ID #3 failed to reveal any nursing documentation about the medication error or notification to the doctor on call and plan for evaluation on 3/31/2021.

During an interview with the Nursing Director on 4/1/2021 at 2:35 PM, she acknowledged that nursing is required to document any event requiring a nursing assessment, which, includes the incorrect medication being administered to Patient ID #3.