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Based on observation, record review, and interview, the provider failed to ensure medications were accurately administered, documented, or transcribed for two of five (9 and 11) patients reviewed for medication administration. Findings include:

1. Review of patient 11's physician's orders revealed:
*She was to undergo a colonoscopy on 4/28/10.
*An order on 4/27/10 at 8:15 a.m. for GoLYTLEY to have been administered in preparation for the colonoscopy.
*A telephone order on 4/27/10 at 6:30 p.m. to discontinue the GoLYTLEY, and then to administer a bottle of magnesium citrate and two tablets of Peri-Colace (DSS/Senna) at the time of the order (now).
*The telephone order was received and transcribed by registered nurse (RN) 16.

Review on 4/28/10 of patient 11's medication administration record (MAR) revealed:
*A hand written entry for scheduled medications dated 4/27/10 that stated "one bottle mag citrate along with two Peri-Colace now."
*There was no time noted for the above entry.
*The author of the above entry was not identified.
*The MAR did not include any documentation to show the magnesium citrate and Peri-Colace had been administered.

Interview on 4/28/10 at 10:00 a.m. with acute care manager 3 confirmed there was no administration time for the magnesium citrate and Peri-Colace recorded on patient 11's 4/27/10 MAR. She tested the automated dispensing machine at the above time and found there were no 4/27/10 entries for patient 11 to indicate magnesium citrate or DSS/Senna had been removed from the machine in her name. She could not verify if the magnesium citrate and DSS/Senna had been administered to patient 11.

Interview on 4/28/10 at 10:15 a.m. with the director of pharmacy revealed:
*Peri-Colace was not stocked by the hospital, but the approved equivalent stocked in the automated dispensing machines was DSS/Senna.
*There was a process to remove the magnesium citrate and DSS/Senna from the automated dispensing machines without it being designated for a specific patient. That process was known as inventory verification.
*There was an electronic record of all inventory verification attempts.
*An inventory verification form for the nursing station automated dispensing machine dated 4/28/10 at 8:55 a.m. included an entry showing RN 16 had obtained a 300 milliliter bottle of magnesium citrate from the machine on 4/27/10 at 6:21 p.m.
*A different inventory form included the same above information with an additional hand written entry stating patient 11's name and room number.
*Inventory records for both the nursing station and emergency room automated dispensing machines did not include any record showing removal of any DSS/Senna on 4/27/10 by RN 16.
*There was no other location where RN 16 would have obtained the DSS/Senna.

Review of a report of operation dated 4/28/10 and completed by patient 11's physician revealed the colonoscopy procedure was aborted because of an inability to view the colon because of poor bowel preparation.

2. Observation on 4/27/10 at 2:25 p.m. of patient 9's MAR revealed two medications scheduled for administration at 2:00 p.m. were not documented as administered. At the above time the surveyor asked RN 16 if he would be able to watch her administer the medications. RN 16 replied she had already administered the medications but had not yet documented administration.

Interview at the above time with acute care manager 3 revealed the medications should have been documented as administered at the time they were administered.

Review of the provider's policy for administration of oral medications dated March 2010 revealed the third step of medication administration was to remain with the patient until the medication was taken. The fourth step was to document medication administration in an appropriate manner.

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of nursing, 6th Edition, St. Louis, MO, 2005, revealed:
*Page 843 - "After the nurse administers the medication, the MAR is completed per agency policy to verify the medication was given as ordered."
*Page 847 - "After administering a medication, the nurse records it immediately on the appropriate record form. The nurse never (bold print) charts a medication before administering it. Recording immediately after administration prevents errors."

3. Review of resident 9's medication orders for transfer from another hospital dated 4/2/10 revealed an order to administer albuterol/ipratropium nebulizer every six hours as needed.

Review of resident 9's MAR dated 4/27/10 revealed an entry with a start date of 4/2/10 for an albuterol inhaler to have been administered every six hours as needed.

Interview on 4/28/10 at 9:15 a.m. with the director of pharmacy revealed the pharmacist who had transcribed the order had entered the order as albuterol nebulizer rather than the albuterol/ipratropium nebulizer. She stated the information entered by the pharmacist was then used to create the printed MAR. The director of pharmacy stated after the MAR was printed the nursing staff were to verify the accuracy of the MAR by comparing it to the orders as received. The pharmacist stated it appeared neither the pharmacist who entered the order nor the nurse who reviewed the MAR had noticed the mistake. The pharmacist also stated review of the electronic system revealed resident 9 must not have needed the nebulizer. The nebulizer had not been administered during the course of resident 9's stay.

Based on record review, interview, and policy review, the provider failed to ensure all sampled medical record entries from different patient service areas were authenticated with signatures, dates, or times. A sample of 491 medical record entries revealed 458 instances where either the signature, date, or time of the entry was not recorded. Findings include:

1. Review of 212 written physicians' orders during review of medical records on all patient care areas revealed 4 were not signed, 53 were not dated, and 197 were not timed.

2. Review of 99 telephone or verbal physicians' orders during review of medical records on all patient care areas revealed 11 were not signed, 12 were not dated, and 19 were not timed.

3. Review of 96 physicians' progress notes during review of medical records on all patient care areas revealed 3 were not signed, 5 were not dated, and 35 were not timed.

4. Review of 84 miscellaneous forms regarding physician or staff contact with the patient during review of medical records on all patient care areas revealed 20 were not signed, 38 were not dated, and 61 were not timed.

5. Interview with acute care manager 3 on 4/26/10 at 3:30 p.m. revealed she was aware all entries in the patient's medical record should have been signed, dated, and timed. She stated great strides had been made with the physicians completing all of those areas with the onset of electronic medical records. She further revealed not all areas of the patient record were electronically generated yet. She acknowledged timing of an entry in the medical record was most often missed in written entries.

Interview with the director of nursing on 4/27/10 at 10:30 a.m. revealed she was aware all entries should have been signed, dated, and timed. She acknowledged the current emergency room form did not have an area on it for timing, dating, and signing all orders. She stated that form was currently under revision.

Review of the provider's physicians' orders policy reviewed February 2010 revealed all orders in the medical record should have been signed, dated, and timed.