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Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The facility failed to ensure nursing staff followed the facility's established policy regarding
"Administration and Management of Medications" revision date January 2023 revealed
"General Guidelines for Safe Preparation and Administration of All Medications ... A procedure in which two Practioners/Clinicians independently check each targeted component that requires verification when prescribing, dispensing, or administering a medication ... A. Right Time ...B. Right Medication ...C. Right Dosage ... D. Right Route ... E. Right Patient".

The facility failed to ensure nursing staff followed the facility's policy "Automated Dispensing Cabinet 7:15" revision date October 2022 revealed, "Removing Medications ... Users are responsible for verifying the correct patient (via 2 identifiers), medication, dosage form, strength, dose (may be different from strength), and expiration date prior to administration ... For controlled substances, users are required to verify the physical inventory and enter it as a blind inventory count".

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP2, EMP3, EMP4 ) regarding the survey team's concerns related to Nursing Services on August 23, 2023, at approximately 3:27 pm.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure medication orders were administered in accordance with the approved policies and procedures for MR1.

Findings include:

On August 23, 2023, review of facility policy "Administration and Management of Medication " revision date January 2023 revealed General Guidelines for Safe Preparation and Administration of All Medications ... A procedure in which two Practioners/Clinicians independently check each targeted component that requires verification when prescribing, dispensing, or administering a medication ... A. Right Time ...B. Right Medication ...C. Right Dosage ... D. Right Route ... E. Right Patient".

On August 23, 2023, review of facility policy "Wasting of Controlled Substances - Nursing" revision date June 2023 revealed, "Controlled substances that are prescribed in excess of what is used are to be wasted or destroyed in front of a witness. The administering nurse should ensure the controlled substance is sealed and intact and then opened in the presence of the witnessing nurse. Both nurses verify the controlled substance label, that the volume or amount being wasted matches the documentation, that the controlled substance being wasted physically matches the medication in the documentation, and that the wasting occurs in a manner that makes the controlled substance irretrievable ... The witnessing nurse observes the administering nurse open the medication, draw up or cut the correct dose to assure the controlled substance has not been substituted or unadulterated".

Review of facility policy "Automated Dispensing Cabinet 7:15" revision date October 2022 revealed, "Removing Medications ... Users are responsible for verifying the correct patient (via 2 identifiers), medication, dosage form, strength, dose (may be different from strength), and expiration date prior to administration ... For controlled substances, users are required to verify the physical inventory and enter it as a blind inventory count".
Review of MR1 on August 23, 2023 revealed, "HYDROmorphone (DILAUDID) injection 1.5 mg ...every 3 hours prn ordered on 8/11/23 @ 0349" ordered by provider.

Further review of MR1 on August 23, 2023 revealed, the patient was found unresponsive with pulse and required administration of Narcan, was resuscitated and transferred to the Intensive Care Unit (ICU).

Interview with EMP3 on August 23, 2023 at 12:30 PM, revealed "the nurse (EMP13) came forward and admitted to giving the wrong dose" of Hydromorphone (Dilaudid) to the patient involved.

Interview with EMP1 on August 23, 2023 at 12: 40 PM confirmed "the nurse (EMP13) admitted to giving the wrong dose of Dilaudid to the patient " . Further revealed " the nurse officially came off the schedule on 8/16/23, but she hasn ' t worked since 8/11/23".

Interview with EMP2 on August 23, 2023 at 1:00 PM revealed, "it was a nurse (EMP13) medication error that resulted in an overdose" for the patient.

Interview on August 23, 2023 at 3:10 PM with EMP7 confirmed, "Dilaudid vials comes in three different strengths. The nurse involved pulled 2 vials of Hydromorphone which were 2 mg each instead of one vial. The vials come in 1mg and 2 mgm. She gave 3mgm of Dilaudid instead of the ordered 1.5 mgm".
Review of the pharmacy Pyxis audit report provided by the pharmacy manager (EMP6) shows the nurse did waste 0.5mg each time. First dosage of (2)- 2mg vials pulled from Pyxis drawer on 8/11/23 at 1334 with a 0.5 mg waste at 13:36. Second dosage of (2)-2mg vials pulled from Pyxis on 8/11/23 at 1739, 0.5mg wasted at 1740. Medication count started at 15 of the 2mg Hydromorphone drawer on 8/11/23 prior to the withdrawal of the medication. The nurse involved listed a count of 13 vials for the verified inventory (blind count) count in Pyxis drawer on 8/15/23 after her withdrawal of the med. Without any other withdrawal noted since 8/11/23 at 1739, report shows Discrepancy/Resolution with actual count of 11, "wrong count" noted- " user miscounted pocket contents".
Interview with EMP2 on August 23, 2023 at 4:31 PM revealed "I don't think she (the nurse involved- EMP13) scanned the vials".

Interview with EMP2 on August 23, 2023 at 8:38 PM confirmed, "the nurse (EMP13) involved didn't follow the policy in place, when following the Pyxis instructions for giving medication. She didn't scan the meds, that's why the "guardrails" failed".
Cross Reference: Nursing Services 482.23