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Based on a review of 10 patient records, based on a review of the hospital's electronic Event Management System and the hospital's policies and procedures, and based on interviews with a hospital staff member, it was determined that hospital nursing staff members failed to function within acceptable standards and scope of practice. Nursing staff also failed to document medication administration errors, and subsequent notification of the errors to a patient's physician, within the patient record.

Findings include:

Ten patient records were requested and reviewed.

Patient record number 9 contained information regarding a 60 year old patient who had a Positron Emission Tomography (PET) scan which revealed a suspicious mass in his/her colon. The patient underwent a colonoscopy on 02/02/2011 at the hospital, at which time a biopsy was obtained, which later confirmed a diagnosis of adenocarcinoma in the colon. The patient was admitted to the hospital as an in-patient the following day, 02/03/2011, for a colectomy, and was discharged from the hospital on 02/09/2011.

A form in the patient record titled: "HEO MEDS" reflected that the attending physician ordered the oral analgesic "Oxycodone-APAP (Percocet) 1-2 tablets oral Q (every) 4 HR (hours) PRN (as needed) until discontinued" on 02/06/11. No other oral analgesics had been ordered throughout the course of the patient's hospital stay. This form also reflected that the anticoagulant medication "Dalteparin Injectable (Fragmin) 5000 units subcutaneously Q 24 HR routine until discontinued" had been ordered on 02/04/11.

The contents of patient record number 9 were reviewed. The record reflected the administration of an intravenous pain medication, Dilaudid, with the last dose recorded on 02/08/11 at 06:10. The record did not reflect the administration of Percocet, nor of any other oral analgesic, throughout the patient's stay.

The patient record contained numerous documents titled : "FLOWSHEET," which contained, among many categories, i.e. "Neurological," "Cardiovascular," "Gastrointestinal," and "Notify/Communicatn" (sic). Under the "Notify/Communicatn" category on the flow sheets, the following was noted on the flow sheet dated and timed 02/08/11, 15:00 : " pt. has been given heating pad for stomach gas pains, encouraged throughout day to ambulate frequently, use IS (inspiratory spirometer), lie on left side, and to try not to burp on purpose. MD Hughes was in, c-diff order received and sent, has had numerous diarrhea episodes. Hughes notified, states she might order immodium if this is negative."

Similar narrative-style nursing notes spanning the entire length of this patient's stay in the hospital were noted throughout the patient record on these daily flow sheets, documenting telephone calls, conversations, and concerns not otherwise included on the template of the flow sheets. No documentation, either on the flow sheet, nor in any other section of the patient record available for review at the time of this investigation, documented notification of a physician of a medication error.

In an interview with I1 on 04/19/11 at 1200 hours, I1 stated that if a medication error had occurred, it was the facility policy to document this information in the patient record, as well as in an electronic system titled: "the Medication Event Reporting System." When asked if a medication which had been ordered for one patient had been erroneously given to another patient would be documented in the patient record, I1 replied that it would have. When asked what it meant if documentation concerning a medication error could not be located in a patient record, I1 responded that this reflected that an error had not occurred.

The hospital's policy and procedure concerning medication administration and documentation was requested on 04/19/11 at 0955 hours. The policy titled: "SCHS Medication, Administration, and Documentation, Document Number W10113, Revision 0" was received, reviewed, and was noted to contain the following information:

"6. The Five-Rights of Medication Administration procedure shall be used in the administration of all medications.
Right medication--Scan patient armband, ask the patient two identifiers: Name and date of birth name (sic).
Right medication-read label, check AdminRx, scan unopened medication, and verify no error warning.
Right dosage-read label, check AdminRx, scan unopened medication, and verify no error warning.
Right time-
Right route-check AdminRx and label route"

and

"MEDICATION AND ADMINISTRATION RECORD
1. All medications administered to a patient will be charted on AdminRx or IV Manage at the time they are administered documenting site, route and dosage."

The hospital policy and procedure regarding the reporting of medication errors was requested on 04/19/11 at 0920 hours. A document titled: "Medication Event Reporting System, Document Number W09178 Revision D" was received, reviewed, and was found to contain the following information:

"INSTRUCTIONS
1. Medication Categories:
Medication events categories include, but are not limited to, the following:
Incorrect medication, dose, route, time or patient
Medication administered without an order"

and

"2. Medication Event Classifications:
Medication events will be further classified according to the clinical significance to the patient as follows:
Level 0- Incident was caught before it reached the patient
Level 1-No evidence of harm to patient
Level 2-Increased patient monitoring, no change in patient vital signs and no patient harm..."

"3. Reporting Responsibilities:
A. Level 1 and 2 events will be reported to the ordering physician(s)."

On 04/19/11 at 1330 hours, I1 was asked for permission to view the hospital's Medication Event Reporting System. At approximately 14:45 hours, permission was granted.

The electronic Event Management System revealed that on 02/09/11, at 0530 hours, the patient received "Norco," a medication that was not ordered for the patient, but had been ordered for a different patient. The nurse entering the error into the system assigned the incident severity a "Level 1," indicating per the hospital policy that no harm was done to the patient, and that notification of the patient's physician was required. The Event Management System documentation reflected that the physician had been notified by the nurse after the medication error occurred. The Event Management System also reflected a review of the incident by the nurse's supervisor, who documented that, in addition to making the medication error, the nurse had failed to follow the "Five Rs--please see above--and had failed to document either the medication, or the telephone call afterward to the physician, in the patient record. Documentation on this event report by the reviewing pharmacist revealed that the nurse failed to follow hospital protocol by not "scanning" the medication properly, and by overriding the "this medication not ordered" notification that the electronic medication dispensing system automatically provided.

Of note, a second Event Management System record for this patient was observed and reviewed. This incident described the administration of the anticoagulant Dalteparin Injectable given by a student nurse 8 hours earlier than it was scheduled to be given, on February 8, 2011, at "3:12 p.m."; military time was not used in this documentation. The narrative note of 02/08/11, 15:00 described above, just prior to the reported time of over-dosing the patient with an anticoagulant, and a nursing progress note on 02/08/11 at 19:24--"Pt requests to have IV Dc'd. Notified Dr Hughes and message relayed to pt that IV needs to stay in and reasons why"--were the only communications documented between the nursing staff and the physician during that period of time.

Two medication errors were committed within a period of less than twenty-four hours; neither error was documented appropriately within the patient record. Drugs were administered without a physician order, and well below acceptable standards of practice.

Based on a review of 10 patient records, based on a review of the hospital's electronic Event Management System and the hospital's policies and procedures, and based on interviews with a hospital staff member, it was determined that hospital nursing staff members failed to document medication administration errors, and subsequent notification of the errors to a patient's physician, within the patient record.

Findings include:

Please see findings listed at tag 0404: Administration of Drugs.

The hospital failed to assure that all patient records contained complete nursing notes, accurate medication records, and other information necessary to monitor the patient's condition, as required by this regulation.