The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

CITRUS MEMORIAL HOSPITAL 502 W HIGHLAND BLVD INVERNESS, FL 34452 April 23, 2012
VIOLATION: USE OF VERBAL ORDERS Tag No: A0407
Based on observation and interview the hospital failed to ensure that verbal orders are authenticated by the physician for 1(#9) of 5 patients.

Findings:

Observation of medication administration for Patient #9 on 4/24/12 at 10:50 AM by RN #2 revealed that the nurse was at the pyxis machine and obtained Demerol 25 milligrams (mg). He stated that he received a verbal order from the physician. The surveyor then observed the nurse go to the nurse's station write the order on the sheet that had been signed by the physician prior to this order. He then went to the patient's bedside, identified the patient, and explained the medication. The nurse cleaned the IV port with alcohol and slowly administered the medication. The patient was complaining of pain on a scale of 8-9 of 10.

Interview with the Risk Manager (who was present during the medication observation) on 4/24/12 at 11 AM stated that she observed that the nurse wrote the order on a pre-signed order sheet prior to administration.

Interview with the pharmacist on 4/24/12 at 11:15 AM stated that it is up to the nurses to report medication errors.
VIOLATION: REPORTING ADVERSE EVENTS Tag No: A0508
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital was unable to demonstrate that administration errors and potential adverse drug reactions are immediately reported to the attending physician or the Quality Assurance Performance Improvement (QAPI) committee for 3 of 11 sample patients.

Findings:

1.) During record review for Patient #1 it was revealed that the patient arrived by ambulance to the hospital's emergency department on 4/4/12 at 1:35 AM with abdominal distention and complaining of leg pain. The patient stated that he had dental work performed the previous day. On 4/4/12 at 1:37 AM it is documented that the patient's vital signs are as follows: blood pressure: 104/53, temperature= 97.9 F, pulse= 111, respirations= 26 and oxygen saturation= 92%. It is documented that the patient was administered the following medication:

4/4/12 at 3:40 AM Benadryl 25 mg IVP (intravenous push). Response: No adverse drug reaction.
4/4/12 at 3:40 AM Reglan 10 mg IVP. Response: No nausea and vomiting.
4/4/12 at 3:40 AM Toradol 30 mg IVP. Response: No pain.
4/4/12 at 3:50 AM Potassium 40 MEQ (miliequivelents) by mouth. Response: No adverse drug reaction.

There are no other vital signs documented in the medical record. The words" data erased " is written on the area where vital signs are documented. On 4/4/12 at 6:40 AM the patient is discharged in the company of his wife.

Interview with the emergency room (ER) physician on 4/23/12 at 2:46 PM after reviewing the medical record stated that he treated Patient #1 on 4/4/12. He stated that the patient was in liver failure and is awaiting a transplant. He stated that the patient's blood sugar was 600, he had fever and chills and was 1+ jaundice. His liver enzyme tests were also high. He stated that the patient was hyponatremic, hypokalemic and tachycardia. He stated that the patient was given 40 of potassium for his low potassium levels. He stated that the patient had a history of migraines. He stated that in his practice he orders Reglan, toradol and Benadryl to treat migraines. He stated that this "cocktail" usually relieves the symptoms.

2.) During review of the grievance log it was noted that on 2/21/12 Patient #2 wrote a letter to the hospital concerning her ER visit on 2/19/12. She stated that she had laryngitis so she wrote her medical history including allergies on paper. She also was wearing a medic alert bracelet indicating her allergies were albuterol and codeine. She stated that she was administered albuterol in the ER by a named physician's assistant. She also stated that on her ER paperwork indicated that she did not have any allergies. On 2/21/12 an acknowledgement letter went out to the patient informing her that her concerns would be investigated. On 3/2/12 a follow-up letter was sent to the patient informing her of the hospital's findings. The letter stated that the ER physician and ER manager were investigated her concerns.

Interview with the pharmacist on 4/24/12 at 11:15 AM stated that it is up to the nurses to report medication errors.

3.) During review of the grievance log it was noted that on 2/15/12, Patient #3's daughter wrote a letter to the hospital concerning her mother's care in the ER on 2/14/12. The patient advocate wrote a letter on 2/15/12 apologizing for her mother's experience and acknowledging that her concerns would be investigated. On 3/13/12 the daughter received a letter from the hospital revealing that her mother received pain medication within 3 hours and fifty minutes apart from another pain medication. The letter stated that metabolism in the elderly can lead to prolonged sedation.

Review of the ER record for Patient #3 revealed that on 2/14/12 at 3:39 PM the patient arrived to the hospital's ER for abdominal pain and nausea. The patient home medication profile documented in the ER record does not indicate that she is on any medication. The physician documented that the patient had a history of gallbladder removal, appendix removal, and hysterectomy and colon surgery. On 2/14/12 the patient received the following medication:

2/14/12 at 2 PM normal saline per IV to increase hydration.
2/14/12 at 7 PM morphine 2 mg IVP (intravenous push). Response: decreased pain.
2/14/12 at 7 PM Zofran 4 mg IVP. Response: decreased nausea.
2/14/12 at 10:50 PM Dilaudid 1 mg IM (intramuscular). Response: no pain.
2/14/12 at 10:52 PM Maalox and donnatal 40 mg by mouth. Response: no pain.

The nurse documented on 2/15/12 at 12:55 AM "attempting to give discharge instructions, patient very sleepy, unable to stand, physician informed." At 1:50 AM the patient was transferred to the 3rd floor for observation. On 2/15/12 at 8:52 AM the patient was discharged in the company of her daughter with the following new prescriptions: Protonix 40 mg once a day, Zofran 4 mg tablets one tablet three times a day and lobrax 5-2.5 mg one capsule three times a day.

Interview with the pharmacist on 4/23/12 at 3:30 PM provided the surveyor additional information concerning Dilaudid dosing. Dilaudid 1.5 mg is equivalent to Morphine 10 mg when given intravenously. When the pharmacist was asked if Patient #3 had an opiate naive response to the Dilaudid, he did not answer. He stated that Dilaudid 1 mg is considered a normal dose. Review of the patient's medication profile revealed that the patient was not on any opiates prior to admission to the hospital. Review of the information concerning Dilaudid dosing provided by the pharmacist revealed that precautions for intramuscular administration: variation absorption and a lag time to peak effect may result from IM use. Geriatric considerations: elderly may be particularly susceptible to the CNS (central nervous system) depressant and constipating effects of narcotics. Initial dosages of the drug should be in the lower end of the usual range. The usual range was documented as 0.8 mg-1 mg intramuscularly for opiate naive patients.

4.) During review of the grievances it was noted that the mother of Patient #4 filed a grievance by telephone on 2/28/12 concerning her son's visit to the emergency room on [DATE]. The mother was upset that the physician wrote a prescription for an antibiotic that her son was allergic to which she had filled at her pharmacy. She was upset because the medication was listed as an allergy on his medical record. The mother received an acknowledgement letter on 2/29/12. She received a conclusion letter on 3/13/12. The letter stated that an investigation of her concerns revealed that the allergy was documented in the medical record and that the physician had ordered a derivative of that medication. An apology for the incident was conveyed to the mother. A courtesy write off of her balance owed to the hospital was also provided to offset the cost of her purchase of medication should could not use.

Interview with the pharmacist and the Risk Manager on 4/23/12 at 12:30 PM revealed that they could not confirm if a medication incident report was generated for this incident as they both did not have password access to the system. The pharmacist who has access to the system was out of state at a conference. The nursing Quality Assurance Manager who has access to the system was out on leave at the time of the survey.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital's Quality Assurance Performance Improvement (QAPI) failed to ensure that there was a mechanism in place to monitor medication errors when the designated personnel with password protected access to the system were not available.

Findings:

1.) During review of the grievance log it was noted that on 2/21/12 Patient #2 wrote a letter to the hospital concerning her emergency room (ER) visit on 2/19/12. She stated that she had laryngitis so she wrote her medical history including allergies on paper. She also was wearing a medic alert bracelet indicating her allergies were albuterol and codeine. She stated that she was administered albuterol in the ER by a named physician's assistant. She also stated that on her ER paperwork it indicated that she did not have any allergies. On 2/21/12 an acknowledgement letter went out to the patient informing her that her concerns would be investigated. On 3/2/12 a follow-up letter was sent to the patient informing her of the hospital's findings. The letter stated that the ER physician and ER manager were investigated her concerns.

2.) During review of the grievance log it was noted that on 2/15/12, Patient #3's daughter wrote a letter to the hospital concerning her mother's care in the ER on 2/14/12. The patient advocate wrote a letter on 2/15/12 apologizing for her mother's experience and acknowledging that her concerns would be investigated. On 3/13/12 the daughter received a letter from the hospital revealing that her mother received pain medication within 3 hours and fifty minutes apart from another pain medication. The letter stated that metabolism in the elderly can lead to prolonged sedation.

Review of the ER record for Patient #3 revealed that on 2/14/12 at 3:39 PM the patient arrived to the hospital's ER for abdominal pain and nausea. The patient home medication profile documented in the ER record does not indicate that she is on any medication. The physician documented that the patient had a history of gallbladder removal, appendix removal, and hysterectomy and colon surgery. On 2/14/12 the patient received the following medication:

2/14/12 at 2 PM normal saline per IV to increase hydration.
2/14/12 at 7 PM morphine 2 mg IVP (intravenous push). Response: decreased pain.
2/14/12 at 7 PM Zofran 4 mg IVP. Response: decreased nausea.
2/14/12 at 10:50 PM Dilaudid 1 mg IM (intramuscular). Response: no pain.
2/14/12 at 10:52 PM Maalox and donnatal 40 mg by mouth. Response: no pain.

The nurse documented on 2/15/12 at 12:55 AM "attempting to give discharge instructions, patient very sleepy, unable to stand, physician informed." At 1:50 AM the patient was transferred to the 3rd floor for observation. On 2/15/12 at 8:52 AM the patient was discharged in the company of her daughter with the following new prescriptions: Protonix 40 mg once a day, Zofran 4 mg tablets one tablet three times a day and lobrax 5-2.5 mg one capsule three times a day.

Interview with the pharmacist on 4/23/12 at 3:30 PM provided the surveyor additional information concerning Dilaudid dosing. Dilaudid 1.5 mg is equivalent to Morphine 10 mg when given intravenously. When the pharmacist was asked if Patient #3 had an opiate naive response to the Dilaudid, he did not answer. He stated that Dilaudid 1 mg is considered a normal dose. Review of the patient's medication profile revealed that the patient was not on any opiates prior to admission to the hospital. Review of the information concerning Dilaudid dosing provided by the pharmacist revealed that precautions for intramuscular administration: variation absorption and a lag time to peak effect may result from IM use. Geriatric considerations: elderly may be particularly susceptible to the CNS (central nervous system) depressant and constipating effects of narcotics. Initial dosages of the drug should be in the lower end of the usual range. The usual range was documented as 0.8 mg-1 mg intramuscularly for opiate naive patients.

4.) During review of the grievances it was noted that the mother of Patient #4 filed a grievance by telephone on 2/28/12 concerning her son's visit to the emergency room on [DATE]. The mother was upset that the physician wrote a prescription for an antibiotic that her son was allergic to which she had filled at her pharmacy. She was upset because the medication was listed as an allergy on his medical record. The mother received an acknowledgement letter on 2/29/12. She received a conclusion letter on 3/13/12. The letter stated that an investigation of her concerns revealed that the allergy was documented in the medical record and that the physician had ordered a derivative of that medication. An apology for the incident was conveyed to the mother. A courtesy write off of her balance owed to the hospital was also provided to offset the cost of her purchase of medication should could not use.

Interview with the pharmacist and the Risk Manager on 4/23/12 at 12:30 PM revealed that they could not confirm if a medication incident report was generated for these incident as they both did not have password access to the system. The pharmacist who has access to the system was out of state at a conference. The nursing Quality Assurance Manager who has access to the system was out on leave at the time of the survey.
VIOLATION: PROVIDING ADEQUATE RESOURCES Tag No: A0315
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure adequate resources that would monitor medication errors when the designated personnel, who has password protected acess to the system, were not available.

Findings:

1.) During review of the grievance log it was noted that on 2/21/12 Patient #2 wrote a letter to the hospital concerning her emergency room (ER) visit on 2/19/12. She stated that she had laryngitis so she wrote her medical history including allergies on paper. She also was wearing a medic alert bracelet indicating her allergies were albuterol and codeine. She stated that she was administered albuterol in the ER by a named physician's assistant. She also stated that on her ER paperwork it indicated that she did not have any allergies. On 2/21/12 an acknowledgement letter went out to the patient informing her that her concerns would be investigated. On 3/2/12 a follow-up letter was sent to the patient informing her of the hospital's findings. The letter stated that the ER physician and ER manager were investigated her concerns.

Interview with the pharmacist on 4/24/12 at 11:15 AM stated that it is up to the nurses to report medication errors.

2.) During review of the grievance log it was noted that on 2/15/12, Patient #3's daughter wrote a letter to the hospital concerning her mother's care in the ER on 2/14/12. The patient advocate wrote a letter on 2/15/12 apologizing for her mother's experience and acknowledging that her concerns would be investigated. On 3/13/12 the daughter received a letter from the hospital revealing that her mother received pain medication within 3 hours and fifty minutes apart from another pain medication. The letter stated that metabolism in the elderly can lead to prolonged sedation.

Review of the ER record for Patient #3 revealed that on 2/14/12 at 3:39 PM the patient arrived to the hospital's ER for abdominal pain and nausea. The patient home medication profile documented in the ER record does not indicate that she is on any medication. The physician documented that the patient had a history of gallbladder removal, appendix removal, and hysterectomy and colon surgery. On 2/14/12 the patient received the following medication:

2/14/12 at 2 PM normal saline per IV to increase hydration.
2/14/12 at 7 PM morphine 2 mg IVP (intravenous push). Response: decreased pain.
2/14/12 at 7 PM Zofran 4 mg IVP. Response: decreased nausea.
2/14/12 at 10:50 PM Dilaudid 1 mg IM (intramuscular). Response: no pain.
2/14/12 at 10:52 PM Maalox and donnatal 40 mg by mouth. Response: no pain.

The nurse documented on 2/15/12 at 12:55 AM "attempting to give discharge instructions, patient very sleepy, unable to stand, physician informed." At 1:50 AM the patient was transferred to the 3rd floor for observation. On 2/15/12 at 8:52 AM the patient was discharged in the company of her daughter with the following new prescriptions: Protonix 40 mg once a day, Zofran 4 mg tablets one tablet three times a day and lobrax 5-2.5 mg one capsule three times a day.

Interview with the pharmacist on 4/23/12 at 3:30 PM provided the surveyor additional information concerning Dilaudid dosing. Dilaudid 1.5 mg is equivalent to Morphine 10 mg when given intravenously. When the pharmacist was asked if Patient #3 had an opiate naive response to the Dilaudid, he did not answer. He stated that Dilaudid 1 mg is considered a normal dose. Review of the patient's medication profile revealed that the patient was not on any opiates prior to admission to the hospital. Review of the information concerning Dilaudid dosing provided by the pharmacist revealed that precautions for intramuscular administration: variation absorption and a lag time to peak effect may result from IM use. Geriatric considerations: elderly may be particularly susceptible to the CNS (central nervous system) depressant and constipating effects of narcotics. Initial dosages of the drug should be in the lower end of the usual range. The usual range was documented as 0.8 mg-1 mg intramuscularly for opiate naive patients.

4.) During review of the grievances it was noted that the mother of Patient #4 filed a grievance by telephone on 2/28/12 concerning her son's visit to the emergency room on [DATE]. The mother was upset that the physician wrote a prescription for an antibiotic that her son was allergic to which she had filled at her pharmacy. She was upset because the medication was listed as an allergy on his medical record. The mother received an acknowledgement letter on 2/29/12. She received a conclusion letter on 3/13/12. The letter stated that an investigation of her concerns revealed that the allergy was documented in the medical record and that the physician had ordered a derivative of that medication. An apology for the incident was conveyed to the mother. A courtesy write off of her balance owed to the hospital was also provided to offset the cost of her purchase of medication should could not use.

Interview with the pharmacist and the Risk Manager on 4/23/12 at 12:30 PM revealed that they could not confirm if a medication incident report was generated for these incident as they both did not have password access to the system. The pharmacist who has access to the system was out of state at a conference. The nursing Quality Assurance Manager who has access to the system was out on leave at the time of the survey.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, record review and interview the facility failed to ensure that nursing services was provided appropriately during medication administration for 2 of 11 (#1 and #9) sampled patients.
Findings:

Reference A 404: Based on record review, interview and observation, the facility failed to follow the facility's policy and procedure regardin re-assessing 1 of 11 (#1) patients. The facility also failed to ensure the physician properly authenticated physician's verbal orders for 1 of 11 (#9) patients.

Reference A 405: Based on record review and interview the hospital failed to ensure that 1 (#1) of 11 patients reviewed received nursing assessments and a nursing re-assessment prior to discharging the patient from the facility.

Reference A 407: Based on observation and interview the hospital failed to ensure that verbal orders are authenticated by the physician for 1(#9) of 5 patients.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on record review, interview and observation, the facility failed to follow the facility's policy and procedure regardin re-assessing 1 of 11 (#1) patients. The facility also failed to ensure the physician properly authenticated physician's verbal orders for 1 of 11 (#9) patients.

Findings:

1. During record review for Patient #1 it was revealed that the patient arrived by ambulance to the hospital's emergency department on 4/4/12 at 1:35 AM with abdominal distention and complaining of leg pain. The patient stated that he had dental work performed the previous day. On 4/4/12 at 1:37 AM it is documented that the patient's vital signs are as follows: blood pressure: 104/53, temperature= 97.9 F, pulse= 111, respirations= 26 and oxygen saturation= 92%. It is documented that the patient was administered the following medication:

4/4/12 at 3:40 AM Benadryl 25 mg IVP (intravenous push). Response: No adverse drug reaction.
4/4/12 at 3:40 AM Reglan 10 mg IVP. Response: No nausea and vomiting.
4/4/12 at 3:40 AM Toradol 30 mg IVP. Response: No pain.
4/4/12 at 3:50 AM Potassium 40 MEQ (miliequivelents) by mouth. Response: No adverse drug reaction.

There are no other vital signs documented in the medical record. The words" data erased " is written on the area where vital signs are documented. On 4/4/12 at 6:40 AM the patient is discharged in the company of his wife.

Interview with the emergency room (ER) physician on 4/23/12 at 2:46 PM after reviewing the medical record stated that he treated Patient #1 on 4/4/12. He stated that the patient was in liver failure and is awaiting a transplant. He stated that the patient's blood sugar was 600, he had fever and chills and was 1+ jaundice. His liver enzyme tests were also high. He stated that the patient was hyponatremic, hypokalemic and tachycardia. He stated that the patient was given 40 of potassium for his low potassium levels. He stated that the patient had a history of migraines. He stated that in his practice he orders Reglan, toradol and Benadryl to treat migraines. He stated that this "cocktail" usually relieves the symptoms.

Interview with the spouse of Patient #1 on 4/23/12 at 10 AM she stated that her husband arrived by ambulance to the ER on 4/4/12. She stated that when the hospital discharged her husband from the ER he was lethargic. She stated that she took him to the VA hospital after 6 hours at home and no improvement in his sleepiness.

On 4/26/12 at 4:21 PM the Risk Manager stated that assessments are to be done every hour.

Review of the facility's policy (#1160) titled Standards of Patient Care in the Emergency Department implemented 8/09 on page 4 A. prior to transfer of a patient from the ER revealed "Assessment of patient's current status."

2. Observation of medication administration for Patient #9 on 4/24/12 at 10:50 AM by RN #2 revealed that the nurse was at the pyxis machine and obtained Demerol 25 milligrams (mg). He stated that he received a verbal order from the physician. The surveyor then observed the nurse go to the nurse's station write the order on the sheet that had been signed by the physician prior to this order. He then went to the patient's bedside, identified the patient, and explained the medication. The nurse cleaned the IV port with alcohol and slowly administered the medication. The patient was complaining of pain on a scale of 8-9 of 10.

Interview with the Risk Manager (who was present during the medication observation) on 4/24/12 at 11 AM stated that she observed that the nurse wrote the order on a pre-signed order sheet prior to administration.

Interview with the pharmacist on 4/24/12 at 11:15 AM stated that it is up to the nurses to report medication errors.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on record review and interview the hospital failed to ensure that 1 (#1) of 11 patients reviewed received nursing assessments and a nursing re-assessment prior to discharging the patient from the facility.

Findings:

During record review for Patient #1 it was revealed that the patient arrived by ambulance to the hospital's emergency department on 4/4/12 at 1:35 AM with abdominal distention and complaining of leg pain. The patient stated that he had dental work performed the previous day. On 4/4/12 at 1:37 AM it is documented that the patient's vital signs are as follows: blood pressure: 104/53, temperature= 97.9 F, pulse= 111, respirations= 26 and oxygen saturation= 92%. It is documented that the patient was administered the following medication:

4/4/12 at 3:40 AM Benadryl 25 mg IVP (intravenous push). Response: No adverse drug reaction.
4/4/12 at 3:40 AM Reglan 10 mg IVP. Response: No nausea and vomiting.
4/4/12 at 3:40 AM Toradol 30 mg IVP. Response: No pain.
4/4/12 at 3:50 AM Potassium 40 MEQ (miliequivelents) by mouth. Response: No adverse drug reaction.

There are no other vital signs documented in the medical record. The words" data erased " is written on the area where vital signs are documented. On 4/4/12 at 6:40 AM the patient is discharged in the company of his wife.

Interview with the emergency room (ER) physician on 4/23/12 at 2:46 PM after reviewing the medical record stated that he treated Patient #1 on 4/4/12. He stated that the patient was in liver failure and is awaiting a transplant. He stated that the patient's blood sugar was 600, he had fever and chills and was 1+ jaundice. His liver enzyme tests were also high. He stated that the patient was hyponatremic, hypokalemic and tachycardia. He stated that the patient was given 40 of potassium for his low potassium levels. He stated that the patient had a history of migraines. He stated that in his practice he orders Reglan, toradol and Benadryl to treat migraines. He stated that this "cocktail" usually relieves the symptoms.

Interview with the spouse of Patient #1 on 4/23/12 at 10 AM she stated that her husband arrived by ambulance to the ER on 4/4/12. She stated that when the hospital discharged her husband from the ER he was lethargic. She stated that she took him to the VA hospital after 6 hours at home and no improvement in his sleepiness.

On 4/26/12 at 4:21 PM the Risk Manager stated that assessments are to be done every hour.

Review of the facility's policy (#1160) titled Standards of Patient Care in the Emergency Department implemented 8/09 on page 4 A. prior to transfer of a patient from the ER revealed "Assessment of patient's current status."