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.

UF HEALTH LEESBURG HOSPITAL 600 E DIXIE AVE LEESBURG, FL 34748 July 14, 2011
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based record review and interview the facility failed to ensure that the pharmacy had a mechanism in place to safeguard patients from receiving medications above manufacturer's recommendations for 1 (#1) of 10 patients reviewed.

Findings:

During medical record review for Patient #1 it was revealed that the patient arrived to the facility on [DATE] by Emergency Medical Services for altered mental status. The patient was transferred to 4 North at 10 PM. At 11:25 PM telephone orders were received for the patient. On 5/8/11 at 1:15 AM the patient received his medication that was ordered by the physician. On 5/8/11 at 3:15 PM the nurse received an order to change the patient's Abilify to 10 milligrams (mg). Review of the Medication Administration Record the patient received the following medication:

5/8/11 at 1:15 AM= Ability 30 mg and Zonegram 300 mg (3 capsules).
5/8/11 at 10:38 AM= Lopressor 25 mg, Os Cal 500 mg, and Theragran multivitamin
5/8/11 at 3:45 PM= Abilify 10 mg
5/8/11 at 7:43 PM= Elimite topical cream, Lopressor 25 mg, Os Cal 500 mg, Zonegram 300 mg (3 capsules), and Xanax 1 mg
5/8/11 at 11:47 PM= Xanax 1 mg

Interview with Patient #1 on 7/14/11 at 9:30 AM stated that while he was in the facility the nurse's overdosed him with his Abilify. He stated he has always taken Abilify 10 mg.

Interview of the Chief Pharmacist on 7/14/11 at 2:15 PM stated that when a patient is admitted the unit faxes the orders to the pharmacy. He stated that the medication order for Patient #1 was received at midnight on 5/7/11. The medication was dispensed to the unit and it would be expected that the nurse administer the medication to the patient at that time. He stated that in reviewing Patient #1's medical record it is noted that he had not taken his medication for days resulting in this hospitalization . He confirmed that according to the medication administration record the patient received a total of 40 mg of Abilify within a 24 hour period. He stated that in his opinion the dosage would not harm the patient. He confirmed that the computerized medication dispensing system does not have any safeguards to prevent a medication from being administered outside of the manufacturer's recommended dosage.

Review of the Nursing 2011 Drug Handbook revealed that the dosage for Abilify is 10 to 15 mg daily with a maximum dosage of 30 mg.