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UF HEALTH SHANDS HOSPITAL 1600 SW ARCHER RD GAINESVILLE, FL 32610 July 12, 2011
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and interview the facility failed to provide medications according to physician's orders for 1 (#1) of 10 patients reviewed.

Findings:

During medical record review for Patient #1 it was revealed that the patient admitted to the facility on [DATE] with complaints of nausea and vomiting and midline dehiscence of a surgical wound. The patient had been discharged from the facility on 3/14/11 after recovering from surgery to repair gunshot wound injuries. On 3/28/11 the patient had skin graft surgery to repair the dehisced wound. The surgery report indicated no complications as a result of the surgery. The patient was transferred to the recovery room on 3/28/11 at 1:13 PM. At 3:15 PM on 3/28/11 the patient was transferred to 5 West. On 3/28/11 at 4:10 PM a code was called because the patient was found unresponsive. The patient expired at 5:08 PM.

Review of the risk management investigation revealed that on 3/27/11 at 5 AM Patient #1 had requested pain medications. The nurse administered 2 mg of Dilaudid intravenously. On 3/27/11 at 5:20 AM the patient became unresponsive with an oxygen saturation of 88%. The patient was given Narcan 0.4 mg stat and his oxygen saturation returned to 100% on 2 liters of oxygen. The physician decreased the Dilaudid order to 0.5-1 mg IV every 4 hours for pain. The risk management team determined that this episode was not communicated to the surgeon, anesthesiologist and perianesthesia team. On 3/28/11 at 10:10 AM the patient went to pre-op surgery. The patient arrived in the recovery room at 1:13 PM with vital signs listed as blood pressure = 113/82, oxygen saturation of 88% on room air and counted respirations of 12. The patient was placed on 3 liters of oxygen and his oxygen saturation level increased to 95%. The post anesthesia orders included " hydromorphone 0.5 mg IV every 4 minutes as needed for severe or break through pain (not to exceed 2 mg per hour) and hold for respirations less than 12 and oxygen saturation less than 92%, nausea and vomiting and sleep. " There was also an order for " Roxicet liquid 5-15 ml PO PRN [by mouth as needed] moderate pain 1 dose. " Review of the Recovery Room documentation revealed that the patient was given medications as follows:
3/28/11 at 1:35 PM: Dilaudid 0.5 mg IV with a documented respiration of 7 (physician ordered hold medication if less than 12) and oxygen saturation of 95% on 3 liters of oxygen.
3/28/11 at 1:41 PM: Dilaudid 0.5 mg IV with documented respirations of 8. There was no documentation of oxygen saturation levels.
3/28/11 at 1:45 PM: Dilaudid 0.5 mg IV with documented respirations of 8 and oxygen saturation of 97% on 3 liters of oxygen.
3/28/11 at 1:51 PM: Dilaudid 0.5 mg IV. There was no documentation concerning his respirations. There was no documentation of oxygen saturation levels.
3/28/11 at 1:57 PM: Roxicet 10 mls via feeding tube. There was no documentation concerning his respirations or oxygen saturation levels.
3/28/11 at 2 PM: Dilaudid 0.5 mg IV (total 2.5 mg in less than one hour) with documented respirations of 9 and oxygen saturation level of 96% on 3 liters of oxygen.

On 3/28/11 at 2:15 PM the patient ' s respirations were documented as 6 on 2 liters of oxygen and a documented oxygen saturation level of 97%. On 3/28/11 at 3:15 PM the patient ' s vital signs were, blood pressure 116/57, respirations 12, and oxygen saturation level of 95% on 2 liters of oxygen. The patient ' s Aldrete score was 14 upon discharge from the recovery room. The patient was discharged from the recovery room accompanied by a patient care technician (PCT). The patient was placed in his room on 5 West by the recovery room PCT. At 4:09 PM the 5 West PCT went to obtain a blood sugar sample and found the patient unresponsive. A code was called at that time.

Interview on 7/12/11 at 12:10 PM with the clinical leader of the recovery room stated that she helped review the incident and it was discovered that the nurse originally assigned to Patient #1 (and who administered the medication) was relieved for by another nurse (who transferred the patient to the floor). She stated that the original nurse no longer works in the recovery room. The recovery room received education on hand-off communication and monitoring parameters for patients receiving narcotics. The 5 West PCT saw that the patient was in the room and spoke with the patient briefly. She stated that he was groggy and unable to tell her if he was in pain. She left to get equipment to assess the patient. When she returned he was unresponsive and she called a code.

Review of the facility's policy titled "Medication Administration" states that "it is the responsibility of the nurse to be knowledgeable of the medications administered: indications, actions, dosages and routes, side effects, contraindications and monitoring requirements."