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FLORIDA HOSPITAL FLAGLER 60 MEMORIAL MEDICAL PKWY PALM COAST, FL 32164 Feb. 7, 2013
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on medical record review and interviews, the facility failed to follow physician ' s orders for the administration of medications for 1(#1) out of 10 sampled patients. The facility started a Diltiazem intravenous infusion at a higher rate than ordered by the physician.

The findings include:

A medical record review of the emergency room record revealed that Patient #1 arrived via ambulance with a complaint of abdominal pain. Patient #1 was documented as alert, and oriented to person, place, time and situation. Patient #1 was admitted to the Hospitalist Service for abdominal pain and acute pancreatitis.

A physician order for Patient #1 dated 12/12/11 at 9:22 pm revealed that Diltiazem 125 mg intravenous infusion was ordered to start at 5 mg per hour (mg/hr.) and titrate to control heart rate (increase by 5 mg every 15 minutes) maintain heart rate (HR) greater than 60 beats per minute (bpm) and/or systolic blood pressure (BP) greater than 100 mmHg (max dose 15 mg per hour).

A review of the Medication Administration Record (MAR) for Patient #1 dated 12/12/11 revealed the Diltiazem intravenous infusion was started at 10:00 pm at 10 mg/hr. The physician orders were to start the diltiazem intravenous infusion at 5 mg/hr.

A staff interview with the Intensive Care Unit (ICU) charge nurse on 12/19/12 at 9:57 am revealed that when patients' become unstable in the unit, the physician is called for further instructions. If a patient's vital signs change and the patient is stable, then the medication causing the vital sign change is stopped until further instructions can be received from the physician.

An interview on 2/7/13 at 10:20 am with Staff Nurse 1 revealed that all intravenous medications are started at the physician ordered rates and then titrated to meet the specified parameters. If for any reason a medication needs to be started at a different rate, then the physician would be contacted to confirm the rate is appropriate and to give a different order. Intravenous medications are stopped if a patient becomes symptomatic due to the medication, but the physician in contacted as soon as possible to notify them of the patients' change in status.

An interview on 2/7/13 at 10:30 am with Staff Nurse 2, revealed that titrated medications are started at the physician ' s ordered dose and then titrated per the orders until the patient's status can be managed within the ordered parameters. Staff Nurse 2 stated, " I cannot recall a time where it required me to start a medication to be titrated outside of the ordered dose. " If I need to start a medication differently than was ordered, then I would call the physician first and ask for a different order. The physicians are able to enter orders from almost anywhere, so they will usually put their own orders in the computer. We only enter verbal or telephone orders in an emergency situation.

An interview on 2/7/13 at 10:45 am with Staff Nurse 3 revealed that all medications are supposed to be started by the physician ordered dose, and then titrated per the physician's order if appropriate. If there ever was a need to start the medication at a different dose than the physician ' s order, it is an expectation that the physician will be notified, and an order received prior to starting that medication.

An interview with the Nurse Manager on 2/7/13 at 11:00 am confirmed the discrepancy between the physician ordered starting dose of the intravenous Diltiazem infusion and the actual documented starting dose. There are no special nursing notes or other physician orders to explain why the medication was started at a different rate than the physician ordered rate.