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.

NORTH CAROLINA BAPTIST HOSPITAL MEDICAL CENTER BOULEVARD WINSTON-SALEM, NC 27157 Jan. 27, 2011
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on review of hospital policy, grievances for selected patients and staff interview, the hospital staff failed to provide a written response to 1 of 3 grievances reviewed (#4).

The findings include:

Review of the hospital's policy, "Patient Grievance Process", revised 02/2010, revealed, "...II. PURPOSE: The purpose of this policy is to define the procedures for responding to patient perceptions (complaints, concerns, appeals, grievances, needs, compliments) of medical care in as compassionate, effective and timely manner as possible. ...III. DEFINITIONS: ...A "patient grievance" is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient or the patient's representative, regarding the patient's care, abuse or neglect. ...A written complaint is always considered a grievance, whether from an inpatient, outpatient, released/discharged patient or their representative regarding the patient care provided... IV. PROCEDURE: C. Complaints should be promptly investigated and a response given to the patient within seven working (7) days. If the nature of the complaint/grievance should require longer than seven (7) working days, the patient should be advised in writing of the extension and notified that they will receive a written response within (60) days. If the nature of the complaint/grievance requires longer than sixty (60) days to investigate, the patient should be advised of an additional extension and when he/she should receive a response. All grievances shall be responded to in writing upon resolution and will include the steps taken to investigate the grievance, the results of the grievance process, date of completion, and the name of a contact person. The Service Excellence Department will determine the most appropriate route to answer each complaint and will follow up to ensure prompt resolution. ...".

Review of the grievance file for Patient #4 on 01/27/2011 revealed a letter received by the Service Excellence director on 08/06/2010. Review of the letter revealed concerns related to Patient #4's care while an inpatient from July 9 - 14, 2010. File review revealed a letter dated 08/10/2010 to the complainant signed by a staff member in the hospital's Service Excellence Department. Review of the letter revealed, "...In your letter I noted that you had sent a copy of this letter of concern to The Joint Commission and to the Division of Health Service Regulation. As you are aware, these two agencies have governing authority over our Medical Center, and we will respect their jurisdiction in this matter. ...It is our understanding that Joint Commission will notify you of their findings and any actions. ...". File review revealed no documentation of a written letter to the complainant of the steps to investigate the grievance, the results of the grievance process, date of completion and the name of a contact person (5 months, 17 days after grievance received).

Interview on 01/27/2011 at 1115 with the director of the hospital's Service Excellence Department revealed "there are special circumstances where my department works with another department in the investigation. In this case, we worked with medical staff services and risk management because a copy of the letter was sent to The Joint Commission and the State". Interview confirmed there was no evidence of a written letter to the complainant of the steps to investigate the grievance, the results of the grievance process, date of completion and the name of a contact person (5 months, 17 days after grievance received). Interview revealed, "our policy was not followed".
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, closed record review and staff interviews, nursing staff failed to assure medications were administered as ordered for 1 of 8 sampled records reviewed (#2).

The findings include:

Review of the "Medication Administration" policy revised January 2009 revealed "...14. Before administering medications, the following items are verified: e. Right patient, right dose, right route, right time and right dosage form."

Review of the "Medication Use Process" policy revised November 2010 revealed "... Routine medications should be administered as designated by the Standard Medication Administration Time (SMAT)." Review of the standard medication administration time for tid (three times a day) is 0900, 1600 and 2200.

Closed record review on 01/26/2011 of Patient #2 revealed a [AGE] year-old male admitted [DATE] with L3L4 spinal stenosis, L4L5 right lateral recess stenosis, multi level degenerative disk disease and spondylosis. Review revealed the patient had an L3L4 bilateral microlaminotomy and L4L5 right-sided microlaminotomy (surgical procedure) performed under general anesthesia on 07/20/2010 (day of admission). Review of physician's medication orders revealed an order written by a Nurse Practioner (NP #5) on 07/20/2010 at 1459 for "Neurontin (medication for neuropathic pain) 300 mg (milligrams) po (by mouth) tid (three times a day)." Review of the medication administration record (MAR) revealed the patient was administered Neurontin 300 mg po on 07/20/2010 at 2132 and 07/21/2010 at 0818. Review of physician's orders revealed an order written by the nurse practioner on 07/21/2010 at 0900 for "Neurontin 900 mg po tid." Review of the MAR revealed the patient was administered Neurontin 900 mg po on 07/21/2010 at 0900. Review of the MAR revealed the patient received a total of 1200 mg of Neurontin during the 0900 administration time on 07/21/2010. Review of the record revealed no physician's order for 1200 mg of Neurontin to be administered.

Interview on 01/27/2011 at 1255 with the Director of Pharmacy revealed the nurse had made a medication error. Interview revealed the physician's order for Neurontin was changed from 300 mg to 900 mg three times a day on 07/21/2010. Interview revealed standard administration times for three times a day would be at 0900, 1600 and 2200. The pharmacist stated the nurse had already administered 300 mg at 0818 for the 0900 dose and she should have given an additional 600 mg at 0900 to total the 900 mg ordered rather than the total of 1200 mg she administered. Interview revealed the medication error had not been identified until the interview.
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, drug information review, closed medical record review, incident report review, grievance file review, investigative summary review, medication error report review and staff interviews, the pharmacy department failed to ensure
home medications and dosages were correctly identified prior to administration of medications for 1 of 8 sampled records reviewed (#2).

The findings include:

Review of the "Medication Reconciliation Process" policy revised 06/01/2009 revealed "Patients admitted to (named hospital) shall have a medication review and reconciliation performed upon admission/entry, at the time of transfer to a different level of care or service, and at the time of discharge. A comparison of the patient's home medications with those prescribed at (named hospital) will be conducted to ensure quality of care and patient safety regarding medication use. This review will assist in avoiding medication errors such as omissions, duplications, dosing errors or drug interactions. The medication review will be a collaborative initiative between prescribers and other health care providers as appropriate. At the time of entry to the inpatient setting at (named hospital), the review will consist of home medication list compilation and a pharmacist reconciliation of the patient's home medications versus the admission medication orders.... At the time of entry to the outpatient setting at (named hospital), a home medication list will be compiled. The home medication list will be reviewed and reconciled versus medications planned to be administered.... III.A.2. Pharmacy Medication Reconciliation Technicians (PMRTs) will receive the admission notifications and arrange to interview the patient, appropriate family member, or caregiver. Other healthcare professionals may also assist with the collection of a home medication list, including prescribers who will document the information in the History and Physical. B.1. The PMRTs will obtain a home medication list based upon the interview, medication container labels (as provided), consultation with local pharmacies, and any other means necessary.... 2. PMRTs will contact patients by phone who are scheduled for elective admission no greater than 30 days in advance. 3. The current home medication list will be entered into Centricity (electronic medical record system), the home medication list can be viewed in the Carecast and John Gault electronic medical records.... 5. The Centricity medication list may be updated by a healthcare provider. 6. A reasonable attempt will be made to obtain necessary information in order to construct an accurate and complete home medication list.... C.1. Prescribers may verify the home medication list by indicating whether the medication is to be continued or held/modified upon admission. 2. Documentation of this verification may occur in Centricity or may be included in the dictated History and Physical (H&P) and will be available to be viewed as a transcript in Carecast. D.1. Pharmacists will reconcile the patient's home medication list with the medications ordered upon admission. 2. Admission medications will be compared to the home medication list and/or available prescriber documentation to ensure accuracy and consistency. 3. Documentation of reconciliation activities will occur in Carecast. Pharmacists will document reconciliation activities as either 'Reconciled' or 'reconciliation Pending.'... b. 'Reconciled' indicates that all known clinically significant discrepancies, if present, have been clarified...."

Review of drug information provided by the pharmacy department on 01/27/2011 revealed "MS Contin (narcotic medication for pain) Adult Dosing ... 100 mg (milligram) and 200 mg capsules are for use only in opioid-tolerant patients.... Precautions ... opioid-intolerant patients; high dosage strengths should not be used; increased risk for fatal respiratory depression...."

Closed record review on 01/26/2011 of Patient #2 revealed a [AGE] year-old male admitted [DATE] with L3-L4 spinal stenosis (narrowing of the spinal canal), L4L5 right lateral recess stenosis, multi level degenerative disk disease and spondylosis (degenerative arthritis of the spine). Review revealed the patient had an L3-L4 bilateral microlaminotomy (surgical procedure of the spine) and L4-L5 right-sided microlaminotomy performed under general anesthesia on 07/20/2010 (day of admission).

Review of a "Home Medication List" signed by Pharmacy Tech #1 (pre-operative assessment clinic) on 07/12/2010 at 1432 revealed a list of ten medications that included "Morphine Sulfate (Morphine Sulfate CR 200 mg XR12H-TAB) (MS Contin 200 mg) one by mouth two times a day (every 12 hours)." Further review of the home medication list recorded "Changes to Medications: ... Added Morphine Sulfate CR 200 mg XR12H-TAB (MS Contin 200 mg) ..."

Review of a "Preop/PAC History and Physical" form dated 07/15/2010 revealed the patient presented for a preoperative assessment prior to the scheduled surgical procedure. Review revealed a pre-anesthesia evaluation was recorded. Review of the assessment form revealed "Current Medication Homegoing Instructions" with "Morphine Sulfate Cr 200 mg XR12-H-TAB (MS Contin 200 mg) one by mouth two times a day (every 12 hours) Instruction: take as usual." Further review revealed no documentation that the patient brought in pill bottles (or other information) to verify home medications or dosages. Review of the electronic documentation revealed the assessment was signed by a registered nurse on 07/15/2010 at 0922 and signed by an anesthesiologist (Physician A) on 07/15/2010 at 0810.

Review of an "Anesthesia Case Record Holding Room Document" signed by RN #2 on 07/20/2010 at 0610 revealed "Regular Medications ... Morphine Sulfate Cr 30 mg XR 12-H TAB (MS Contin 30 mg)." Review revealed a change recorded in the home medication dosage of MS Contin from 200 mg to 30 mg. Review of the electronic documentation revealed the information was recorded electronically in the hospital's "John Gault Systems." Further review revealed no documentation that the patient brought in pill bottles (or other information) to verify home medications or dosages.

Review of "Reconciliation Documentation" dated 07/21/2010 at 0840 revealed Pharmacist #3 "reconciled" the patient's medication (1 day after admission).

Review of a "Home Medication List" signed by Pharmacist #4 dated 07/26/2010 at 0844 revealed "Clinical Date: 07/23/2010 at 1632 Source of Information: PA (Physician Assistant) from 2SB (orthopedic unit where patient was located) Home Medications: ... Morphine Sulfate (Morphine Sulfate CR 200 mg XR12H-TAB) (MS Contin 200 mg) one by mouth two times a day (every 12 hours) ... Other Comments: MS Contin dose corrected after this entry." Review of the electronic documentation revealed a new "Home Medication List" that included "Morphine Sulfate (Morphine Sulfate CR 30 mg XR12H-TAB) (MS Contin 30 mg)."

Review of physician's medication orders revealed an order written by a Nurse Practioner (NP #5) on 07/20/2010 at 1459 for "Morphine Sulfate 200 mg SR TAB (MS Contin) po (by mouth) Q12H (every 12 hours). Review of the Medication Administration Record (MAR) revealed the patient was administered MS Contin 200 mg on 07/20/2010 at 2132, 07/21/2010 at 0818 and 2008 and on 07/22/2010 at 0935. Review revealed on 07/22/2010 at 2000 the MS Contin was "held" because the "patient unable to arouse." Review of a nursing note dated 07/22/2010 at 2100 revealed "Patient was found in patient's bed being difficult to arouse and shallow breathing. Patient very somnolent, decreased O2 sats (oxygen saturation), not oriented person, place or time, pupils equal and reactive +1, and incontinent of bowel and bladder. Patient's lungs sound clear, but diminished. Patient was placed on 4LNC (4 liters of oxygen via nasal cannula), elevated HOB (head of bed), Rapid Response notified at bedside..." Review of the record revealed the Rapid Response Team was notified on 07/22/2010 at 2100 that the patient was having "difficulty breathing." Review of the Rapid Response Team nursing notes revealed the patient had respiratory depression and decreased oxygen saturation. Review revealed oxygen and Narcan (opioid reversal medication) were administered and the patient was stabilized. Review of a physician's progress note dated 07/22/2010 at 2135 revealed "Called to evaluate patient for decreased mental status, low SPO2 (oxygen saturation) on RA (room air) 69%. Patient somnolent, but arousable.... SPO2 89% on 5L O2 NC. Patient incontinent of urine, gown soiled. Responds to commands, deep stimulus... unable to move RLE (right lower extremity)... Patient given 2 mg IV (intravenous) Narcan with immediate return of mental awareness and SPO2 increased to 98% on 2LNC... likely oversedated..." Review of a physician's Discharge Summary dictated 07/24/2010 revealed "Hospital Course: The patient was brought to the OR (operating room) on July 20, 2010 and subsequently underwent the procedures as listed above. The patient tolerated the procedure well. He was awakened and transported to PACU (post anesthesia care unit) in stable condition before being transferred to the floor for observation. Once reaching the floor, the patient was doing well, up and tolerated as well as given a corset for comfort while awake and up. However, once on the floor pain control was an issue, so he was started on his home dosage of pain medications per his reconciled med list. On postop day 2, the orthopedic team was consulted around 2135 due to decreased altered mental status and low SPO2 on room air of 69% and only increasing to 89% on 6 liters oxygen via nasal cannula. Rapid Response was called. Upon arrival to the room, the patient was examined and the decision was made to administer Narcan, which quickly reversed his symptoms, and his SPO2 quickly rose to 97-98% on 2L.... Immediately following the event, the patient was complaining of inability to move his right leg, thus Neurology was consulted to rule out CVA (stroke). In brief, Neurology came and examined the patient but they believed that this altered mental status was most likely due to improper analgesic, his RLE weakness is mostly likely due to his spinal cord pathology...." Record review revealed the patient was discharged home on 07/27/2010.

Review of an "Event Report" recorded by NP #5 on 07/23/2010 at 1609 revealed "Patient home medication rec (reconciliation) stated patient was on 200 mg of MS CR (MS Contin) every 12 hours. I prescribed that dose due based on his home medication list. Patient was over narcotized and required a dose of Narcan. He had right sided weakness and neurology consult had to be called to rule out stroke. All narcotics were stopped. Patient is on 20 mg of MS CR NOT 200 mg MS CR." Further review revealed "Recommendations for system improvement to prevent recurrence: Triple check home med reconciliation and ask patient about home medication list multiple times.... Cause of Medication Error: Home medication reconciliation incorrect." Review revealed the medication error was referred to pharmacy to review. Review of the documentation of the pharmacy review revealed "Policies and procedures unclear or ambiguous... What was done to remedy the situation or reduce its likelihood for recurrence? Policies and procedures, referred issue to medical leadership or administrative."

Review of a grievance submitted by Patient #2 on 07/26/2010 revealed the patient "expressed concern regarding his being given double the amount of medication that he was suppose to receive. He stated that he brought his pill bottles and written meds into the clinic and pre-op where they took the information. The patient's information stated he was to take 30 mg of Morphine every 12 hours and following his surgery he was given 200 mg...." Review of follow-up revealed "The Medication Safety Committee is looking into this issue and is reporting back to (Chief Medical Officer) and other administration with their findings."

Review of an "Investigative Summary" revealed documentation dated 09/14/2010 at 1731 that recorded "The patient reported he was taking 200 mg of MS Contin twice a day when pharmacy contacted him to get home med info. This is not an unusual dose of this med and it is actually made up in this dose. This occurred because the patient reported the wrong dose." Review of the investigative notes dated 07/23/2010 recorded "Summary of conversation with (NP #5): (NP #5) advised that she had seen doses this high in chronic pain patients and that (Patient #2) is a VA patient so she accepted it without checking further. They found out later that the dose on the home medication reconciliation was incorrect and he was prescribed for 10 times the dose he receives at home. Staff responded appropriately and called Rapid Response. We just figured out what happened this evening. ((Pharmacy Tech #1) was the pharmacy tech who did the home med reconciliation." Review the investigative notes dated 09/14/2010 recorded "Summary of conversation with (Pharmacist #4): It is common to call prior to surgery to get a list of meds from the patient. If we had the bottles, we would have looked at them, but in this case we got the meds and doses verbally from the patient. He reported he was taking 200 mg of MS Contin twice a day. This is not an unusual dose of this medication and it is actually made up in this dose. When neurology was consulted we found that he was actually on a 30 mg dose rather than 200 mg. This occurred because the patient reported the wrong dose. This is still an agenda item for the medication reconciliation group to decide if changes need to be made to the system for gathering home medication info." Further review of the report revealed "PA (Physician's Assistant) educated on controlled substances" dated 08/19/2010. Review of the summary revealed Pharmacy Tech #1 called the patient on 07/12/2010 to gather a list of the patient's current home meds. Review revealed MS Contin 200 mg every 12 hours was a new medication that was added to the patient's home medication list and recorded in the Carecast electronic medical record. Further review revealed "It is the responsibility of the physician or PA to review the home medication list of the patient during the pre-operative assessment visit and to dictate and document instructions for each home medication based on the patient's assessment and procedure or surgery scheduled." Review revealed the patient was evaluated by Physician A and instructed to take his MS Contin 200 mg "as usual" during the pre-operative visit on 07/15/2010. Notes revealed that the patient presented for surgery on 07/20/2010 and orders were written for MS Contin 200 mg every 12 hours. Review revealed the patient received 4 doses of MS Contin as ordered and on 07/22/2010 experienced a respiratory event requiring Narcan to reverse the effects of narcotic medication. Review revealed that the MS Contin was changed to 30 mg every 12 hours on 07/23/2010. Further review of the notes revealed "In review of the holding room documentation (John Gault System) created prior to the 07/20/2010 surgery, it shows the home medication list regarding the Morphine Sulfate to read 30 mg XR 12H-TAB. It is believed that changes made after the fact in the home medication list of a patient are drafted into previously completed documents in the John Gault System.... (Physician A) advised that she is an intern (started July 2010) and that at the time of (Patient #2's) visit she probably would not have noted that the 200 mg Morphine Sulfate BID (twice a day) might have been excessive."

A medication error report (not dated or signed) and reported by administrative staff as presented to Quality Management on 09/15/2010 regarding Patient #2's medication error of receiving an overdose of MS Contin was (MDS) dated [DATE]. Review of the report revealed "Potential Root Cause: There were multiple failures related to this error. Patient incorrectly communicated his home medication list. In the absence of any indication that the patient was a poor historian, the technician would not seek to verify the information as part of the normal process. The NP did not question the dose. The pharmacists did not question the dose. Possible over-reliance on the HML (Home Medication List)? Note: MS Contin 200 mg is not an uncommon dose for many patients. It is commercially available in a 200 mg tablet, so one still wouldn't question upon order entry. For patients on ortho, it is recognized that this dose is not beyond the dose that some folks might be on, if you were in chronic pain, etc. This medication error has been discussed in multiple teams, including the Centricity/Med Rec team, as well as the Pharmacy Medication safety Team. Thus far, a single failsafe for future prevention has yet to be identified."

Interview on 01/27/2010 at 0945 with Pharmacy Technician #1 revealed she worked in the pre-operative assessment clinic and had called the patient on 07/12/2010 to obtain a list of his home medications. Interview revealed the staff member records the list of medications into the electronic medical record while she is talking with the patient on the telephone. The staff member stated the home medication list already exists from prior clinic or hospital visits and she updates the list based on the patient's current medications. The staff member stated she asks the patient to read from their list or from the medication bottles. Interview revealed Morphine was added to the patient's list based on the telephone conversation on 07/12/2010. The staff member stated she prints the list and the anesthesiologist reviews the home medication list the next day when the patient comes in for their pre-operative clinic visit. The staff member stated the patient is told to bring their medication bottles to the clinic visit. Interview revealed the patient also received printed instructions that request that home medications should be brought in for review.

Interview on 01/27/2010 at 1220 with the nursing manager of the Pre-operative clinic where the patient (MDS) dated [DATE] revealed the nursing staff member and Physician A who provided care to the patient on 07/15/2010 were not available for interview. Interview with the manager revealed the patient's home medication list electronically updated on 07/12/2010 was used for review by the anesthesiologist (Physician A) to record patient instructions for medication prior to surgery. Interview revealed the electronic system for each of the home medications was defaulted to "take as usual." Interview revealed the staff member was unable to tell if the anesthesiologist reviewed the patient's home medication list for MS Contin because it was listed "take as usual." Interview revealed there is not documentation regarding the patient bringing medication in and she was unable to tell if that was done. The staff member stated "Patients are usually told not to bring in meds on the day of surgery, except inhalers." Interview further revealed that the home medication list from the pre-operative clinic visit on 07/15/2010 should "carry over" to the holding room list (dated 07/20/2010).

Telephone interview on 01/27/2010 at 1330 with RN #2 revealed she worked in the Pre-operative holding area where Patient #2 presented prior to surgery on 07/20/2010. Review revealed the nurse remembered the patient. The nurse stated "The first thing I do is to find out what medication took the morning of surgery. Then I ask them what their regular medications are. I compare that with the list that is already done in the outpatient clinic. When I saw the difference in the MS Contin dose, from 30 mg to 200 mg, I notified the Pharmacy Tech who was suppose to change it in the system."

Interview on 01/27/2010 at 1015 with Pharmacist #4 revealed she became involved with this patient on 07/23/2010 when the orthopedic nurse practioner (NP #5) called her to notify her about the medication incident. The staff member stated the nurse practioner told her that she had prescribed the MS Contin dose based on the home medication list and the list was incorrect. The staff member stated the patient had an adverse event and that she corrected the MS Contin from 200 mg to 30 mg on the home medication list on 07/23/2010. Interview revealed "someone from the ortho team contacted the VA and got his correct MS Contin dosage from the VA records. I did not verify any other home medications after this incident." The pharmacist stated that she was the coordinator of the Medication Safety Medication Reconciliation Oversight Committee. Interview revealed the committee had discussed and reviewed the process during committee meetings. Interview further revealed there were no meeting minutes kept during these meetings. Interview revealed the outcome of the review of this adverse event was that "multiple steps in the process failed." The pharmacist further stated that "The process seems to be a sound process. The process failed this patient. I feel confident that it would not happen as long as home information is obtained." Interview revealed Pharmacy Technician #1 followed the process for medication reconciliation correctly. The pharmacist stated the patient was seen by the nurse and anesthesiologist in the pre-op clinic and medications were reviewed. The patient was admitted on [DATE] and admission orders were placed by the nurse practioner. A pharmacist compared the home medication list and nurse practioner orders for reconciliation on 07/21/2010 and the pharmacist reconciled the medications. The pharmacist stated "The prescriber is responsible for reviewing the home medication list and ordering. I don't recall if the home medication list was documented as reviewed by the prescriber." Interview revealed there was no concern with the reconciliation or medication dosages prescribed. Interview revealed the Medication Reconciliation Oversight Committee had not reached a final conclusion regarding this event and "no action had been taken due to still evaluating this situation." Interview confirmed there had been no policy changes related to home medication lists since this event on 07/22/2010.

An attempt was made to interview NP #5 and the patient's surgeon on 01/27/2010. Both were not available for interview.

Interview on 01/27/2010 at 1255 with the Director of Pharmacy Services revealed the patient came to the pre-operative clinic on 07/15/2010 and Physician A reviewed the home medication list. The pharmacist stated Physician A had only been at the hospital for two weeks at that time. The pharmacist stated "She saw the meds and did not question them. Per interview the nurse practioner saw the meds and did not question them due to chronic pain patient. She felt the dose was appropriate. The nurse practioner placed an order (for MS Contin 200 mg every 12 hours) and the pharmacist verified the order. There was no reason to question the dose or to think that the patient was a poor historian. After the event, the nurse practioner called the VA and found that the patient's home dose was 30 mg every 12 hours. She called Pharmacist #4 who made the changes to the home medication list on 07/23/2010. All information was turned over to the Medication Reconciliation Team for review. Interview confirmed no meeting minutes existed for the Medication Reconciliation Team. Interview further revealed an investigation had been conducted and findings presented to Quality Management on 09/15/2010. Interview revealed no changes had been made to policies or processes because the findings were "human error."

Interview with administrative staff on 01/27/2010 at 1300 revealed administration was aware of "problems" resulting from having three different electronic medical record systems to record patient information. Interview revealed the information does not always "populate" from one system to another. Interview revealed that the change in MS Contin dosage (30 mg) recorded by the nurse on 07/20/2010 was made in the John Gault System. Interview revealed that the information in the John Gault System cannot be seen in the Carecast System. Interview revealed administration has plans to fix these systems in the next two years.

Administrative staff were asked for any evidence of physician or staff education provided as a result of this adverse event. Any meeting minutes or actions taken as a result of this event were requested. No evidence was provided.

Consequently, a pharmacy technician listed an inaccurate narcotic dosage on Patient #2's home medication list during a pre-operative phone call on 07/12/2010. An anesthesiologist failed to assure the accuracy of the narcotic dosage during a pre-operative clinic visit on 07/15/2010. Nursing staff correctly identified a change in the patient's narcotic dosage (MS Contin 30 mg every 12 hours) on 07/20/2010 and documented the change in the patient's home medication list in the John Gault electronic medical record system. Nursing staff communicated to a pharmacy technician to correct the narcotic dosage in the Carecast electronic medical record system because the systems do not integrate information. Review revealed the changes were not made prior to surgery to the patient's home medication list in the Carecast system. A Nurse Practioner ordered narcotic medication based on the patient's home medication list (MS Contin 200 mg every 12 hours). Pharmacy staff reconciled the medication orders with the home medications on 07/21/2010. Patient #2 was administered medication as ordered and was found with depressed respirations and decreased mental status on 07/22/2010. Rapid Response was called and Narcan was administered with immediate response. The hospital's pharmacy department failed to have systems in place to ensure home medications and dosages were accurately identified, verified and reconciled prior to administration of the medication.
VIOLATION: RESPIRATORY CARE PERSONNEL POLICIES Tag No: A1161
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on Respiratory Therapy Department Policy review, closed record review and staff interviews the Respiratory Therapy Department failed to ensure staff were in-serviced on Respiratory equipment brought in from a patient's home for 1 of 2 record reviews of patients with BiPAP systems (#3).

The findings include:

The Respiratory Care Department policy with last revision date of 02/08/2008 entitled Home Care and Diagnostic Equipment supplied by outside agencies and home care equipment for use on hospital inpatients revealed "Policy: (Named hospital) requires that appropriate safety testing and in-service education be provided for equipment that the Respiratory Care Department is responsible for; that is supplied by outside vendors (rentals/demonstration, evaluation equipment) or patients' home care equipment for use in the hospital."

Closed record review of patient #3 showed the patient was admitted on [DATE] at 1517 for a complaint of right jaw swelling. The patient had been seen by dental services and was scheduled for a exploratory procedure on 09/15/2010. The patient also had a history of [DIAGNOSES REDACTED], Spinal [DIAGNOSES REDACTED] and was a Quadriplegic. The patient had brought in his home BiPAP system that he uses continuously to provide assistance with breathing.

On 09/14/2010 at approximately 2130 the Respiratory Therapist came into patient #3's room to check his BiPAP machine. After telling the patient of his intentions he proceeded to check the machine. At that time the patient complained of not being able to breath, accusing the Respiratory Therapist of shutting off the machine. Documented hospital investigations as well as interview with the Respiratory Therapist on 01/27/2011 at 0915 indicated the Therapist denied shutting off the BiPAP machine. This interview also revealed that the patient's home BiPAP machine (a Sullivan VPAPII sta) was not the same as any BiPAP machines currently used by the hospital. This same interview revealed the Therapist had not had any in-service on the patient's machine prior to doing checks on the machine. Review of the Therapists education documentation indicated no in-service had been provided on this particular machine, although the therapist had been inserviced on BiPAP machines used by the hospital.

Interview with the Respiratory Therapy Department manager on 01/27/2011 at 0915 confirmed the named Therapist had not been specifically in-serviced with the type of BiPAP machine the patient had brought in from home.