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UPMC ST MARGARET 815 FREEPORT ROAD PITTSBURGH, PA 15215 March 17, 2015
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure their policy related to physician notification of and documentation related to unusual patient events in the medical record was followed for three of 12 medical records reviewed (MR3, MR5 and MR9).

Findings include:

Review of facility policy "Medication Event: Reporting, Documentation, and Evaluation", Policy : HS - NA0404, Nursing, dated September 8, 2014, ... . IV. Definitions A. "Medication Events": Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer. ... . Section VI. Procedure A. Notification: 1. If a medication event or adverse drug reaction reaches the patient, ... attending physician must be notified. When attending ... not available, notification to the covering physician must occur. Notification will be documented in the medical record. 2. ... . Documentation: The medication event or adverse drug reaction, as well as notification of the physician(s) is to be documented in the medical record.

1. Review of MR3 on March 16, 2015, at 11:00 AM revealed that the patient was administered Heparin Subcutaneously on February 11, 2015, at 4:00 PM after receiving Lovenox 70 mg in the Emergency Department at 2:00 PM.
There was no documentation in the medical record regarding the medication error, and there was no documentation that the physician was informed of the medication error for MR3.
During an interview on March 16, 2015, at approximately 2:00 PM EMP2 confirmed that there was no documentation of the medication error as required by facility policy.
2. Review of MR5 on March 17, 2015, at 11:45 AM revealed the patient received five (5) incorrect doses of Oseltamivir beginning on December 9, 2014 at 9:00 PM.
There was no documentation in the medical record regarding the medication error, and there was no documentation that the physician was informed of the medication error for MR5.
During an interview on March 17, 2015, at 11:50 AM EMP3 confirmed that there was no documentation that the medication error occurred or that the physician was notified of the error for MR5.
3. On March 16, 2015, at approximately 2:30 PM review of MR9 revealed the patient was ordered a Heparin drip during an inpatient stay in October 2014.

Review of a medication event report related to this patient revealed that nursing staff identified the patient's rate of heparin infusion should have been changed per protocol on October 10, 2014, based on a lab result received at approximately 4:48 AM. There was no documentation in the medical record that the rate of the infusion was adjusted per protocol.

There was no documentation in the medical record related to the discovery of the missed medication rate adjustment or notification of the physician about the same.

On March 17, 2015, at approximately 10:00 AM EMP2 confirmed the above information.