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Based on interviews and record reviews the facility failed to ensure medication reconciliation was completed accurately so accurate medications were administered to a patient (Patient #1).

This failure resulted in an adverse patient outcome from the wrong medication being prescribed and administered to a patient.



According to the facility policy Medication Reconciliation the Registered Nurse (RN) documents a complete list of all medications the patient is currently prescribed. For each medication the patient was taking prior to admission , the physician or physician extender will designate if the medication will be continued or discontinued.

Generic name: Guanfacine
Brand name: Tenex
Treating high blood pressure.

Generic name: Guanfacine
Brand name: Intuniv - extended - release tabs (ER)
Treating attention deficit hyperactivity disorder

1. The facility failed to ensure the nursing staff completed an accurate medication list so correct medications were prescribed and administered.

a) A review of Patient #1's medical record was conducted and revealed documentation of medications the patient was currently prescribed. The Admission Orders and Medication Reconciliation form completed by Registered Nurse #10 (RN) listed Guanfacine (Tenex), a high blood pressure medication. The order form was signed by Physician #12 with no corrections identified. There was no evidence the patient's pharmacy was called to verify his/her current medications.

A review of a medical record, presented to the facility by Patient #1's parent, revealed a past medication list from a recent emergency room visit that showed the medication Guanfacine (Intuniv) extended release (ER) 4 mg tablet every 24 hr as a current medication the patient received.

This was in contrast with the current medication ordered by the facility of Tenex.

According to the Medication Administration Record (MAR), dated 05/13/17, Patient #1 was given a dose of Tenex 4 milligrams(mg) by mouth at 8 p.m.

A subsequent entry on 05/14/17 at 8 p.m. showed the patient's Tenex 4 mg was held due to a low blood pressure (BP) of 96/48. The patient's admitting blood pressure was 111/56.

On 05/15/17 the Nurse Daily Assessment Sheet showed documentation Patient #1's parent was contacted to clarify prescription medications. The parent arrived at the facility on 5/15/17 at 10:50 a.m. with medication bottles in hand which showed the patient was on Guanfacine (Intuniv) ER and not Guanfacine (Tenex).

b) An interview was conducted on 08/08/17 with RN #1 at 3:03 p.m., who reported when completing the Admission Orders and Medication Reconciliation form the list of medications was developed from information obtained from the patient or the pharmacy. S/he stated a call was always placed to the patient's pharmacy to verify medications and the phone call would be documented in the patient's chart.

c) A interview was conducted with RN # 3, on 08/09/17 at 9:23 a.m., who reported when completing the Admission Orders and Medication Reconciliation form the medication list was gathered from various sources. According to RN #3, the facility could review the medical record sent from the referring facility, call the pharmacy the patient used to get a list of the most recent medications prescribed for the patient, and find out if the medications were extended release or immediate release. RN #3 stated this process was used because family was not always considered an accurate source. The RN would then document on the Nursing Assessment form with whom the medications were reviewed.

d) An interview was conducted on 08/08/17 at 3:52 p.m. with Pharmacist (RPh) #2 who reported Guanfacine was available in 2 forms, immediate release(IR) and extended release(ER). The extended release medication was used for ADHD. RPh #2 stated that if the IR was used instead of the ER the most common symptom would have been a decrease in the patient's blood pressure. RPh #2 stated s/he remembered Patient #1 and the order for the Guanfacine was transcribed wrong in the chart. Patient #1's parent was called and asked to read the medication off of the bottle and the parent brought in the bottle to the facility later that day.

e) During an interview, on 08/09/17 at 12:30 p.m., Director of Nursing (DON) #4 stated s/he expected the nurse to review the past medical record and complete history, review the referral paperwork, ask the family or patient, and call the patient's pharmacy for medication reconciliation. DON #4 reported all nurses in the facility were trained on the medication reconciliation process. DON #4 reported that Patient #1 had gotten a dose of the wrong medication; Guanfacine (Tenex) instead of Guanfacine ER (Intuniv).

There was no documentation in the medical record to show the admitting nurse contacted the patient's pharmacy or reviewed the prior medical records for completion of the Admission Orders and Medication Reconciliation form.
Based on interviews and record review the facility failed to ensure staff filled out an incident report for missed doses of medication and the use of a medication incorrectly (Patient #1).

This failure resulted in a patient not receiving the full intended effects of a medication that was administered and not receiving the medication as prescribed.



According to the Medication Errors policy, medication errors will be investigated. An error is defined as an omission of any dose not given, wrong drug, wrong dose, and an occurrence report will be prepared by the nurse or the pharmacist.

According to the Medication Variance policy a medication variance is defined as any preventable event which may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care profession.

According to the Medication Discrepancies and medication errors policy in the event of a medication error, immediate action shall be taken, as necessary, to protect the safety of the patient involved.

1. The facility failed to ensure nursing and/or pharmacy staff filled out an incident report on all medication errors to allow for investigation of the error.

a) Record review of Patient #1' medical record revealed there had been 5 medication errors. One error had a incident report which was completed on 05/17/17, but the other 4 medication errors showed no evidence an incident report was completed. As example:

On Saturday 05/13/17, Tenex 4 mg at bedtime (a medication that is used to treat high blood pressure generic name: Guanfacine Hydrochloride) was prescribed and administered to Patient #1 who did not have a documented diagnosis of high blood pressure.

Patient #1 had been prescribed, by his/her primary physician, a medication called Intuniv (generic name: Guanfacine ER) which was used to treat Attention Deficit Hyperactivity Disorder which was a documented diagnosis. The patient's admitting blood pressure was 111/56 and after being given Tenex 4 mg the patient's blood pressure dropped to 96/48.

b) An interview was conducted on 08/09/17 at 10:52 a.m., with Pharmacist (RPh) #2 who reported that medication errors were to be reported so they could be investigated. RPh #2 stated administering an immediate release blood pressure medication like Tenex could cause a patient to become dizzy and develop low blood pressure. S/he confirmed that Patient #1 received too large of a dose of medication all at once. RPh#2 stated s/he found the medication error on the following Monday 05/15/17.

RPh #2 reported s/he did not remember filling out an incident report and s/he expected the nurse to do the report because the nurse spoke with the patient's parent about the correct medications.

In addition to the wrong medication being prescribed and administered (Tenex instead of Intuniv), Patient #1 also received the following medications in error:

On 05/13/17 Invega (generic name: paliperidone) 1.5 mg by mouth (po) daily was prescribed. An extended release 3 mg tablet was cut in half and administered to Patient #1.

On 05/14/17 Invega 1.5 mg by mouth daily was prescribed for Patient #1. An extended release 3 mg tablet was cut in half and was given to Patient #1.

RPh #2 stated cutting a 3 mg extended release medication changed the form to an immediate release medication and was considered a medication error.

On 05/15/17 a dose of Invega 1.5 mg by mouth daily was scheduled to be given at 8:00 a.m., the medication administration record was blank for the 8:00 a.m. documentation space. This was considered a medication error.

c) An interview was conducted with Director of Nursing (DON) #4 on 08/09/17 at 12:02 p.m., who reported giving a dose of a wrong medication (Tenex instead of Intuniv) was definitely a medication error and an incident report should have been completed.

According to DON #4 the staff were likely told by either the physician or nurse practitioner to cut the extended release medication in half and give it to Patient #1. S/he reported that was considered a medication error, yet no evidence of an incident report could be found.

DON #4 reported that if a dose of medication was not given as prescribed it was considered a medication error. The expected process for nursing staff was to complete an incident report by the nurse who omitted the dose.