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.

RED RIVER BEHAVIORAL HEALTH SYSTEM 1451 44TH AVENUE S GRAND FORKS, ND Oct. 10, 2012
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, review of professional literature, policy and procedure review, review of drug handbook, review of manufacturer's instructions, review of medication error reports, record review, and staff interview, the Hospital failed to ensure supervision of nursing services by failing to ensure nursing staff implemented a system to confirm the identity of hospitalized patients throughout their hospital stay (Refer to A395); failing to evaluate the safe use of side rails and consider side rails as a potential entrapment and safety hazard, assess each patient individually prior to utilizing side rails, provide education to the patient and responsible party regarding the potential hazards of side rail use (Refer to A395); failing to follow infection control practices regarding disinfection of the glucometer (Refer to A395); and failing to follow accepted standards of practice for medication administration (Refer to A405). Failure to ensure adequate delivery of nursing care places the Hospital patients at risk of receiving improper care, risking patient safety.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
1. Based on observation, record review, review of professional literature, review of policy and procedure, and staff interview, the Hospital failed to ensure nursing staff implemented a system to confirm the identity of hospitalized patients by failing to have a means of identification on patients throughout their hospital stay on three of three days of survey (October 8-10, 2012). Failure to ensure a means of identification placed the patients at risk of improper care or treatment, therefore, risking patient safety.

Findings include:

Berman, Snyder, Kozier, and Erb, "Fundamentals of Nursing, Concepts, Process, and Practice," 8th ed., Pearson Education Inc., Upper Saddle River, New Jersey, 2008, page 712 stated, ". . . Client safety problems can include a variety of errors such as . . . mistaken identity . . ."

Beyea's "Patient Identification: A Crucial Aspect of Patient Safety-Patient Safety First," AORN (Association of Perioperative Registered Nurses) Journal, dated September 2003, stated, ". . . Concern for proper patient identification is evidenced in the 2003 National Patient Safety Goals. One of the six identified goals is to improve the accuracy of patient identification. . . . This basic ritual and routine is integral to the medication administration process . . . All clinicians need to be concerned with the processes and systems that support correct identification of patients. . . . The importance of this basic practice cannot be minimized. No assumptions about identity can be made. Every clinician providing care for the patient must make it a routine practice to verify identity. . . . a patient has the right to be identified correctly."

Review of the policy "Patient Identification Policy - Patient Safety" occurred on 10/10/12. This policy, revised/reviewed on 07/25/11, stated, "This policy defines the types of patient identification that are to be used when administering medications, taking blood samples or conducting procedures. . . . It is the policy of RPSPC [Richard P. Stadter Psychiatric Center] to reliably identify patients for whom medications are administered, blood samples are taken, or procedures are performed. . . . For the purposes of identification, a name band will be applied to each patient's wrist upon admission which includes patient name and birth date. A photo is taken as well. Both of these tools will be used for comparison with chart documentation, medication labels, etc. for confirmation of correct patient. . . . Licensed nurse: Responsible for correctly identifying the patient when administering medications by using two patient identifiers. . . . Admission coordinator: Responsible for applying name band . . . on admission. (RN [Registered Nurse] assumes responsibility when Admission staff not on duty) . . ."

- Observation of medication pass occurred on 10/08/12 at 5:05 p.m. in the dining room of the adult nursing unit. A nurse (#2) stated she was new to the hospital and didn't know the patients as it was her second day. The nurse (#2) administered oral medications to Patient #2 without verifying the patient's identity prior to administration. Patient #2's wrists lacked an identification band to ensure proper identification of the patient. Moments later, the nurse (#2) stated, "Who's [first name of patient]?" to an unidentified staff member serving food in the dining room. The unidentified staff member pointed to Patient #2 and the nurse (#2) administered the patient additional oral medications without verifying the patient's identity prior to administration.

- Observation of medication pass occurred on 10/09/12 at 8:05 a.m. and showed a nurse (#3) delivering medications to patients in their rooms. The nurse (#3) administered oral medications to three different patients (Patient #4, #19, and #21) without verifying the patients' identities prior to administration. Patient #4, #19, and #21's wrists lacked an identification band to ensure proper identification of the patients and observation of the patients' rooms lacked any means to identify the patients.

- Observation of medication pass on the geriatric unit occurred on the morning of 10/09/12. A licensed nurse (#7) stated she was new to the hospital and had worked "a couple of weeks." The nurse stated she had not worked at the hospital recently and stated she did not know the current patients. The nurse (#7) brought the patients' pre-filled medication cups into the dining room to administer to each patient. For each patient, the nurse asked a staff member serving food in the dining room to point out the patient to her prior to giving the medication. The nurse (#7) did not ask the patients to state their name. The patients' wrists lacked identification bands to ensure proper identification.

During an interview on the afternoon of 10/09/12, a nurse (#3) stated she did not confirm some of the patient's identities before medication administration because she knew them. The nurse (#3) stated staff used the patient picture in the MAR or patient belonging bag (located in the patient room at the bedside), which included the patient's name, to identify the patient.

During an interview on 10/10/12 at 10:25 a.m., a nurse (#5) stated the Hospital no longer utilized namebands on patients for identification purposes as the patients wouldn't keep the namebands on and removed them. The nurse (#5) stated a picture of the patient is taken upon admission and is filed in the patient's medical record, medication administration record (MAR), and kardex for staff to reference and verify identity.

During an interview on 10/10/12 at 11:10 a.m., an administrative nurse (#1) stated staff confirmed patient identification by nameband. The nurse (#1) stated staff must confirm patient identity before medications are given or treatments/procedures are performed by patient picture and name or nameband.





2. Based on observation, record review, review of professional literature, hospital policy review, and staff interview, the nursing staff failed to evaluate the safe use of side rails and consider side rails as a potential entrapment and safety hazard; failed to assess each patient individually prior to utilizing side rails; and, failed to provide education to the patient and responsible party regarding the potential hazards of side rail use for 4 of 6 patients (Patient #9, #11, #12 and #13) observed with elevated side rails on the geriatric unit. Failure to assess and evaluate the use of side rails, to consider side rails as a potential entrapment and safety hazard, and to educate patients and responsible parties regarding the hazards of using side rails placed patients at risk of entrapment or injury.

Findings include:

The Hospital Bed Safety Workgroup (HBSW) publication titled, "Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings," dated April 2003, stated, ". . . CMS [Centers for Medicare and Medicaid Services] . . . issued guidance in June 2000 . . . 'It is important to note that side rails present an inherent safety risk, particularly when the patient is elderly or disoriented. . . . patients may become trapped between the mattress or bed frame and the side rail. Disoriented patients may view a raised side rail as a barrier to climb over, may slide between raised, segmented side rails, or may scoot to the end of the bed to get around a raised side rail. When attempting to exit the bed . . . the patient is at risk for entrapment, entanglement, or falling from a greater height posed by the raised side rail, with a possibility for sustaining greater injury or death than if he/she had fallen from the height of a lowered bed without raised side rails. . . . The population at risk for entrapment are patients who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain . . ."

The United States Department of Health and Human Services, Food and Drug Administration (FDA), and Center for Devices and Radiological Health (CDRH) publication titled, "Guidance for Industry and FDA Staff: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment," issued on 03/12/06, stated, ". . . FDA is recommending dimensional limits for zones 1 through 4 . . . because . . . the majority of the entrapments . . . have occurred in these zones. . . . Zone 1 is any open space within the perimeter of the rail. Openings in the rail should be small enough to prevent the head from entering. . . . FDA is recommending a measure of less than . . . 4 3/4 inches as the dimensional limit for any open space within the perimeter of a rail. Zone 2 . . . This space is the gap under the rail between a mattress . . . Preventing the head from entering under the rail would most likely prevent neck entrapment in this space. FDA recommends that this space be small enough to prevent head entrapment, less than . . . 4 3/4 inches. . . . Zone 3 . . . This area is the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head. The space should be small enough to prevent head entrapment . . . FDA is recommending a dimensional limit of less than . . . 4 3/4 inches for the area between the inside surface of the rail and the compressed mattress. Zone 4 . . . This space is the gap that forms between the mattress compressed by the patient, and the lowermost portion of the rail, at the end of a rail. . . . The space poses a risk for entrapment of a patient's neck. . . . to prevent neck entrapment. . . . FDA recommends that the dimensional limit for this space . . . be less than . . . 2 3/8 inches. . . ."

The HBSW publication titled, "A Guide to Bed Safety - Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts," revised April 2010, stated, ". . . Potential risks of bed rails may include: Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. . . . Preventing patients, who are able to get out of bed, from performing routine activities . . ."

Review of the hospital's policy "Use of Side Rails on Medical Beds" occurred on 10/10/12. This policy, dated 01/08/11, stated, "1.0 Purpose: To identify the use of side rails on medical beds and the proper procedure for assessment, acquisition and use of side rails. 2.0 Areas/persons Affected: All patients and staff. 3.0 Policy: It is the policy of The Stadter Center to utilize side rails on medical beds for patient comfort and to allow patients the ability to self position. . . . 5.0 Responsibilities: A. It is the responsibility of all patient care staff to assess patients for the use of side rails. 7.0 Procedure: 1. side rails may be utilized as a comfort measure when the patient requests to utilize the side rails on their medical bed. 2. Side rails may be utilized when requested by the patient. 3. Side rails may be utilized to assist the patient to self position/reposition when it is assessed that this is an appropriate intervention for the patient. a. Assessment by Occupational Therapy may be ordered by the MD [medical doctor] to assess the viability of the use of side rails. 4. Side rails are not utilized for the purpose of restraint."

Observation of the beds utilized on the geriatric unit occurred on October 8-10, 2012. The beds differed in make and model, but included two half rails attached to each side of the upper half of the beds. Measurements of the spacing between the bars of the rails on the beds located in Patient #13's room identified seven and three-fourths inch spaces. Random observations of other rooms on the geriatric unit showed beds with the same type of rails. Observations showed Patient #13 resting in bed with elevated upper half rails.

Observations of the rooms for Patients #9, #11, #12, and #13 on October 8-10, 2012 identified two elevated upper half rails on the beds. Review of the above patients' active medical records occurred on October 8-10, 2012. The records lacked individualized assessments of risk and safety for the use of side rails and lacked evidence of patient (or responsible party) education regarding the potential hazards of side rail use. The hospital staff failed to consider the elevated side rails as a potential safety and entrapment hazard for these patients.

During an interview at 11:15 a.m. on 10/10/12, an administrative nursing staff member (#1) stated patients used the elevated side rails for positioning. The staff member stated they assess patients for side rail use, but do not document this assessment.

3. Based on observation, review of professional literature, policy and procedure review, and staff interview, the nursing staff failed to follow infection control practices regarding disinfection of the glucometer on 2 of 3 days of survey (October 8-9, 2012). Failure to disinfect the glucometer after use on each patient has the potential to lead to transmission of bloodborne pathogens and other infections from one patient to another, and placed patients, staff and visitors at increased risk of infection.

Findings include:

A Centers for Disease Control and Prevention publication titled "Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration," dated 03/08/11, stated, ". . . General: . . . Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. . . . Blood Glucose Meters: 1. . . . Infectious agents, such as HBV [hepatitis B Virus] can be transmitted through indirect contact transmission, even in the absence of visible blood. . . . With some blood glucose meters that require pre-loading of the test strip, the device may come into direct or close contact with the patient's fingerstick wound. . . . . Healthcare personnel hands can become contaminated with blood at various points while performing assisted blood glucose monitoring including pricking the patient's finger or handling the test strip. Blood can then be transferred to the meter . . . 2. . . . FDA [Food and Drug Administration] has recently released guidance for manufacturers regarding appropriate products and procedure for cleaning and disinfection of blood glucose meters. . . . 'The disinfection solvent you choose should be effective against HIV, Hepatitis C, and Hepatitis B virus. . . . Please note that 70% ethanol solutions are not effective against viral bloodborne pathogens and the use of 10% bleach solutions may lead to physical degradation of your device. . . ."

Review of the policy "Infection Control: Safe and Sanitary Condition of Treatment Interventions" occurred on 10/10/12. This policy, revised/reviewed 07/25/11, stated, ". . . It is the policy . . . to provide a safe and sanitary environment for the patients . . . relative to therapeutic intervention of any capacity. . . . Licensed Nurses - Responsible for maintaining a clean and sanitary environment relative to medication administration, medical treatment interventions. . . . Any item used in the administration of a treatment intervention must be maintained in a safe and sanitary condition. Treatment interventions may include but are not limited to: Medications . . . Blood glucose testing meters . . . Any item used in the administration of a treatment intervention found not to be in safe or sanitary condition . . . unclean . . . must be removed, segregated from use . . . All interventions and actions relative to unsafe or unclean interventions are to be dealt with in the most effective means to ensure the safety of the patient is maintained at all times. . . ."

Review of facility policy, "Sure Step Pro Cleaning" occurred on 10/10/12. This policy, dated September 2005, stated, "Purpose: To ensure patency of glucometer and prevent contamination to others. . . . Procedure: 1. Clean monitor after use and whenever it appears unclean. . . ."

Observation from 4:20 p.m. to 4:50 p.m. on 10/08/12, showed a licensed nurse (#4) take the glucometer from a plastic caddy in the medication room to the geriatric nursing unit. The nurse (#4) checked the blood glucose levels of Patient #11 and Patient #9 with the blood glucose monitor. The staff member (#4) brought the glucose monitor back into the medication room and placed it in the plastic caddy. The nurse failed to disinfect the glucometer between patients and before placing it in the caddy in the medication room. When asked if she disinfects the glucometer, the staff member stated she does not. Upon prompting, the staff member cleaned the monitor with disinfectant wipes.

Observation at 8:00 a.m. on 10/09/12, showed a licensed nurse (#8) take the glucometer from the medication room to the nursing unit, telling another staff member he/she planned to check a patient's blood sugar level. The staff member (#8) returned a short while later with the glucometer and placed it back in the plastic caddy in the medication room. The nurse failed to disinfect the glucometer.

During interview, at 11:15 p.m. on 10/10/12, an administrative nursing staff member (#1) confirmed staff should disinfect the glucometer between each patient.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, review of professional literature, review of drug handbook, policy and procedure review, review of manufacturer's instructions, review of medication error reports, record review, and staff interview, the Hospital failed to ensure nursing staff administered medications according to accepted standards of practice and followed professional standards of care relating to infection control practices during observations of medication administration on two of two days of survey (October 8-9, 2012). Failure to confirm identification of a patient prior to medication administration risked patient safety and has the potential for staff to administer medication to the wrong patient. Failure to follow established infection control practices during medication administration may allow transmission of organisms and pathogens to patients.

Findings include:

Beyea's "Patient Identification: A Crucial Aspect of Patient Safety-Patient Safety First," AORN (Association of Perioperative Registered Nurses) Journal, dated September 2003, stated, ". . . Concern for proper patient identification is evidenced in the 2003 National Patient Safety Goals. One of the six identified goals is to improve the accuracy of patient identification. . . . This basic ritual and routine is integral to the medication administration process . . . All clinicians need to be concerned with the processes and systems that support correct identification of patients. . . . The importance of this basic practice cannot be minimized. No assumptions about identity can be made. Every clinician providing care for the patient must make it a routine practice to verify identity. . . . a patient has the right to be identified correctly."

Review of the policy "Patient Identification Policy - Patient Safety" occurred on 10/10/12. This policy, revised/reviewed on 07/25/11, stated, "This policy defines the types of patient identification that are to be used when administering medications, taking blood samples . . . It is the policy of RPSPC [Richard P. Stadter Psychiatric Center] to reliably identify patients for whom medications are administered, blood samples are taken . . . This is done by using two patient identifiers to correctly identify the patient. . . . Approved patient identifiers include any of the two following: Patient name. Patient birth date. Patient photo. For the purposes of identification, a name band will be applied to each patient's wrist upon admission which includes patient name and birth date. A photo is taken as well. Both of these tools will be used for comparison with chart documentation, medication labels, etc. for confirmation of correct patient. . . . Licensed nurse: Responsible for correctly identifying the patient when administering medications by using two patient identifiers. . . . Admission coordinator: Responsible for applying name band . . . on admission. (RN [Registered Nurse] assumes responsibility when Admission staff not on duty) . . ."

Review of the policy "Medication Administration, Monitoring and Documentation" occurred on 10/10/12. This policy, revised/reviewed on 01/20/12, stated, "The purpose of this policy is to establish a mechanism for safe and accurate administration of medications . . . When administering medication, licensed staff will follow the five rights of medication administration which are as follows: 1. Right drug. 2. Right dose. 3. Right route. 4. Right patient. 5. Right time. . . . Licensed Nurses - Responsible for administering/documenting all medications safely and accurately. . . . Patients/Families - Responsible to alert staff if they do not believe they are getting the correct medication and to alert staff to possible medication reactions. . . . A. Medication Administration . . . 2. Prior to administering medication the licensed nurse will determine that he/she has the right patient by verifying the patient using two identifiers. The two identifiers may be any two of the following: the patient's picture, having the patient state his/her name and/or date of birth. The correct patient is then compared against the Medication Administration Record [MAR]. 3. The licensed nurse will verify that the medication selected for administration is the correct one based on the medication order and the product label. . . . 6. The licensed nurse will verify that the medication is being administered at the proper time, in the prescribed dose . . . B. Medication Documentation . . . 2. Documentation on medication administration will be done immediately following the patient receiving the medication. 3. Each dose of medication given will be initialed on the MAR . . . C. Medication Monitoring . . . 2. Each patient's response to his/her medication is monitored . . . 3. Monitoring a medications effect on a patient includes gathering the patients own perceptions about side-effects . . . 4. Monitoring a medications effect on a patient includes the assessment of the patient's medical record . . . clinical response, and medication profile. . . ."

Review of the policy "Infection Control: Safe and Sanitary Condition of Treatment Interventions" occurred on 10/10/12. This policy, revised/reviewed 07/25/11, stated, ". . . It is the policy . . . to provide a safe and sanitary environment for the patients . . . relative to therapeutic intervention of any capacity. . . . Licensed Nurses - Responsible for maintaining a clean and sanitary environment relative to medication administration, medical treatment interventions. . . . Any item used in the administration of a treatment intervention must be maintained in a safe and sanitary condition. Treatment interventions may include but are not limited to: Medications . . . Blood glucose testing meters . . . Any item used in the administration of a treatment intervention found not to be in safe or sanitary condition . . . unclean . . . must be removed, segregated from use . . . All interventions and actions relative to unsafe or unclean interventions are to be dealt with in the most effective means to ensure the safety of the patient is maintained at all times. . . ."

Review of the Levemir FlexPen manufacturer's instructions, revised January 2012, stated, ". . . Attach the needle tightly onto your FlexPen. . . . Before each injection, small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure you take the right dose of insulin: E. Turn the dose selector to select 2 units. F. Hold your Levemir FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. G. While you keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. . . . H. Turn the dose selector to the number of units you need to inject. . . ."

Review of the Nursing 2011 Drug Handbook, page 847, administration instructions for albuterol sulfate stated, "If more than 1 inhalation is ordered, wait at least 2 minutes between inhalations. . . . and on page 854, administration instructions for ipratropium bromide stated, "If more than 1 inhalation is ordered, wait at least 2 minutes between inhalation. . . ."

- Review of the Hospital's medication error reports from the last five months (May through September 2012) occurred on 10/08/12. One of the reports, dated 05/22/12, showed an incident in which a nursing staff member administered the wrong medication to a patient. The description of the error on the report stated, "I labeled med [medication] cups for [first name of patient] [and] [first name of another patient]. I by mistake gave [full name of patient], [first name of patient]'s medications." Additional comments made on the report stated, "Child patient given geriatric patient medication [due to] similarity in names." The action plan to prevent reoccurrence identified on the report stated, "Meds not to be dished up. Write legible."

- Observation of medication pass occurred on 10/08/12 at 5:05 p.m. in the dining room of the adult nursing unit. A nurse (#2) stated she was new to the hospital and didn't know the patients as it was her second day. The nurse had pre-dished five different patients' medications into medication cups labeled with the patients' first names at the adult nurse station, with the intention of administering the medications to the patients in the dining room at supper. To verify the medications already placed in the medication cups, the nurse (#2) took out each patients' individual medication cassettes and showed the surveyor which medications she placed into each patients' medication cups. As the patients entered the dining room for supper, the nurse (#2) began to administer medications and went back and forth to the medication room, sometimes bringing out medication cups for two different patients, and sometimes only one medication cup for one patient. The nurse (#2) did not look at the photo in the MAR prior to taking the medication to the dining room, nor did she bring the patient photo or MAR with her.

The nurse (#2) administered oral medications to Patient #2 without verifying the patient's identity prior to administration and attempted to give the patient a can of chocolate Ensure (labeled with the first name of a different patient on top of the can). Patient #2 stated she received a nutritional fruit drink rather than the Ensure, which the nurse (#2) then retrieved from a refrigerator located in the adult nurse station and brought to the patient. Moments later, after administering medications to two other patients, the nurse (#2) stated, "Who's [first name of patient]?" to an unidentified staff member serving food in the dining room. The unidentified staff member pointed to Patient #2, and the nurse (#2) administered the patient additional oral medications (the medications verified to the surveyor by the nurse) without verifying the patient's identity prior to administration. After completion of the above observation, it could not be determined which medications the nurse (#2) administered to Patient #2 first, as the surveyor did not witness the nurse (#2) pre-dish two medication cups for Patient #2.

At the completion of the medication pass in the dining room, the surveyor noticed only four of the five patients, which the nurse (#2) pre-dished medications for, received medications. The surveyor noticed an unidentified patient sitting in the dining room eating, who did not receive medications, and had been present in the dining room throughout the entire medication pass. An unidentified staff member serving food in the dining room identified the patient as Patient #1. When the surveyor asked the nurse (#2) about the patient who didn't receive medications (Patient #1), the nurse stated she administered the patient's medications to him in his room as he recently came back to the nursing unit from an ECT procedure and didn't come to the dining room.

- During medication pass on 10/08/12 at 5:05 p.m. in the dining room of the adult nursing unit, a nurse (#2) attempted to administer medications to Patient #5 after having the patient state his first name, but Patient #5 hesitated and stated, "I thought the doctor said he was going to make some changes to my medications today?" The nurse (#2) stated, "I didn't hear anything about it." Patient #5 stated, "So, I just take these then?" The nurse (#2) nodded yes and Patient #5 proceeded by taking the medications given to him. The nurse (#2) did not attempt to review Patient #5's medical record to verify whether the physician made changes to the patient's medications. Moments later, as the nurse (#2) attempted to administer Patient #2 her medications, the patient asked the nurse (#2) the names of the medications in the medication cup, to which the nurse (#2) replied, "I don't know, I can't remember." Patient #2 proceeded by taking the medications given to her. The nurse (#2) did not attempt to review Patient #2's MAR and tell the patient which medications she received.

A random observation of a staff/patient interaction on 10/08/12 at 5:12 p.m., showed Patient #6 standing in the doorway of the adult nurse station telling two nurses (#2 and #4) she felt tremors and disorientation and stated, "I think it's because I started a new medication and don't have my Cymbalta [used to treat major depression and general anxiety] anymore." One of the nurses (#2) reviewed Patient #6's MAR and stated the MAR showed completion of the Cymbalta and a new medication called Lamictal [used to treat seizures or bipolar disorder]. The other nurse (#4) stated, "We'll have to look at your chart to see why the doctor started the new medication." Patient #6 stated, "What do I do to prevent from dying right now?" One of the nurses (#2) stated, "You'll feel rough for a while, but you'll be fine." The two nurses (#2 and #4) did not attempt to question Patient #6 further about her symptoms, or review the patient's medical record to verify the medication change. Review of Patient #6's medical record occurred on 10/09/12 and failed to include evidence of the above complaints from the patient of her symptoms, further monitoring to ensure the symptoms resided, and/or physician notification.

- Observation of medication pass occurred on 10/09/12 at 8:05 a.m. and showed a nurse (#3) delivering medications to patients in their rooms. The nurse (#3) pre-dished several different patients' medications into medication cups labeled with the patient's first names at the adult nurse station and brought the medication to the individual patient rooms to administer. The nurse (#3) went back and forth to the medication room, sometimes bringing out medication cups for two different patients, and sometimes only one medication cup for one patient. The nurse (#3) did not look at the photo in the MAR prior to taking the medication to the patient's room, nor did she bring the patient photo or MAR with her. The nurse (#3) administered oral medications to three different patients (Patient #4, #19, and #21) without verifying the patients' identities prior to administration. Prior to administering Patient #21's medications, the nurse (#3) stated to the surveyor, "I do not know this patient and have not met him."

- Observation of a licensed nurse (#7) preparing medications for administration at the geriatric nurse station occurred at 7:45 a.m. on 10/09/12. The nurse (#7) stated she started pre-dishing medications at 6:30 a.m. The nurse had pre-dished several patients' medications into medication cups labeled with the patient's first names, with the intention of administering the medications to the patients in the dining room at breakfast. Observation showed plastic medication cups on the countertop of the medication room, along with insulin pens, inhalers, and ointments. The nurse (#7) stated she was new to the hospital and had not worked at the hospital recently. The nurse stated she did not know the current patients.

Observation showed the nurse (#7) preparing medications for Patient #9 at 7:45 a.m. The nurse dialed a Levemir insulin pen to 10 units for Patient #9. The nurse pre-dished one 81 milligram (mg) tablet of aspirin into a plastic medication cup for Patient #1 along with her other medications. The nurse signed her initial in the medication administration record (MAR) after dishing the pills into the medication cup. Review of the physician's orders for Patient #9 at 7:50 a.m., identified an order for one 325 mg tablet aspirin, not 81 mg. When shown the order, the nurse discarded the 81 mg aspirin tablet and placed the 325 mg aspirin tablet into the medication cup.

At 8:05 a.m., the nurse (#7) then began pre-dishing medications for Patient #23. The nurse took two inhalers out of the medication cart, both labeled for Patient #23 - Albuterol/Ipratropium inhaler and Ventolin inhaler (Albuterol). The MAR identified Combivent inhaler twice a day. The nurse asked the charge nurse (#8) which of the two inhalers was the Combivent inhaler and he/she identified the Albuterol/Ipratropium inhaler. The label on the Combivent inhaler identified 2 puffs twice a day. The nurse placed the inhalers on the medication counter and continued to pre-dish medication for other patients. The nurse signed her initials on the MAR after taking medications from the cart and placing them in the medication cups and/or on the counter.

At 9:00 a.m., the licensed nurse (#7) crushed the medications she had pre-dished in Patient #9's medication cup. She then placed a new needle on the Levamir insulin pen. The nurse did not prime the needle with 2 units of insulin. (The nurse had already dialed the insulin pen to 10 units at 7:45 a.m.) The nurse (#7) brought the medications to the dining room, and asked a staff member to identify Patient #9. The nurse did not bring Patient #9's MAR or the patient's photo from the MAR to the dining room, and did not ask the patient to state his/her name. Patient #9 was not wearing a name band.

At 9:20 a.m., the licensed nurse (#7) brought Patient #23's medications into the dining room and asked a staff member to identify Patient #23. The nurse did not bring Patient #23's MAR or the patient's photo from the MAR to the dining room. The nurse gave the patient the Ventolin inhaler, which he held in his mouth, and the nurse administered one puff. The nurse then administered 1 puff of the Combivent inhaler immediately after the Ventolin inhaler. The nurse did not wait at least 2 minutes between the two inhalations.

Review of Patient #23's medical record, on 10/12/12, identified the following medication orders from 10/07/12, "Albuterol HFA [hydrofluoroalkane] inhaler 2 puffs TID [three times a day] PRN [as needed] . . . Albuterol/Ipratropium 18-103 mcg [micrograms] . . .inhaler BID [twice a day]." The physician's orders did not specify how many puffs twice a day. Review of the MAR (which the nurse (#7) signed prior to giving medications on 10/11/12) did not identify the PRN Ventolin (Albuterol) inhaler the nurse administered to Patient #23 on 10/09/12 at 9:20 a.m. Upon review, the charge nurse (#8), determined the Ventolin inhaler (PRN) did not get transcribed to the MAR on 10/08/12 and 10/09/12. Review of the nurse's notes from 10/09/12 did not identify any breathing difficulty or request for a PRN dose of Ventolin inhaler.

- The following observations showed staff failed to perform sanitary medication administration:
*Observation on 10/08/12 at 4:20 p.m., showed a staff nurse (#2) standing at the medication cart in the adult nurse station pre-dishing several different patient medications to administer with supper. The nurse (#2) prepared to place Patient #5's medications into a medication cup, touched one of the medications with her bare fingers, and placed the medication into the cup. The nurse (#2) later administered the medication to Patient #5.
*Observation on 10/09/12 at 8:05 a.m., showed a nurse (#7) standing at the medication cart in the geriatric nurse station pre-dishing medications. The medication cup with Patient #23's pills tipped over and one of the pills rolled onto the top of the medication cart. The nurse (#7) picked up the medication with her bare fingers and placed it back into the cup. The nurse later administered the medications to Patient #23.
*Observation on 10/09/12 at 8:29 a.m., showed a nurse (#3) standing at the medication cart in the adult nurse station preparing to administer an Abilify [used to treat schizophrenia, bipolar disorder, and major depression] tablet to Patient #19. Review of the MAR showed Abilify 5 milligram (mg), 1/2 tablet. The nurse (#3) popped the Abilify tablet out of the medication cassette into her bare hand and broke the tablet in half, placed half of the tablet in a medication cup, threw the other half in the garbage, and administered the half tablet to Patient #19.
*Observation on 10/09/12 at 8:45 a.m., showed a nurse (#3) attempted to administer two medications to Patient #22 in his room. Patient #22 stated he took his medications mixed in chocolate pudding. The nurse (#3) brought Patient #22's medications to the medication room in the geriatric nurse station, obtained one of the medications from the cup with her bare finger, placed the medication into another cup to crush the medication, and added pudding to the cup to mix with the medication. The nurse (#3) walked back to Patient #22's room and administered the medication to the patient.
*Observation on 10/09/12 at 8:45 a.m., showed a nurse (#8) administering medications from the doorway of the geriatric nurse station to an unidentified patient standing in the doorway. The unidentified patient dropped the medications on the floor and the nurse (#8) stated, "You dropped some pills [first name of patient], wait, let me get them for you." The nurse (#8) picked the pills off the floor and administered them to the unidentified patient.

During an interview on 10/08/12 at 5:30 p.m., a nurse (#2) stated the Hospital accepted the practice of pre-dishing medications.

During an interview on 10/09/12 at 7:55 a.m., a nurse (#3) stated most nurses pre-dish medications and stated the Hospital accepted the practice of pre-dishing medications.

During an interview on the afternoon of 10/09/12, a nurse (#3) stated she did not confirm some of the patient's identities before medication administration because she knew them. The nurse (#3) stated staff used the patient picture in the MAR or patient belonging bag (located in the patient room at the bedside), which included the patient's name, to identify the patient.

During an interview on 10/10/12 at 11:10 a.m., an administrative nurse (#1) stated pre-dishing medications is highly discouraged and it is not the Hospital's practice, dished up medications must be administered immediately, and the medication must be administered by the person who dished the medication up. The nurse (#1) stated staff must confirm patient identity before administration of medications or treatments/procedures by patient picture and name or nameband. The administrative nurse (#1) stated staff must not touch medications with their bare hands and confirmed staff must dispose of medications that fall on the floor or top of the medication cart.
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observation and staff interview, the Hospital failed to store drugs and biologicals in a secure manner to prevent access by unauthorized personnel in 1 of 3 medication storage areas (Crash Cart in geriatric nurse station). Failure of the Hospital to adequately secure and restrict access of drugs and biologicals created an opportunity for unsafe and unauthorized use of medications.

Findings include:

Observation of the geriatric nurse station with a nurse (#4) on 10/09/12 at 3:45 p.m., showed a crash cart, locked with a red plastic break away lock, located against a wall. The crash cart contained various medications used in life-threatening situations and additional red plastic locks, used as replacements for the lock on the cart, in the top drawer of the crash cart.

During an interview on 10/10/12 at 11:10 a.m., an administrative nurse (#1) stated she did not realize staff kept the plastic red replacements locks in the drawer of the crash cart, making the cart unsecure. The nurse (#1) stated the Hospital should store medications securely to prevent unauthorized access and use.
VIOLATION: AFTER-HOURS ACCESS TO DRUGS Tag No: A0506
Based on observation, review of policy and procedure, and staff interview, the Hospital failed to designate an individual to remove medications from the after-hours supply, document the removal of medications from the after-hours supply, and ensure a pharmacist reviewed all medication removal activity from the after-hours supply for 1 of 1 after-hours medication storage area. These failures allowed an opportunity to create an insufficient distribution, control, and accountability of medications and for unsafe and unauthorized use of medications.

Findings include:

Review of the policy "Contingency Medication" occurred on 10/10/12. This policy, revised/reviewed on 07/27/11, stated, ". . . This policy and procedure establishes a process for safely providing medications to meet the patient needs when the pharmacy is closed. . . . contingency medications will be used when available so that patients admitted late at night and on the weekends when the pharmacy is closed will have their medications started as soon as possible following admission. . . . Contingency medications are a limited set of medications . . . to be kept on site in a secured medication room that may by (sic) used to start patients medications as soon as possible after admission when the Pharmacy is closed. . . . It is the responsibility of the LPN medication nurses to check the contingency medication stock routinely and order medications that need refilling from the pharmacy. . . . 1. When it is identified that a contingency medication will be used the licensed nurse will obtain the medication from the secured med room at the main workstation. . . . 3. The medication orders will be processed and sent to the pharmacy so the patient's medications are delivered at the next scheduled delivery time. . . . 7. The consulting pharmacy has a pharmacist on-call at all times to answer questions or provide medications beyond those accessible to non-pharmacy staff. This process is evaluated on an ongoing basis to determine the medications accessed routinely and the causes of accessing the pharmacy after hours. Changes will be implemented to minimize the number of times non-pharmacist health care professionals obtain medications after the pharmacy is closed. . . ."

During an interview on 10/09/12 at 3:45 p.m., a nurse (#4) stated during the time the pharmacist is unavailable (after hours, weekends, and holidays) and providers ordered new medications or medication changes for patients, nursing staff removed medications from the contingency medication carts for administration to patients.

Observation of the medication storage area on the geriatric nursing unit occurred on 10/09/12 at 4:00 p.m. with a nurse (#4). Observation showed a large medication cart, located in the locked medication room, which the nurse (#4) identified as the contingency medications (after-hours medication supply). The cart contained multiple medications packaged in different doses in bottles and cassettes, including antipsychotics and antibiotics. The nurse (#4) stated nursing staff did not log (name/dose/amount of medication, name of person removing, etc.) removal of the contingency medications.

During an interview on 10/09/12 at 4:10 p.m., the nurse (#4) stated nursing staff worked 12 hour shifts, and the Hospital staffed two charge RN's and two other nurses designated as the medication nurses (usually two LPN's) on each shift. The nurse (#4) stated the LPN's or medication nurses on each shift administered all of the medications, therefore, carried the keys to the medication areas. The nurse (#4) stated the LPN's accessed and removed the contingency medications and confirmed the two LPN's or medication nurses could perform this task.

During an interview on 10/10/12 at 11:15 a.m., an administrative nurse (#1) confirmed the above nurse's (#4) interview, and stated she is unaware of the pharmacist reviewing the removal activity from the after-hours supply or contingency medications as she has not heard discussion or reviewed any reports about it.