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CEDAR HILLS HOSPITAL 10300 SW EASTRIDGE STREET PORTLAND, OR 97225 May 11, 2011
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on a review of 8 patient records, based on a review of the hospital's policies and procedures, and a review of documented medication errors, and based on interviews with hospital staff members, it was determined that in 1 of 8 medical records, Record #6, the hospital failed to administer drugs in accordance with the physician's orders and accepted standards of practice, and failed to accurately document drugs that had been administered.

Findings include:

The records of eight patients admitted to the hospital in March of 2011 were requested and reviewed. Record #6 contained the following information:

A review of the physician's orders and the Medication Administration Record (MAR) in patient file #6 revealed that the patient had been prescribed Depakote 1500 mg (milligrams) PO (orally) Q (every) HS (hour of sleep/bedtime). A review of a hospital policy titled: "Medication Administration" contained the following information:
"1. Medication Administration Times:
Daily= 9 a.m.
Bedtime=9 p.m."

The documentation for the Depakote on the MAR, handwritten initials of the nurse administering the medication, reflected that the Depakote had been given at "2000"--8 p.m.-- on March 17, 2011, March 18, 2011, March 19, 2011, and March 20, 2011. Of special note: The handwritten initials of the nurse administering the medications did not match any of the signatures/initials that were listed in the "key" on the left lower corner of the MAR, the place that staff members had been using to identify nurses by signatures and initials. No other medication administration error was apparent according to the documentation on the MAR.

A hospital policy titled: "Medication Occurrences" was reviewed, and was found to contain the following information:

"Policy:
It is the policy of Cedar Hills Hospital to assure that all patients receive medications in a safe manner. Any medication occurrences will receive immediate follow up related to patient care, and will be followed by reporting, and trending for analysis by medical staff."

"Drug administration occurrences (medication occurrences) shall be reported and reviewed in accordance with this policy."

and

"Examples of medication occurrences include but are not limited to:
Wrong date or time"

A request was made for all medication occurrences in the last two weeks of March 2011. Several documents titled "Medication Occurrence Report" were received and reviewed. A medication Occurrence Report had been generated for patient #6 on 03/20/2011, indicating that the Depakote had been given at the wrong time, that the physician had been notified, and that the evening dose of Depakote would be held for 03/20/2011.

In an interview with I1 and I2 at 1105 hours on 03/20/2011 in the administrative office, 12 stated that she recalled this patient and this incident. When asked to explain what the error was, as the MAR reflected that the medication Depakote had been given at 2000 hours, I2 stated that the Depakote had in fact been given at 0900 hours in the morning, and that s/he had a clear recollection of giving the medication, then as soon as the patient had swallowed the medication, became aware of the error. When asked why the MAR reflected that the medication had been given by her at 2000 hours, I2 stated that s/he didn't work at eight o'clock at night, and admitted that s/he had incorrectly documented the time that the medication had actually been administered. I2 was asked to describe what occurred after the Medication Occurrence Report had been submitted. I2 stated "I wrote myself up, and I turned the report in to my supervisor" and that no other action had taken place, to his/her knowledge. I1 stated that all medication occurrence records were routinely reviewed and evaluated for trends, and that no trend had been noted in this incident.

The hospital failed to administer drugs as ordered by the physician, and failed to accurately document drugs that had been administered by a Registered Nurse.