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MERCY HOSPITAL SPRINGFIELD 1235 E CHEROKEE SPRINGFIELD, MO 65804 Nov. 2, 2017
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, interview, record review and nursing orientation content review the facility failed to administer two intravenous (IV-within the vein-a tube placed into the vein so medications and/or fluid can be administered) antibiotics (Vancomycin and Gentamicin) as ordered and in a timely manner for two patients (#23 and #29) of two patients reviewed for timely medication administration. This delay had the potential to affect the effectiveness of the antibiotic and the overall treatment of an infection. The facility census was 414.

Findings included:

1. Record review of 2017 nursing orientation contents showed the antibiotic Vancomycin should be started when the first dose is received. Following doses are based on frequency ordered. About 30% of medication errors are from the lack of performing the 7 rights of medication administration: right patient, right drug, right dose, right time, right route, right reason, and right documentation.

2. During an interview on 10/31/17 ay 3:10 PM, Patient #29 stated that she was admitted the day prior for a bacterial infection in her right leg. She stated that she had received a dose of IV Vancomycin in the Emergency Department (ED) at about 1:00 PM the day prior. Patient #29 stated that she was concerned because she had not received a subsequent dose since that time and was fearful of delayed treatment and/or improvement. The patient stated that the nurse brought the IV bag of medicine in the room (about 30 minutes prior) but left because she needed fluids to administer with it.

Observation on 10/31/17 at 3:15 PM, showed the IV bag of Vancomycin 2000 milligrams, lying on the counter near the computer.

During an interview on 10/31/17 at 3:20 PM, Registered Nurse (RN), Staff QQ, stated the following:
- She had not administered the Vancomycin yet because the delivery from pharmacy was delayed.
- She confirmed the order as 2000 mg IV every 12 hours, due at 11:00 AM.
- She stated that she could not administer it now because she did not have an IV pole available.

During an interview on 10/31/17 at 3:23 PM, Pharmacist, Staff SS, stated the following:
- The Vancomycin order was received in Pharmacy at 10:21 AM.
- The Vancomycin was filled and reviewed at 10:51 AM.
- He did not know exactly when it was delivered to the unit, but that it was indeed late.

3. Record review of Patient #23's History and Physical (H&P) showed that the patient was being treated for five wounds between his right thigh and his right knee. Gentamicin (antibiotic) 350 milligrams daily dose was ordered to prevent and treat a wide variety of bacterial infections.

Record review of Patient #23's medication administration report for 10/25/17, showed that Staff KKK, RN, scanned Gentamicin 350 milligrams at 2:00 PM.

During an interview on 10/31/17 at 10:05 AM, Patient #23 stated that Staff KKK, RN, left the clamp on the IV line and he did not receive the Gentamicin until the nightshift nurse arrived. He stated that the IV pump kept beeping and was ignored.

During an interview on 11/01/17 at 10:50 AM, Staff YY, RN, Nightshift, stated that when she came on shift and entered Patient #23's room, the Gentamicin was hanging but the tubing was clamped. She stated that it was the morning dose, so she unclamped it and let it run in. The medication was delayed 6 hours.

During an interview on 11/01/17 at 11:37 AM, Staff KKK, RN, stated that she did not recall the delay of antibiotics for Patient #23.