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.


Based on record and policy review the facility failed to administer drugs in accordance to the orders of the practitioner and accepted standards of practice for 1 (SP#4) out of 4 sample patients (SP).

Findings include:

Review of sample patient (SP) #4 medical records showed he was admitted on [DATE] with right foot [DIAGNOSES REDACTED] (infection). Medication administration observation of SP#4 and Registered Nurse-Staff C on 02/12/2019 at 1:30 PM revealed Staff C entered a note that pharmacy was contacted. Staff C explained that there is a time conflict with another IV antibiotic and inquired with pharmacy to readjust time. The IV Vancomycin 1750 mg in 500mg was given at 13:36 PM. The medication was scheduled to be given at 10:00AM. Staff C opened a new piggyback tubing, primed the tubing with medication and administered the medication via piggyback. Staff C entered a rate of 150cc/hr (per hour). into the infusion pump. The medication rate ordered was for 125cc/hr. The IV tubing was not labeled with date and time.

SP #4 PHA orders showed that on 02/12/2019, Vancomycin (1,750 mg) in 500 ML IV, 10:00 AM dose was given at 13:36 PM.

The orders revealed that Vancomycin IV (intravenous) 1,000mg Vial (1,750 mg) in 500 ML (milliliters) rate of 125 MLs/HR was ordered every 12 Hours at 10:00 AM and 22:00 PM.
The PHA orders also showed that IV Zosyn 3.375 GM/ Vial in 100 ML was ordered every 8 hours at 02:00 AM, 10:00 AM, and 18:00 PM. The 10:00 AM dose was ordered at the same time as the Vancomycin.

Interview with the Pharmacist and Pharmacy Manager on 02/14/2019 at 12:30 PM, stated that this patient was on two antibiotics that requires 4 hours infusion on 02/12/2019 in the afternoon. The Nurse called pharmacy for the difficulty for the past two days giving the medications on time because of the Vancomycin BID (twice a day) over 4 hours each, and Zosyn in every 8 hours over 4 hours each, and both medications were scheduled at 10:00 AM. Then Zosyn was rescheduled to 4:00 AM, 12:00 and 8:00 PM and Vancomycin was maintained at 10:00 AM and 10:00 PM.

Review of the policy "Standard Hours For Administration of Medication", Department: Pharmacy/Nursing; Effective Date: 03/18; revealed Procedure: Medications with Special Consideration 1. B. Timed Doses: Doses of vancomycin (pharmacokinetic dosing) must be given and charted precisely and timed from the initial dose of the medication. These medications should be administered within 1 hour before or after the scheduled dosing time for a total window of 2 hours unless otherwise prescribed. Do not use standardized times. Notify the pharmacist immediately of any missed or incorrectly timed doses so levels can be retimed. E. Missed or Late Administration of Medications 1. At times, medications eligible for scheduled dosing times are not administered within their permitted window of time. This includes doses which may have been missed due to the patient being temporarily away from the nursing unit, for example, for tests or procedures, patient refusal; patient inability to take the medication; problems related to medication availability, such as shortage; or other reasons that result in missed or late dose administration. 2. The physician or other practitioner responsible for the care of the patient must been consulted regarding missed or omitted doses for time-critical medications and medications not eligible for schedule dosing.

The policy " IV Therapy Protocol" (revised 11/17) , states J. All tubings shall be labeled with the date, time and initials of the person who initiated tubing. All

The facility failed to follow its policies.