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 review and interview, the hospital failed to ensure the Quality Assurance Performance Improvement (QAPI) plan measured and analyzed causes of medication errors, implemented preventive actions, and tracked the performance to determine sustainability of improvements.

This failed practice had the likelihood to affect the safety and health outcomes of all patients receiving care in the hospital due to the hospital's failure to identify risks and quality improvement opportunities and implement action plans to improve patient outcomes.


Review of hospital policy, titled "Medication Variances" (date 03/11) showed a Medication Variance Performance Improvement (PI) team would investigate medication variances. Members of the PI team would include the pharmacist, Director of Nursing (DON) and/or interim DON, Risk Manager, Clinical Nurse Manager, one staff nurse, and a member of the medical staff. The PI team would meet quarterly, and can meet as needed to the investigate medication variances, identify trends and root causes, and take action to reduce variances that occurred in the facility.

Review of hospital documents titled QAPI Meeting, from 07/17/18 and 09/18/18 showed the number of medication variances reported 07/17/18 was two and the number and on 09/18/18 was three. Documents failed to show an analysis of the cause of medication errors, implementation of preventive actions, or tracking of performance to ensure sustainability of proposed improvements. There is no evidence the PI team investigated medication variances per hospital policy. The minutes failed to show the cause of medication errors, implementation of preventive actions, or of tracking performance to ensure sustainability of proposed improvements. There was no evidence that a PI team investigated medication variances per hospital policy.

Review of hospital documents for Pharmacy and Therapeutics Committee Minutes failed to show evidence of a comprehensive ongoing process that tracked medication errors, analyzed causes, and implemented preventive actions and mechanisms that include feedback and learning throughout the hospital. There was no evidence that a PI team investigated medication variances per hospital policy. The minutes showed the following:
04/25/18 Child/Adolescent
a. Omissions 41%
b. Wrong Drug 6%
c. Wrong Dose 24%
d. Unauthorized Use 18%
e. Near Miss 5%
a. Omission 33%
b. Wrong Drug 67%

07/24/18 Child/Adolescent
a. Omissions 33%
b. Wrong Time 42%
c. Wrong Dose 15%
d. Wrong Patient 7%
Adult No Errors.

Review of hospital documents titled "Medication Variances" from 06/07/18 to 01/07/19, contained patient identification information and a short description of each medication variance. There were a total number of 55 variances for this period. The documents indicate medication variances occurred and included some detailed information that was collected that could be used to conduct analysis and performance improvement planning.

On 01/08/19 at 8:29 am, during a tour of the Geropsych nursing unit, Staff I displayed a written order, dated 12/31/18, in medical record, one of one (Patient #5) . Staff I compared the order in the paper medical record with what had been entered into the Health Care System (HCS) order entry system. Staff I stated the order in the paper record did not match the information that had been entered into the HCS order entry system.

On 01/07/19 1:40 pm, Staff B stated that medication variances were reviewed in a medication variance committee. Staff B stated that there were no minutes for these meetings.

On 01/07/19 at 2:00 pm, Staff F stated he/she was concerned nursing staff were receiving in-person verbal orders from physicians and transcribing them into the automated order entry system (HCS) without having an established written record of the order in the patient's medical record. Staff F stated "this practice could be a safety issue that may result in an error in transcription and lead to a med error."

On 01/08/19 9:16 am, Staff J (pharmacist) stated "I am the one who usually catches the medication errors." Staff J stated most of the medication errors were on the weekends. Staff J stated that there was not a "paper trail" for some of the medication orders that were put directly into the HCS system and he/she verified them with the physician or the campus supervisor.

On 01/08/19 at 2:00 pm, Staff F and Staff B (Chief Nursing Officer) stated there was generalized staff confusion (nurses, physicians, pharmacy) regarding the simultaneous usage of the patient medical record and the HCS order entry system used to order and document the administration of medications for patients. Staff B stated improvement was needed with the utilization of the order entry system.