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.

DALE MEDICAL CENTER 126 HOSPITAL AVE OZARK, AL 36360 Feb. 21, 2020
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review of Medical Records (MR), facility policy, and interviews with staff it was determined the facility failed to ensure:

1. Reassessment was performed after the administration of as needed (prn) medications in the New Day Unit

2. The specific reason for administration was documented for prn medications in the New Day Unit.

3. The physician was notified of patient slurred speech and drowsiness due to prn medications in the New Day Unit.

This deficient practice affected 1 of 1 New Day Unit MR's reviewed that required prn medications and did affect Patient Identifier (PI) # 2 and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Medication Administration
Revised: 5/2008

Purpose: To provide uniform guideline for administering medications

...D. Medication Administration

j. Reassess the patient to evaluate response and any untoward effects as indicated...

PI # 2 was admitted to New Day on 1/11/2020 with diagnoses of Personal History of Self-Harm and Bipolar Disorder, Current Episode Depressed, Severe, with Psychotic Features.

Review of the Physician Orders revealed the following verbal orders for medications prescribed on 1/11/2020: Ativan 2 mg (milligrams) oral prn every 6 hours, Haldol 5 mg IM (intramuscular) injection prn every 6 hours, Haldol 5 mg oral prn every 6 hours, Benadryl 50 mg oral prn every 6 hours, Benadryl 25 mg IM prn every 6 hours, Benadryl 50 mg IM prn every 6 hours, and Ativan 2 mg IM prn every 6 hours. There was no documentation of the indication for the use of the previous prn medications.

Review of the Medication Patient Progress Notes (MedPPN) dated 2/2/2020 at 8:29 AM revealed PI # 2 was administered Haldol 5 mg tablet for "anxiety", Ativan 2 mg tablet for "anxiety", and Benadryl 50 mg tablet for "sleep/insomnia" prn.

Review of the Nursing Patient Progress Notes (NPPN) dated 2/2/2020 at 8:30 AM revealed documentation of "pt (patient) becoming agitated requested and received Ativan 2 mg Haldol 5 mg and Benadryl 50 mg P.O. (oral) prn will monitor." There was no documentation of how the patient was becoming agitated and no documentation of a reassessment of the patient's response to the prn medications administered.

Review of the MedPPN dated 2/3/2020 at 4:50 PM revealed PI # 2 was administered Ativan 2 mg IM injection for "anxiety."

Review of the NPPN dated 2/3/2020 at 4:52 PM revealed documentation of the Ativan administration due to the patient yelling, cursing, kicking, and beating on the doors. There was no documentation of a reassessment of the patient's response to the prn medication administered.

Review of the MedPPN dated 2/5/2020 at 8:37 AM revealed PI # 2 was administered Haldol 5 mg (milligram) tablet for "anxiety", Ativan 2 mg tablet for "anxiety", and Benadryl 50 mg tablet for "sleep/insomnia" prn.

Review of the NPPN dated 2/5/2020 at 8:58 AM revealed documentation of "pt requested and received Ativan 2 mg Haldol 5 mg and Benadryl 50 mg P.O. prn for anxiety and agitation." There was no documentation of how the patient was displaying anxiety and agitated behavior and no documentation of a reassessment of the patient's response to the prn medication administered.

Review of the NPPN dated 2/5/2020 at 5:53 PM revealed documentation of "pt irritable threw supper tray (at) another pt...pt received Ativan 2 mg Haldol 5 mg and Benadryl 50 mg IM." There was no documentation of a reassessment of the patient's response to the prn medication administered.

Review of the MedPPN dated 2/5/2020 at 5:58 PM revealed PI # 2 was administered Benadryl 50 mg IM injection for "anxiety" prn.

Review of the MedPPN dated 2/5/2020 at 6:04 PM revealed PI # 2 was administered Ativan 2 mg IM injection for "anxiety" and Benadryl 50 mg IM injection for "anxiety" prn. There was no documentation the physician was notified of the second Benadryl injection administered 6 minutes from the previous Benadryl injection and no documentation the Haldol IM injection was administered.

Review of the NPPN dated 2/6/2020 at 7:31 AM revealed documentation of "pt reports feeling anxious this AM requested and will receive Ativan 2 mg Haldol 5 mg and Benadryl 50 mg po." There was no documentation of a reassessment of the patient's response to the prn medication administered.

Review of the MedPPN dated 2/6/2020 at 8:02 AM revealed PI # 2 was administered Ativan 2 mg tablet for "anxiety", Haldol 5 mg tablet for "anxiety" and Benadryl 50 mg tablet for "anxiety" prn.

Review of the NPPN dated 2/7/2020 at 5:42 PM revealed documentation of "patient has been calm and compliant this shift. Requires prn anxiety medications..." There was no documentation of what behaviors the patient was displaying to require prn medication and no documentation of a reassessment of the patient's response to the prn medications administered.

Review of the MedPPN dated 2/7/2020 at 6:02 PM revealed PI # 2 was administered Ativan 2 mg IM injection for "anxiety", Haldol 5 mg IM injection for "anxiety" and Benadryl 50 mg IM injection for "anxiety" prn.

Review of the MedPPN dated 2/8/2020 at 2:03 AM revealed PI # 2 was administered Ativan 2 mg tablet for "anxiety", Haldol 5 mg tablet for "anxiety" and Benadryl 50 mg tablet for "sleep/insomnia" prn.

Review of the NPPN dated 2/8/2020 from 1:00 AM to 8:00 AM revealed no documentation of what behaviors the patient was displaying to require prn medication and no documentation of a reassessment of the patient's response to the prn medications administered.

Review of the MedPPN dated 2/8/2020 at 8:42 AM revealed PI # 2 was administered Ativan 2 mg tablet for "anxiety", Haldol 5 mg tablet for "anxiety" and Benadryl 50 mg tablet for "sleep/insomnia" prn.

Review of the NPPN dated 2/8/2020 at 8:45 AM revealed documentation of "patient resting in bed after eating breakfast. Request and receives prn anxiety medication. Compliant with meds (medications) and care." There was no documentation of what behaviors the patient was displaying to require prn medication and no documentation of a reassessment of the patient's response to the prn medications administered.

Review of the NPPN dated 2/8/2020 at 8:09 PM revealed documentation the patient had slurred speech with slowed psychomotor behavior and "pt is lying quietly in bed... Pt is very drowsy from all of the medications he's/she's taken today. Pt's speech is slurred. No anxiety or depression noted..." There was no documentation the physician was notified of the patient's slurred speech, slowed psychomotor behavior, and drowsiness in response to the medications taken.

Review of the MedPPN dated 2/8/2020 at 8:10 PM revealed PI # 2 was administered Ativan 2 mg tablet for "anxiety" and Haldol 5 mg tablet for "anxiety" prn.

Further review of the NPPN dated 2/8/2020 from 8:00 PM to 11:00 PM revealed no documentation of what behaviors the patient was displaying to require prn medication and no documentation of a reassessment of the patient's response to the prn medications administered.

Review of the NPPN dated 2/9/2020 at 7:56 AM revealed documentation of slowed speech, slowed psychomotor behavior and"...complained of feeling anxious and beginning to show s/s (signs/symptoms) of agitation. Decision was made at pt's request to given (give) anxiety medication in IM injection form. pt is currently lying in bed resting at this time. Will continue to monitor." There was no documentation of what s/s of agitation the patient was displaying and no documentation of a reassessment of the patient's response to the prn medications administered.

Review of the MedPPN dated 2/9/2020 at 8:31 AM revealed PI # 2 was administered Ativan 2 mg IM injection for "anxiety", Haldol 5 mg IM injection for "anxiety" and Benadryl 50 mg IM injection for "anxiety" prn.

Review of the NPPN dated 2/9/2020 at 8:01 PM revealed documentation of slowed, slurred speech, slowed psychomotor behavior and "pt is lying quietly in bed...pt appears to be very drowsy from his/her medications. Pt's speech is slurred. Pt reports continuing anxiety..." There was no documentation the physician was notified of the patients slowed, slurred speech, slowed psychomotor behavior, and drowsiness from medications.

Review of the NPPN dated 2/9/2020 at 11:10 PM revealed documentation of "appears to be sleeping..."

Review of the MedPPN dated 2/9/2020 at 11:26 PM revealed PI # 2 was administered Ativan 2 mg tablet for "anxiety" and Benadryl 50 mg tablet for "sleep/insomnia" prn.

Further review of the NPPN dated 2/9/2020 from 11:00 PM to 2/10/2020 at 7:00 AM revealed no documentation of what behaviors the patient was displaying to require prn medication and no documentation of a reassessment of the patient's response to the prn medications administered.

Review of the NPPN dated 2/10/2020 at 7:24 AM revealed documentation of "resting in bed no distress..."

Review of the MedPPN dated 2/10/2020 at 8:08 AM revealed PI # 2 was administered Ativan 2 mg tablet for "anxiety", Haldol 5 mg tablet for "anxiety" and Benadryl 50 mg tablet for "sleep/insomnia" prn.

Review of the NPPN dated 2/10/2020 at 8:20 AM revealed documentation of "pt received Ativan 2 mg Haldol 5 mg and Benadryl 50 mg po for anxiety" There was no documentation of what behaviors the patient was displaying to require prn medications and no documentation of a reassessment of the patient's response to the prn mediations administered.

Review of the MedPPN dated 2/10/2020 at 8:56 PM revealed PI # 2 was administered Ativan 2 mg IM injection for "anxiety", Haldol 5 mg IM injection for "anxiety" and Benadryl 50 mg IM injection for "anxiety" prn.

Further review of the NPPN dated 2/10/2020 from 8:00 PM to 11:00 PM revealed no documentation of what behaviors the patient was displaying to require prn medications and no documentation of a reassessment of the patient's response to the prn mediations administered.

Review of the MedPPN dated 2/11/2020 at 8:32 AM revealed PI # 2 was administered Ativan 2 mg IM injection for "anxiety", Haldol 5 mg IM injection for "anxiety" and Benadryl 50 mg IM injection for "anxiety" prn.

Review of the NPPN dated 2/11/2020 at 8:32 AM revealed documentation of "pt c/o (complaint of) anxious/agitation and requesting IM Cocktail (Haldol, Ativan, and Benadryl) in which was given, will continue to monitor" There was no documentation of what behaviors the patient was displaying to require prn medications and no documentation of a reassessment of the patient's response to the prn mediations administered.

Review of the MedPPN dated 2/11/2020 at 3:42 PM revealed PI # 2 was administered Haldol 5 mg tablet for "anxiety" and Benadryl 50 mg tablet for "sleep/insomnia" prn.

Review of the NPPN dated 2/11/2020 at 3:42 PM revealed documentation of "pt has isolated to his/her room majority of the day...received Benadryl and Haldol this afternoon for anxiety. Will continue to monitor." There was no documentation of what behaviors the patient was displaying to require prn medications and no documentation of a reassessment of the patient's response to the prn mediations administered.

Review of the MedPPN dated 2/11/2020 at 8:35 PM revealed PI # 2 was administered Ativan 2 mg tablet for "anxiety."

Review of the NPPN dated 2/11/2020 from 8:00 PM to 11:00 PM revealed no documentation of what behaviors the patient was displaying to require prn medications and no documentation of a reassessment of the patient's response to the prn mediations administered.

Review of the NPPN dated 2/12/2020 at 7:16 AM revealed documentation of "patient is in the dayroom watching TV (television). He/She states he/she is depressed and anxious...No agitation noted at this time."

Review of the MedPPN dated 2/12/2020 at 8:24 AM revealed PI # 2 was administered Ativan 2 mg tablet for "anxiety", Haldol 5 mg tablet for "anxiety", and Benadryl 50 mg tablet for "sleep/insomnia."

Further review of the NPPN dated 2/12/2020 from 7:00 AM to 12:00 PM revealed no documentation of what behaviors the patient was displaying to require prn medications and no documentation of a reassessment of the patient's response to the prn mediations administered.

Review of the MedPPN dated 2/12/2020 at 9:11 PM revealed PI # 2 was administered Haldol 5 mg tablet for "anxiety", and Benadryl 50 mg tablet for "sleep/insomnia."

Review of the NPPN dated 2/12/2020 from 8:00 PM to 2/13/2020 at 1:00 AM revealed no documentation of what behaviors the patient was displaying to require prn medications and no documentation of a reassessment of the patient's response to the prn mediations administered.

Review of the MedPPN dated 2/14/2020 at 8:34 AM revealed PI # 2 was administered Haldol 5 mg IM injection for "anxiety", and Benadryl 50 mg IM injection for "anxiety."

Review of the NPPN dated 2/14/2020 at 8:35 AM revealed documentation "...pt complained of having anxiety. Stated, 'they are sending me to ICP (Integrated Care Program). I'm getting anxious about that because I don't want to go there...I need something to help calm me down' Gave anxiety meds per IM injection... Results pending. Will continue to monitor for changes in pt's status." There was no documentation of a reassessment of the patient's response to the prn mediations administered.

Review of the MedPPN dated 2/15/2020 at 8:28 PM revealed PI # 2 was administered Haldol 5 mg tablet for "anxiety" and Benadryl 50 mg tablet for "sleep/insomnia."

Review of the NPPN dated 2/15/2020 from 7:00 PM to 11:00 PM revealed no documentation of what behaviors the patient was displaying to require prn medications and no documentation of a reassessment of the patient's response to the prn mediations administered.

Review of the MedPPN dated 2/16/2020 at 10:30 AM revealed PI # 2 was administered Haldol 5 mg tablet for "anxiety" and Vistaril 25 mg IM injection for "anxiety."

Review of the NPPN dated 2/16/2020 at 10:30 AM revealed documentation of "pt approached nurses station and requested Haldol and Ativan. Informed him/her Ativan was not ordered (discontinued on 2/13/2020). Very anxious so gave IM Vistaril. There no documentation of a reassessment of the patient's response to the prn mediations administered.

Review of the MedPPN dated 2/17/2020 at 9:43 AM revealed PI # 2 was administered Haldol 5 mg tablet for "anxiety" and Benadryl 50 mg tablet for "sleep/insomnia."

Review of the NPPN dated 2/17/2020 at 9:44 AM revealed documentation of "tried to educate patient on drug use and getting off controlled medication. Patient is thinking about decreasing controlled medications." There was no documentation of what behaviors the patient was displaying to require prn medications and no documentation of a reassessment of the patient's response to the prn mediations administered.

Review of the NPPN dated 2/17/2020 at 5:51 PM revealed documentation of "...he/she states he/she does not want to stay here and wants to go home but does not want any of his/her controlled medications cut back so he/she can leave. No request this afternoon for additional anxiety medications."

Review of the MedPPN dated 2/17/2020 at 6:24 PM revealed PI # 2 was administered Haldol 5 mg tablet for "anxiety" and Vistaril 25 mg IM injection for "anxiety."

Further review of the NPPN dated 2/17/2020 from 5:00 PM to 10:00 PM revealed no documentation of what behaviors the patient was displaying to require prn medications and no documentation of a reassessment of the patient's response to the prn mediations administered.

Review of the MedPPN dated 2/18/2020 at 5:54 PM revealed PI # 2 was administered Haldol 5 mg tablet for "anxiety" and Benadryl 50 mg tablet for "sleep/insomnia."

Review of the NPPN dated 2/18/2020 at 6:18 PM revealed documentation of "pt lying in bed at this time. Requested Benadryl and Haldol earlier with med given. Pt has been calm today with no behaviors noted..." There was no documentation of what behaviors the patient was displaying to require prn medications and no documentation of a reassessment of the patient's response to the prn mediations administered.

An interview was conducted on 2/21/2020 at 2:21 PM with Employee Identifier (EI) # 1, Director of Nursing and EI # 2, Director of New Day who confirmed the above findings of no documentation of the behaviors the patient was displaying to require prn medications and no documentation of an reassessment following the administration of prn medications. EI # 2 also confirmed there was no documentation of physician notification of the patient's slowed, slurred speech, slowed psychomotor behavior, and drowsiness from medications. At 3:02 PM the surveyor asked, what timeframe would the facility expect a reassessment to be performed of a prn psychiatric medication administration. EI # 1 verbalized "1 hour."
VIOLATION: USE OF VERBAL ORDERS Tag No: A0407
Based on review of New Day (psychiatric unit) medical records (MR), facility policy, National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) Recommendations to Reduce Medication Errors Associated with Verbal Medication Orders and Prescriptions and staff interviews, it was determined the facility failed to ensure the staff documented indications for the use of as needed (prn) medications.

This deficient practice affected 1 of 1 New Day Unit MR's reviewed that required prn medications and did affect Patient Identifier (PI) # 2 and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Medication Administration
Revised: 5/2008

Policy:

...B. Medication Orders

1. ...Both written and verbal orders for medications must be recorded in the patient's chart and may include the following:

...h. Reasons for prn (as needed) administration or specific instructions for use...

NCCMERP: Recommendations to Reduce Medication Errors Associated with Verbal Medication Orders and Prescriptions
Revised: 5/1/15

Recommendations:
The NCCMERP makes the following recommendation to reduce confusion pertaining to verbal orders and minimize medication errors:

...5. Information that should be given in a verbal order include the following:

...Purpose or indication

PI # 2 was admitted to New Day on 1/11/2020 with diagnoses of Personal History of Self-Harm and Bipolar Disorder, Current Episode Depressed, Severe, with Psychotic Features.

Review of the Physician Orders revealed the following verbal orders for medications prescribed on 1/11/2020: Ativan 2 mg (milligrams) oral prn every 6 hours, Haldol 5 mg IM (intramuscular) injection prn every 6 hours, Haldol 5 mg oral prn every 6 hours, Benadryl 50 mg oral prn every 6 hours, Benadryl 25 mg IM prn every 6 hours, Benadryl 50 mg IM prn every 6 hours, and Ativan 2 mg IM prn every 6 hours. There was no documentation of the indication for the use of the previous prn medications.

An interview was conducted on 2/21/2020 at 2:21 PM with Employee Identifier (EI) # 1, Director of Nursing and EI # 2, Director of New Day who confirmed the above verbal orders should have included an indication for the administration of the prn medications.