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.

ALLEGIANCE HEALTH CENTER OF MONROE 3421 MEDICAL PARK DRIVE, MONROE, LA 71203 May 21, 2020
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services. The RN who was responsible for supervision and evaluation of the nursing care for each patient failed to ensure that care was provided in accordance with accepted standards of nursing practice and hospital policy relative to admission orders. Medication orders, laboratory testing, diet orders and observation levels upon admission were written as verbal orders and initiated by nursing staff without the prior ordering and approval of a physician/LIP. The intake coordinator (S14Intake LPN), admitting RN (S12RN) and 2 of 2 physicians (S15Physician, S16Psychiatrist) interviewed indicated that physicians were not routinely called to review and provide verbal authorization for all admission orders that were written by nursing staff prior to the nurses implementing the orders.

Patient #13's admission orders were written as verbal orders by nursing staff without the prior ordering and approval of the patient's physician. These admit medication orders included the patient and his wife's medications, which was copied by S12RN from a list faxed over from the patient's assisted living facility. As a result of receiving his wife's medications for 7 days, which included insulin and an oral hypoglycemic, Patient #13 (who was not a diabetic) was transferred to the hospital per EMS unresponsive with a blood glucose level of 10 (normal 80-130).

This deficient practice had the potential to affect all patients admitted to the hospital (See findings in tag A-0395).

An Immediate Jeopardy situation was identified on 05/20/20 at 5:35 p.m. due to the hospital failing to ensure that all admission orders were ordered and approved by the physician/LIP prior to being initiated by nursing staff.

S2CEO and S11DON presented a corrective action plan for lifting the immediacy of the Immediate Jeopardy situation on 05/21/20 at 9:30 a.m. The written plan was reviewed by the survey team which indicated the following actions had been taken:
1) Effective immediately, admission RN will obtain patient orders from physician upon admit. This includes admit order and preliminary plan of care. If receiving a verbal order, nursing must receive in real time while the order is being written. All new admit orders will be audited by DON upon admission until 100% compliance is met for 3 months.
2) Effective immediately upon admission, admitting RN will obtain and reconcile home medications and present to physician for physician to provide medication orders. As well as audit physician orders for any medication requiring additional monitoring. All new admit orders will be audited by DON upon admission until 100% compliance is met for 3 months.
3) Effective immediately, DON will educate every RN, LPN and admissions prior to admitting a new patient. Nursing staff to be trained on physician verbal and written orders. Policies on medication administration and verbal and written orders competency to be passed prior to admitting a patient. 100% compliance of training acknowledgement monitored by HR and Quality.
4) Effective immediately, change of forms implemented for: Admit Order/Preliminary Plan of Care, Reconcile Home Medication and Physician Order Form, Physicians Orders. DON monitors new forms used and 100% compliance is met for 3 months.

On 05/21/20 at 11:40 a.m., an interview with S5RN, who was on duty at the main campus, confirmed that she had been in-serviced on the changes to the policy and procedure related to the admissions process, including medication reconciliation and receiving of physician's orders and verbalized understanding of the process.

On 05/21/20 at 12:00 p.m., an interview with S19RN, who was on duty at the off-site campus, confirmed that she had been in-serviced on the changes to the policy and procedure related to the admissions process, including medication reconciliation and receiving of physician's orders and verbalized understanding of the process.

The corrective action plan was accepted by the survey team on 05/21/20 at 12:23 p.m. The immediacy of the Immediate Jeopardy situation was lifted but noncompliance remains at the Condition Level due to current non-compliance.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the RN who was responsible for supervision and evaluation of the nursing care for each patient failed to ensure that care was provided in accordance with accepted standards of nursing practice and hospital policy relative to admission orders. This deficient practice was evidenced by failure to ensure medication orders, laboratory testing, diet orders and observation levels upon admission were not written and initiated by nursing staff without the prior ordering and approval of a physician/LIP. The intake coordinator (S14Intake LPN), admitting RN (S12RN) and 2 of 2 physicians (S15Physician, S16Psychiatrist) interviewed indicated that physicians were not routinely called to review and provide verbal authorization for all admission orders that were written by nursing staff prior to the nurses implementing the orders. As a result, Patient #13 received incorrect medication and was transferred to the ED with a blood sugar of 10. This had the potential to affect all patients admitted to the hospital.
Findings:

Review of the Louisiana State Board of Nursing Statutory Definition for RN Scope of Practice R.S. 37:913 revealed the following, in part: (13) "Practice of Nursing" means the performance, with or without compensation, by an individual licensed by the board as a registered nurse, of functions requiring specialized knowledge and skills derived from the biological, physical, and behavioral sciences. The practice of nursing or registered nursing shall not be deemed to include acts of medical diagnosis or medical prescriptions of therapeutic or corrective nature.

Review of the hospital policy titled, "Verbal Orders", Policy Number 3.169, last reviewed 08/13/15, revealed in part that a verbal order shall be considered to be in writing if dictated to a duly authorized person functioning within his/her sphere of competence and signed by the responsible ordering practitioner. Order must be repeated by the person taking the order to the practitioner. All verbal orders will be written directly on the patients' physician order sheet in the chart.

Review of Patient #13's intake paperwork that was faxed over from his assisted living facility revealed a form that included emergency contacts, allergies, medical conditions and diet restrictions. It also included a health form (no date) completed by the patient's primary physician which included current diagnoses (CAD, hypertension, history of CVA and dementia) and current medications (Amlodipine, Lisinopril, Omeprazole, Tizanidine, Ultram). Further review of the intake paperwork revealed a printed list of medications that included Amlodipine, Cilostazol, Lisinopril, Omaprazole, Seroquel, Tizanidine and Ultram. Under the printed list of medications was a handwritten list of medications with the patient's wife's name above the following medications: Metformin, Tresiba insulin, Carvedilol, Aspirin, Losartan and Amlopdipine.

Review of Patient #13's electronic medical record revealed an admitted to the psychiatric hospital of 04/03/20 at 1:30 p.m. Review of the physician orders revealed the first orders written were dated 04/03/20 at 7:42 p.m. and included the following medications: Omeprazole 40mg daily, Lisinopril 40mg daily, Crestor 20mg at bedtime, Ultram 50mg at bedtime and Tizanidine 2mg every 8 hours PRN. These orders were written as verbal orders given by S16Psychiarist and read back and recorded by S12RN. The record revealed that S16Psychiatrist signed and approved these orders on 04/04/20 at 8:08 a.m.

Further review of the physician orders revealed the next orders written were on 04/03/20 at 10:44 p.m. These included the following medications: Norvasc 10mg daily, Cilostazol 100mg twice daily, Seroquel 25mg twice daily, Tramadol 50mg every 8 hours PRN, Metformin 500mg twice daily, Tresiba Insulin 40 units every morning, Carvedilol 6.25mg twice daily and Aspirin 81mg daily. These orders were written as verbal orders given by S16Psychiatrist and read back and recorded by S12RN. The record revealed that S16Psychiatrist signed and approved these orders on 04/04/20 at 8:08 a.m.

Further review of the patient's medical record revealed no other admission physician orders such as diet, labs, observation level or code status. Further review revealed no physician orders for monitoring of blood sugars due to the patient's ordered medications of insulin and Metformin (oral hypoglycemic). Review of a physician progress note (S15Physician) dated 04/05/20 at 11:57 p.m. revealed the physician wrote to obtain fingerstick blood sugars before meals and at bedtime, however this order was not listed in the patient's physician orders in the electronic medical record.

Review of the H & P dated 04/04/20 at 11:28 p.m. by S15Physician revealed the patient's chief complaint was increasing aggressiveness with history of hypertension, GERD, depression and dementia. Further review of the H &P, under the section titled Instructions/Recommendations/Plan, revealed a diagnosis of [DIAGNOSES REDACTED]

Review of Patient #13's April MAR revealed that he received 5 doses of Tresiba insulin and 11 doses of Metformin 500mg from 04/04/20 to 04/11/20. The patient would refuse medications at times.

Review of a physician progress note written by S18NP dated 04/11/20 at 12:09 p.m. revealed that she "received a call from the nurse related to the patient's decrease in responsiveness. VS 98.3, 41, 18, 99/40. She notes that he has poor arousal and had not eaten breakfast." Further review of the note revealed that patient is severely functionally impaired, medical status has declined and acute medical attention is warranted. Patient to be transferred to Hospital A via ambulance.

Review of the patient's nurses notes revealed the last documented note was on 04/11/20 at 12:46 a.m., which stated that patient is much calmer tonight and more cooperative with staff. There were no nurses notes documented after this time. There were no nurses notes related to the patient's transfer to Hospital A on 04/11/20.

A review was conducted of the patient's medical record from Hospital A, where he was transferred on 04/11/20. The ED notes dated 04/11/20 at 2:00 p.m. revealed that per EMS, they attempted to obtain a capillary blood glucose however their machine read as low. The History and Physical dated 04/11/20 at 5:03 p.m. revealed that since being in the ED, lab work was done which showed a blood glucose of 10 at 1:30 p.m. Patient was given dose of D50 intravenous and labs were then drawn. Blood sugar was 296 however patient could still not be aroused. Further review of the record revealed that the patient was pronounced dead on 04/16/20 with discharge diagnoses including acute respiratory failure, [DIAGNOSES REDACTED], altered mental state, azotemia and Covid-19 positive.

On 05/19/20 at 10:10 a.m., interview with S13RN, who worked at the hospital's offsite campus, revealed when admitting new patients, the usual procedure is to use the medication list that is faxed over from the intake coordinator. She further stated that she then writes the medications as verbal orders and the physician reviews them when he makes rounds. She confirmed that she does not call the physician prior to writing these verbal orders for new admissions. When asked if she verifies the medication list, she stated that the intake coordinator does.

On 05/19/20 at 2:00 p.m., interview with S2CEO and S11DON revealed that on the day that Patient #13 was admitted (04/03/20), S14Intake LPN was not at work that day. They stated that S14Intake LPN writes all admission orders (except medications) and obtains all intake paperwork, but since she was not working the day Patient #13 was admitted , the patient arrived to the hospital with no admission orders or paperwork from his assisted living. S11DON stated that she contacted the assisted living after the patient arrived and requested all paperwork to be faxed over to the hospital. S11DON stated that the paperwork was faxed sometime during the night of 04/03/20 and included a list of the patient and his wife's medications. S12RN copied the patient and his wife's medication list as verbal orders from the physician. When asked if this was the hospital's usual protocol for new admissions, S11DON stated that if they have a legitimate list of medications, the nurses will write the medications as verbal orders- read back to the physician and the physician will review the medications when he make rounds. When asked why the nurses do not call the physicians for medication orders for new admissions, S11DON stated, they trust us to have the correct medication list. Further interview revealed that as a result of S12RN writing verbal orders, without contacting the physician first, for Patient #13's wife's medications (which included insulin and an oral hypoglycemic), the patient received 5 doses of insulin and 11 doses of Metformin. When asked if fingerstick blood sugars were obtained, S11DON stated that S15Physician put an order for fingerstick blood sugars AC and HS into the electronic medical record on 04/05/20, but he put it in the wrong section and it never made it to the physician orders. S11DON confirmed that the patient did not receive fingerstick blood sugars AC and HS as ordered by the physician. When asked if Patient #13 was a diabetic, they stated no.

Further interview with S2CEO and S11DON revealed that Patient #13 was transferred to the hospital on [DATE] due to a decrease in responsiveness. S11DON confirmed that there was no nurses note in the record regarding the patient's status and transfer to the hospital. They further stated that they were not aware of the issues with the patient receiving his wife's insulin and medications until the patient's daughter called them on 04/14/20 stating that the patient was not a diabetic but had been receiving insulin and Metformin at this hospital.

On 05/19/20 at 2:40 p.m., interview with S14Intake LPN revealed that she was responsible for obtaining all information from the patients' referral source and prior facility, and getting approval to admit the patient from the physician, CEO and DON. She stated that after she gets approval, she faxes all information to the nurse, including medication lists. When asked if she verifies the medication lists, she stated no. She further stated that the nurses are responsible for verifying the correct medications and obtaining physician orders for them. S14Intake LPN stated that she does write verbal admission orders for things such as diets, observation level, labs and vital sign frequency. She confirmed that she does not contact the physician prior to writing these admission orders as verbal-read back orders.

On 05/19/20 at 3:30 p.m., interview with S11DON confirmed that Patient #13 had no admission orders, besides medications. S11DON confirmed the patient never had any admission orders written for diet, observation level or labs. She again stated that S14Intake is responsible for writing these orders.

On 05/20/20 at 4:00 p.m., a phone interview was conducted with S12RN. She stated that when she arrived to her shift on 04/03/20 at 6:45 p.m., Patient #13 had been at the hospital since 1:30 p.m. but still had no admission orders or any intake paperwork faxed over from his assisted living. S12RN stated that she called the patient's daughter to inform her that they needed the information faxed over from the assisted living. S12RN stated that around 11:00 p.m., the assisted living faxed over the information, which included a printed list of medications with a handwritten list of medications written under them. She stated that she input both sets of medications into the electronic medical record as read back verbal orders from S16Psychiatrist. She confirmed that she did not call the physician prior to writing these verbal medication orders, as this was their usual protocol for new admissions. S12RN further stated that the physician would review the medications when he made rounds the next day.

On 05/20/20 at 4:45 p.m., phone interview with S15Physician confirmed that the usual procedure is for nurses admitting patients to write verbal orders from the medication list that was sent over during intake and the physicians would review the medications when they made rounds. S15Physician further stated that he is the medical physician and that S16Psychiatrist is the primary physician, so S16Psychiatrist would be the one signing off on the admission medications. Further interview with S15Physician revealed that he remembered Patient #13. When asked why a diagnosis of [DIAGNOSES REDACTED].

On 05/21/20 at 9:15 a.m., phone interview with S16Psychiatrist confirmed that he is the psychiatrist for the hospital. He confirmed that the usual procedure is for the nurses to write verbal medication orders from the intake information that was faxed over from their prior facility and that he would review them when he made rounds. S16Psychiatrist further stated that the intake nurse should be verifying the medications and that he trusts the nurses to have accurate lists. S16Psychiatrist confirmed that the nurses do not contact him for medication orders upon admit.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






I. Based on record review and interview, the hospital failed to ensure that drugs and biologicals were prepared and administered in accordance with the orders of the practitioner by failing to document a thorough investigation of potential medication errors for 5 (#8, 7, 9, 10, 3) of 6 (#8, 7, 9, 10, 3, 1) patients reviewed who received medications on the evening of 02/05/2020. All 17 patients in the facility on 02/05/2020 had the potential to be affected.
Findings:

Review of the hospital's procedure/policy for Medication/Treatment Variance last reviewed by the Governing Body on 07/20/2015 revealed, in part, the following:
I. All variances in medication/treatment administration will be reported in writing as soon as they occur.
III.A. Definition: A medication error is considered to have occurred when: ...
3. The patient receives a medication at the wrong time.
5. A patient receives an extra dose of medication.
B. Criteria:
1. The ordering physician and the immediate nursing supervisor are to be notified as soon as the medication/treatment error is discovered.
2. A hospital incident report form with attached follow-up is to be completed within eight hours of occurrence.
3. The incident report with attached follow-up is to be forwarded to the nursing office within 24 hours of occurrence.

Patient #8:
Review of the medical record for Patient #8 revealed an admission date of [DATE] at 8:45pm.
Admission orders included:
Gabapentin 100mg PO TID (8am;2pm;8pm)
Norco 10/325 PO TID (8am;2pm;8pm)
Prazosin 1mg PO TID (8am;2pm;8pm)
Ranitidine 300mg PO QHS (8pm)
Trazadone 50mg PO QHS (8pm)
Review of the Pyxis (overnight drug cabinet) report dated 02/05/20 for Patient #8 revealed one dose of Gabapentin 100mg, one dose of Norco 10-325mg, one dose of Prazosin 1mg and one dose of Trazadone 50mg was removed by S6LPN at 5:30pm, but none of the medications were documented as administered on the MAR.
Review of the Patient Narcotic Count Sheet for Patient #8 revealed 21 tablets of Norco 10-325mg was delivered to the facility on [DATE] at 7:00pm. Further review of the Narcotic Sheet revealed S9LPN removed one dose of Norco 10/325mg from the punch card, which was documented on the MAR as administered to Patient #8 on 02/05/20 at 8:00pm. Further review of the MAR revealed S9LPN administered Trazadone 50mg to Patient #8 at 8:00pm.
Review of the MAR for Patient #8 revealed Ranitidine 300mg PO QHS was documented as administered on 02/05/20 at 8:00pm, both by S6LPN and again by S9LPN.

Patient #7
Review of the medical record for Patient #7 revealed an admission date of [DATE] at 8:55pm.
Admission orders included:
Xanax 0.25mg BID (8am;8pm)
Review of the Patient Narcotic Count Sheet for Patient #7 revealed one dose of Xanax 0.25mg was removed from the punch card by S6 LPN for the 8:00pm dose and a second dose was also removed by S9LPN for the 8:00pm pm dose. Review of the MAR for Patient #7 on 02/05/2020 revealed no doses were documented as administered at 8:00pm.

Patient #9
Review of the Admissions Activity Report revealed patient #9 was admitted to the facility on [DATE] at 3:53pm.
Review of the MAR revealed the patient was scheduled to receive Zoloft 50mg PO daily (8am) and Clonazepam 0.5mg PO QHS (8pm).
Review of the Pyxis report for Patient #9 on 02/05/2020 revealed one dose of Zoloft 50mg was removed at 8:38am by S8LPN- there was no documentation on the MAR that the medication was administered to Patient #9.
On 02/05/2020 at 5:34pm, one dose of Clonazepam 0.5mg was removed from the Pyxis by S6LPN - there was no documentation on the MAR that the medication was administered by S6LPN to Patient #9. Further review of the MAR revealed S9LPN administered Clonazepam 0.5mg to Patient #9 at 7:40pm.

Patient #10
Review of the medical record for Patient #10 revealed an admission date of [DATE].
Review of the MAR revealed the patient was scheduled to receive Xanax 0.5mg POQHS (8pm).
Review of the Patient Narcotic Count Sheet for Patient #10 revealed one dose of Xanax 0.5mg was removed from the punch card by S6LPN on 02/05/2020 for 8:00pm. There is no documented evidence on the MAR that S6LPN administered the Xanax to Patient #10. Review of the MAR revealed S9LPN administered Xanax 0.5mg at 7:43pm.

Patient #3
Review of the medical record for patient #3 revealed an admission date of [DATE].
Review of the MAR revealed the patient was scheduled to receive Lorazepam 0.25mg PO TID (8am;2pm;8pm).
Review of the Patient Narcotic Count Sheet for Patient #3 revealed one dose of Lorazepam 0.5mg (1/2 tab) was removed by S6LPN on 02/05/2020 for 8:00pm. There is no documented evidence on the MAR that S6LPN administered the Lorazepam to Patient #3. Review of the MAR revealed S9LPN administered Lorazepam 0.25mg at 9:08pm.

Review of the nurse schedule for 02/05/2020 revealed S8LPN and S6LPN worked on the day shift (7:00am-7:00pm); S9LPN worked on the night shift (7:00pm-7:00am)

Review of a Medication Error Investigation form dated 02/07/2020 revealed S7NP had called on 02/07/2020 at 2:30pm to report that a nurse had informed her that all the patients were "double dosed" on 02/05/2020. She stated that S4LPN had found the errors at 11:00pm, investigated and informed S3ADON, but no one had informed the doctors, and nothing was done until S7NP came to do rounds on 02/06/2020. She further stated that S6LPN gave the 8:00pm medications early to every patient on the unit, and then S9LPN came on her shift and gave the medications again. S7NP reported she had ordered lab work on all the patients, which was good.
Further review of the investigation report revealed the issue was discussed with S3ADON, who stated she only found 3 med variances that occurred on the 02/05/2020 evening shift, and that staff had notified the medical director per protocol. She stated one of the LPNs was a "new" nurse and she suspected she may have entered information wrong into the MAR. She stated that med variance reports were completed and as far as she could tell the 3 errors were all that could be validated. She stated she had already spoken to the nurse involved one-on-one about proper process and documented such. Stated that she is going to educate and in-service all nursing staff regarding proper medication administration process.

Review of a Pharmacy Variance Report completed by S4LPN on 02/05/2020 at 11:45pm for Patient #7 revealed a wrong dosage was dispensed of alprazolam 0.25mg - the med was given at 6:47pm and 8:13pm. The order is for 8a and 8p. She had already had the 8a dose. The variance was given to CNO to notify MD, etc.
Action taken: MD notified and S7NP. No new orders. Nurse educated on proper narcotic/MAR documentation. New LPN.
Review of a Pharmacy Incident Report completed by S3ADON for Patient #8 for 02/05/2020 at 8:00pm revealed a wrong dosage was dispensed and LPN administered 2 Norco 10/325mg HS when order calls for 1 pill. Also Ultram 100mg given at HS instead of 50mg dose.
Action taken: Medical Director and S7NP notified with no new orders. No injury. Nurse educated on proper narcotic documentation and med dispense.

On 04/3/2020 at 11:30am, phone interview with S10Pharmacy Director confirmed that the pharmacy sends medications to the hospital in pill packs, but the hospital does have a med dispense machine for staff to use for emergencies only, or when the pharmacy is closed, like a night cabinet. He stated that staff orders pill packs for 7 days at a time. He further stated that he had not been notified by the hospital of any medication errors or discrepancies. He further stated that the only time he would be notified of a med error is if he is responsible for the error, like sending the wrong medication. He confirmed that he is the pharmacy director and makes monthly visits to the hospital.

On 04/03/2020 at 1:25pm, an interview with S4LPN confirmed she came on shift 02/05/2020 at 11:00pm; she noticed on the electronic MAR that the medications for patients' 8:00pm doses were documented twice - once by S6LPN at 6:30pm and again by S9LPN at 8:00pm, who came on shift at 7:00pm. She wasn't sure if they had actually been given twice or not, but she copied the MARs and gave them to S3ADON. She said S3ADON stated she "couldn't do med variance reports because it was on all patients."
She stated the next day, S7NP came in and she reported the concern to her. S7NP reviewed the MARs and confirmed she had not been notified of any double dosing. The S7NP ordered labs (CMP, CBC, relevant drug levels) on all patients affected. She reviewed narcotic logs, which showed they had been signed out twice in the book. She stated S7NP called S2CEO and S3ADON to request an investigation of all medications. She reported that S3ADON did not do an investigation, but S1CO investigated about 3-4 weeks ago.

On 04/07/2020 at 12:30pm, an interview with S8LPN confirmed she worked on 02/05/20 and was the preceptor for S6LPN on the 7am-7pm shift. She stated with normal census they staff 1 RN and 2 LPNs - 1 LPN is the medication nurse and the other assists the RN with assessments and charting. She was the med nurse that day along with S6LPN. She worked with S6LPN that morning during the med pass, but allowed S6LPN to do the afternoon med pass independently since there were not as many meds to pass. She stated that routine meds are not marked on the back of the pill packs with the start date or with dosing; only Narcotics and antibiotics are marked with first dose. She stated S6LPN did not report anything to her about giving medications in error or ask her to witness any wasting of medications.

On 04/03/2020 at 3:45pm, an interview with S6LPN confirmed she was in orientation when she worked on 02/05/2020 on the 7am-7pm shift. She confirmed that she had signed out meds for the first pass of the night shift in error, but stated she did not actually pass the medications to the patients. She stated that the electronic MAR system shows the patient name and time of med administration each time you click on it, and will allow more than one click. She stated that the night nurse from the shift after she left noticed that she had documented meds given early and called her and asked "Did you give 8pm meds?" - she stated "No, I stopped at 7." States she was contacted by S3ADON after the LPN called her and was told to "fix the computer - it looks like they were given early" - she came in the next day and removed her initials from the electronic MAR for all medications documented as administered for 8:00pm. She stated S3ADON wrote her up and counseled her on the do's and don'ts of med administration. She confirmed she had used a medication schedule that had been printed from the computer rather than the MAR to administer medications and some discrepancies had been found in that system; she was told to no longer use that printout, but to use the MAR. When asked about the medications that she signed out of the Pyxis and the Narcotic Logs, she stated she could not recall, but confirmed if she had wasted the medications, it would have been documented in the system or on the log.

On 04/03/2020 at 4:45pm, an interview with S7NP confirmed she came in the facility for rounds on 02/06/2020 and S4LPN asked her if she had been notified about double dosing of patients on 02/05/2020 at 8:00pm - she stated she had not been notified. She then went to the med room to review the MARs and saw that the 8:00pm meds were documented as administered the night before at 6:40pm by S6LPN and again at 8:20pm by S9LPN for all patients - double doses. She ordered lab work to be drawn and talked with the two attending physicians to see if they had been notified (they had not). She stated she called S3ADON and found that nothing had been done at that time. She stated she called S2CEO and S1CO and requested that all meds be counted to see if the counts were off. S3ADON texted her the next day and told her that no meds were double dosed - S3ADON stated she had called the nurse and the nurse said she did not give them, only documented that she did. She stated the nurses print a med list out, then pull meds and give them, then document on MAR. S3ADON sent her the narcotic log and the Pyxis report showing the medications signed out. She reported that the double dosing was documented on six of her patients, but confirmed that none of those had negative outcomes.

On 04/03/20 at 4:30pm, an interview with S1CO confirmed that she was contacted by S7NP about suspicion of medication errors on 02/05/2020. S1CO spoke with S3ADON, who said she had investigated and found 2 med errors - Norco signed out of Pyxis (didn't know where it went); showed 2 Norco were given (called MD); also one other medication with double dose. S1CO stated she compared the MAR to the narcotic logs; she observed the medication pass and determined some nurses were not following protocol (they were printing out a paper which showed patient names and meds/time due instead of using the MAR). She stated pills are kept in the med cart with a laptop on the top with access to the electronic MAR; she stated training and re-education has been done with RNs and LPNs related to proper medication administration process and documentation.
On 04/06/2020 at 3:15pm, a follow-up interview with S1CO confirmed there was no documented evidence of an investigation of all medications that had been documented as administered on the electronic MAR by S6LPN on 02/05/2020 (only for narcotics) and no medication variance reports were completed for those medications. She further confirmed that she was aware that S6LPN had removed her initials from the electronic MAR for all medications including the narcotics, and that there was no documentation to account for the wasting of medications signed out of the Pyxis system or the narcotic logs if not administered. She stated that the facility protocol for missing narcotics is to immediately do a count of the narcotics with nursing administration, in-services with nursing staff, and notify the pharmacy. She confirmed that none of these measures were taken.

On 05/19/2020 at 9:30 a.m., an interview with S13RN who was working at the off-site campus, confirmed that when she administers medications, she prints out a list of medications that shows all the patient's names and the medications due for that medication pass, and prepares and administers medications using that list.

On 05/19/2020 at 2:30 p.m., an interview with S11DON confirmed she had failed to include the nurses at the off-site campus during the in-service regarding discontinued use of the medication list during the administration of medications.

II. Based on observation, record review and interview, the hospital failed to ensure that nurses prepared and administered drugs and biologicals in accordance with accepted standards of practice as evidenced by a nurse (S17LPN) who failed to follow the hospital's policy and procedure for medication administration by pre-drawing medications without proper labeling for multiple patients (#17, 18, 16, 15, 19) to be administered simultaneously and documenting the administration of the medications prior to administration to the patients.
Findings:

Review of the hospital's policy and procedure 4.105 Medication Administration Policy revised 11/25/15 revealed, in part, the following:
Page 3, VI. Administration of Medication - D. Any pre-drawn medications must be properly labeled with medication name and dose and the initials of the person preparing the medication.
Page 4, VII. Documentation in the Medical Record - A. All entries noting administration of medication must be entered properly in the medical record. All entries must include the: Time of administration.
Page 6, XI. Hospital Division Protocol - D. Medications are not to be pre-poured.

On 05/19/2020 at 8:30am, observation of S17LPN revealed she entered the medication room through an open doorway. There were 5 medication cups labeled only with patient's last names sitting on the countertop with medications inside each cup. S17LPN stated she had previously accessed the electronic MAR, looked up each patient's medications, punched them from the medication cards and initialed the electronic MAR as administered at the time she drew them up.
Further observation revealed S17LPN put all 5 of the labeled med cups and 5 cups of water into a plastic tray and went into the group therapy room, where patient #17 was sitting at a table. S17LPN administered the medications to patient #17 from the cup labeled with her name - S17LPN was unable to confirm what the medications were, stating she would have to go back and look at the medication cards, as she did not have the MAR with her while she administered the medications, only a report sheet with patient names and room numbers. She placed the basket of uncovered medications for the other 4 patients on the table in front of the patient #17.
S17LPN then took the basket of medications for the other 4 patients into the room of patient #18, where she administered her pills at the bedside and set the basket down while she performed hand hygiene. S17LPN then took the basket of meds for the remaining 3 patients and went into the room of patient #16 and administered her medications and set the tray down to perform hand hygiene. She picked up the tray of medications for the remaining 2 patients and continued to the room of patient #15, but was unable to arouse him to take his medications. S17LPN proceeded down the hallway to patient #19, who was sitting in a gerichair outside his room. She was unable to arouse him to take his medications. She then took the tray of medications for patients #15 and 19 back to the medication room and placed the medication cups inside the medication cart, stating she would try to administer them later. At 10:00am, S17LPN reported that the doctor had been notified that patients #15 and 19 did not receive their medications. She erased her documentation from the electronic MAR that the medications had been administered, and documented the missed medication doses.
An interview S17LPN at this time confirmed she was aware that she should not predraw medications that she is not administering immediately, and should not document medications on the MAR as administered prior to the actual administration of the medications.
VIOLATION: PHARMACIST RESPONSIBILITIES Tag No: A0492
Based on record review and interview, the hospital failed to ensure that the consulting pharmacist was responsible for developing, supervising, and coordinating all the activities of the pharmacy services as evidenced by the pharmacist failing to be notified and involved in medications errors and Quality Assurance activities related to pharmacy issues and by failing to conduct first dose reviews for all medications. Findings:

Review of the written Pharmacy Services Agreement dated 04/19/18 (reviewed 01/19) between the hospital and S10Pharmacist failed to identify the pharmacist responsibilities related to involvement in medication errors and Quality Assurance activities, and first dose review of all medications.

On 5/20/2020 at 11:25 a.m., a telephone interview with S10Pharmacist confirmed he is the hospital's pharmacy director. He stated that his responsibilities included filling patient medications and delivering in blister packs, taking inventory and restocking the night medication storage cabinet. He inspects the medication room monthly, removes out of date medications and performs drug destruction. He also attends quarterly Medical Executive Committee meetings for the purpose of reviewing and revising the formulary.
S10Pharmacist confirmed that he is not notified of any medication administration errors and is not involved in the hospital's Quality Assurance activities. He stated, "The nurses track and trend medication errors, but I don't have anything to do with that." He confirmed that he does not review records or medication administration logs related to patient-specific issues, and reviews daily logs from the night cabinet for medication replacement purposes only.
S10Pharmacist further confirmed that orders for new admissions are faxed to the pharmacy by the nurses, and that if the orders come in after pharmacy hours, he conducts the review the next day. He confirmed that it is rare for the nurses to call him after hours.
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
Based on record review and interview, the hospital failed to ensure that drugs and biologicals were controlled and distributed in accordance with applicable standards of practice and hospital policy by failing to ensure that the pharmacist conducted a review of all medication orders upon admission for appropriateness prior to dispensing the first dose.
Findings:

Review of the hospital's policy 4.103a for First Dose Review dated 09/02/15 revealed the following:
1. All medication orders will be reviewed by the pharmacist before the first dose is dispensed.
2. The pharmacist will review for:
a. therapeutic appropriateness
b. duplication of a medication regimen
c. appropriateness of drug route
d. appropriateness of drug use
e. frequency
f. possible medication interaction
g. patient allergies and sensitivities
h. variations in criteria for use
i. other contraindications
3. The RN/LPN will fax all medication orders to the pharmacist for review. The pharmacist will review and return all medication orders showing "First Dose Review" with statement, "These medication orders have been reviewed and deemed appropriate or inappropriate" with signature and date. Should any medication be inappropriate, the pharmacist will notify the medication nurse within 30 minutes.

Review of Patient #13's intake paperwork that was faxed over from his assisted living facility revealed a form that included emergency contacts, allergies, medical conditions and diet restrictions. It also included a health form (no date) completed by the patient's primary physician which included current diagnoses (CAD, hypertension, history of CVA and dementia) and current medications (Amlodipine, Lisinopril, Omeprazole, Tizanidine, Ultram). Further review of the intake paperwork revealed a printed list of medications that included Amlodipine, Cilostazol, Lisinopril, Omaprazole, Seroquel, Tizanidine and Ultram. Under the printed list of medications was a handwritten list of medications with the patient's wife's name above the following medications: Metformin, Tresiba insulin, Carvedilol, Aspirin, Losartan and Amlopdipine.

Review of Patient #13's electronic medical record revealed an admitted to the psychiatric hospital of 04/03/20 at 1:30 p.m. Review of the physician orders revealed the first orders written were dated 04/03/20 at 7:42 p.m. and included the following medications: Omeprazole 40mg daily, Lisinopril 40mg daily, Crestor 20mg at bedtime, Ultram 50mg at bedtime and Tizanidine 2mg every 8 hours PRN.

Further review of the physician orders revealed the next orders written were on 04/03/20 at 10:44 p.m. These included the following medications: Norvasc 10mg daily, Cilostazol 100mg twice daily, Seroquel 25mg twice daily, Tramadol 50mg every 8 hours PRN, Metformin 500mg twice daily, Tresiba Insulin 40 units every morning, Carvedilol 6.25mg twice daily and Aspirin 81mg daily. These orders were written as verbal orders given by S16Physician and read back and recorded by S12RN. The record revealed that S16Physician signed and approved these orders on 04/04/20 at 8:08 a.m.

On 05/20/20 at 4:00 p.m., a phone interview was conducted with S12RN. She stated that when she arrived to her shift on 04/03/20 at 6:45 p.m., Patient #13 had been at the hospital since 1:30 p.m. but still had no admission orders or any intake paperwork faxed over from his assisted living. S12RN stated that she called the patient's daughter to inform her that they needed the information faxed over from the assisted living. S12RN stated that around 11 p.m., the assisted living faxed over the information, which included a printed list of medications with a handwritten list of medications written under them. She stated that she input both sets of medications into the electronic medical record as read back verbal orders from S16Physician. She stated she also faxed the orders to the pharmacy, but confirmed that the pharmacy was closed and that the pharmacist would not review them until the next day. She confirmed that the nurses do not call the pharmacist after hours to conduct a first dose review.

Review of the Pharmacy Services Contract revealed: After hours is considered any services provided before 9:00am or after 6:00pm Monday through Friday and anytime on Saturday, Sunday, or any major holiday that the pharmacy is closed.

Review of the MAR for Patient #13 revealed the following medications were administered prior to 04/04/2020 at 9:00am:
Omepazole 40mg PO daily on 04/04/2020 at 8:00am;
Lisinopril 40mg PO daily on 04/04/2020 at 8:00am;
Metformin 500mg PO BID on 04/04/2020 at 8:00am;
Norvasc 10mg PO daily on 04/04/2020 at 8:00am;
Acetaminophen 500mg PO TID on 04/04/2020 at 8:00am;
Aspirin 81mg PO daily on 04/04/2020 at 8:00am;
Carvedilol 6.25mg PO BID on 04/04/2020 at 8:00am;
Cilostazol 100mg PO BID on 04/04/2020 at 8:00am

On 5/20/2020 at 11:25 a.m., a telephone interview with S10Pharmacist confirmed he is the hospital's pharmacy director. He stated that orders for new admissions are faxed to the pharmacy by the nurses, and that if the orders come in after pharmacy hours, he conducts the review the next day when the pharmacy opens. He confirmed that it is rare for the nurses to call him after hours.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, record review and interview, the hospital failed to ensure a system for controlling infections and communicable diseases of patients and personnel were established during a national pandemic of Covid-19. This deficient practice was evidenced by the hospital's:
1) failure to develop and implement policies and procedures related to social distancing for patients in the hospital
2) failure to develop and implement policies and procedures related to isolation procedures for new admissions
3) failure to inservice all staff on Covid-19 hospital policies and procedures
4) failure to ensure that staff performed hand hygiene after contact with patients for 2 staff observed during patient care
5) failure to ensure that patient care equipment was disinfected after use on each patient
6) failure to ensure that the nurse followed proper infection control practices by taking medications of patients into the rooms of other patients during medication administation pass
This had the potential to affect all patients on census at the hospital.
Findings:

1) Failure to develop and implement policies and procedures related to social distancing for patients in the hospital
2) Failure to develop and implement policies and procedures related to isolation procedures for new admissions
3) Failure to inservice all staff on Covid-19 hospital policies and procedures

Review of CDC guidance revealed that Covid-19 is thought to be spread mainly from person-to-person who are in close contact with one another. The CDC further recommends that people should not be within six feet of other people outside their home (social distancing).

Review of the hospital's infection control policies and procedures related to Covid-19, presented by S1Compliance Officer as current, revealed none that addressed the procedures for social distancing for the patients or procedures to follow for new admits. Further review revealed none that addressed isolation procedures for new admissions.

Review of the minutes from the Infection Control Committee meeting regarding Covid-19 dated 03/13/20 revealed that social distancing was addressed as well as limiting one patient per room. The minutes further revealed that all patients would be kept apart at meals and groups.

Review of Training and Acknowledgement Forms for Covid-19 dated 03/13/20 revealed the purpose of the training was "to educate facility staff in regards to Covid-19 and updates to processes related to such". Review of the signatures on these forms compared to the current staff list, provided by S1Compliance Officer, revealed that only 6 of 11 full time LPNs and only 3 of 16 full time MHTs received the training on Covid-19.

Review of the medical record for Patient #4 revealed an admitted [DATE]. Review of the patient's nurses notes revealed the following:
03/30/20 at 7:15 p.m., patient was received in day room area with staff and peers
03/31/20 at 11:20 p.m., up in dayroom with staff and peers
04/01/20 at 6:55 a.m., up in dining room waiting for breakfast
04/01/20 at 10:30 a.m., sitting at table with other patients about to eat breakfast
04/02/20 at 10:41 a.m., sitting in dining room eating breakfast

There was no documented evidence in the patient's medical record that social distancing techniques were implemented.

Review of the medical record for Patient #5 revealed an admitted [DATE]. Review of the patient's nurses notes revealed the following:
03/30/20 at 11:17 a.m., received patient in day room with staff and peers
03/30/20 at 8:03 p.m., received patient in day room area with staff and peers
03/31/20 at 9:50 a.m., isolating in room, declined instructions to get out of bed and come to breakfast
04/01/20 at 6:39 a.m., patient awake and sitting in the dining room with other patients getting ready to eat breakfast
04/01/20 at 10:09 a.m., assisted out of bed and into robe, escorted to dining room to eat breakfast with other patients

There was no documented evidence in the patient's medical record that social distancing techniques were implemented.

Review of the medical record for Patient #6 revealed an admitted [DATE]. Review of the patient's nurses notes revealed the following:
03/31/20 at 10:48 a.m., in dining room with other patients
04/01/20 at 6:19 a.m., patient is coughing this morning and the more she yells the more she coughs
04/01/20 at 10:43 a.m., in dining room with other patients to eat breakfast
04/01/20 at 8:10 p.m., patient continues to be loud and verbally aggressive but is remaining in day room with peers and staff
04/02/20 at 10:48 a.m., sitting in dining room with other patients

There was no documented evidence in the patient's medical record that social distancing techniques were implemented.

Review of the medical record for Patient #11 revealed the patient was admitted from an acute care hospital on [DATE]. Review of the patient's nurses notes revealed the following:
04/02/20 at 8:16 a.m., sitting in dining room being fed breakfast
04/02/20 at 1:59 p.m., temp 101.5, contacted APRN and ordered isolation and stat labs (including urine culture, flu, CBC)
04/02/20 at 6:22 p.m., on isolation in room pending lab and test results, temp 98.6
04/03/20 at 10:09 a.m., in room, order for patient to be taken off isolation due to no fever and no signs or symptoms
04/03/20 at 10:10 p.m., received in day room, temp 99.4
04/04/20 at 5:40 a.m., temp 102.8, no cough or shortness of breath
Further review of the notes revealed the physician was notified and ordered patient to be sent to the ER

There was no documented evidence in the record that social distancing techniques were implemented. The record further revealed that facility called the acute care hospital on [DATE] at 6:00 p.m. to check on the patient and was informed that the patient was being tested for Covid-19.

On 04/03/20 at 3:45 p.m., phone interview with S6LPN revealed that she was currently working at the facility that day. When asked how many patients ate in the dining room today, she stated that all ten patients ate together in the dining room. When asked how groups are conducted with the patients, she stated that all patients attend the groups together. S6LPN did not discuss any interventions used for social distancing of the patients.

On 04/03/20 at 4:45 p.m., phone interview with S7NP revealed that she makes rounds on the patients almost daily. When asked if the facility was utilizing social distancing techniques, she stated that most of the time, the patients are in the day room "shoulder to shoulder". When asked if she had seen any of the patients or staff wearing masks, she stated that she had seen one staff member wearing a mask.

On 04/06/20 at 3:15 p.m., interview with S1Compliance Officer revealed that all new admissions are to be isolated to their rooms for 7-14 days. She further stated if the patients come out of their rooms, they are to wear a mask on their face. At that time, the surveyor informed her that Patients #4, 5 and 6 were new admissions and did not have documented evidence in their records that they were isolated in their rooms for 7-14 days after admit. S1Compliance Officer was unable to provide any evidence that the above patients were isolated to their rooms upon admit.

On 04/06/20 at 11:55 a.m., interview with S1Compliance Officer confirmed that she was unable to provide a written hospital policy that addressed isolation of new admissions or a policy that detailed the process for social distancing related to Covid-19. S1Compliance Officer again confirmed that new admissions should be isolated to their rooms for 7-14 days and that patients should not be closer than 6 feet from each other at meals and groups, although there was no written policy. At this time, S1Compliance Officer provided an inservice sign in sheet regarding social distancing. The only names on the sign in sheet were hospital executive staff. Further interview with S1Compliance Officer revealed that the executive staff were to educate the rest of the staff at the hospital. When asked if there was documented evidence that the staff had received training on social distancing for the patients of the hospital, she stated no.

On 04/08/20 at 2:50 p.m., interview with S2CEO confirmed that there was no documented evidence that all hospital staff was inserviced on social distancing. S2CEO further confirmed that new admissions should be isolated to their rooms for the first 7-14 days.

4) Failure to ensure that staff performed hand hygiene after contact with patients for 2 staff observed during patient care

Review of the hospital policy titled, Infection Control, revealed in part that handwashing before and after contact with each patient is the single most important means of preventing the spread of infection.

On 05/19/20 at 8:49 a.m., observation revealed S20Tech was sitting in the hallway observing a 1:1 patient when another staff called her down the hall to Patient #15's room. Upon entering the room S20Tech was observed to shake the patient to attempt to wake him. S20Tech then went to the nurses station to obtain a blood pressure cuff/machine and returned back to Patient #15's room to check his blood pressure. After checking the patient's blood pressure, S20Tech returned the cuff/machine back to the rolling cart in the nurses station and sat back down to observe her 1:1 patient. S20Tech was not observed to perform hand hygiene at any time.

On 05/19/20 at 9:06 a.m., observation revealed S21Tech checked Patient #19's blood pressure with the automatic cuff/machine. S21Tech was then observed to return the cuff/machine to the rolling cart in the nurses station, then immediately hold the arm of another patient to walk them down the hall. S21Tech was not observed to perform any hand hygiene between the care of each patient.

5) Failure to ensure that patient care equipment was disinfected after use on each patient

On 05/19/20 at 8:40 a.m., observation revealed S13RN checked Patient #15's blood sugar with the glucometer in his room. Further observations revealed S13RN exited the room at 8:45 a.m., without disinfecting the glucometer and placed it on the counter at the nurses station. As of 10:30 a.m., the glucometer was still sitting on the nurses station counter and had not been disinfected after use.

On 05/19/20 at 8:49 a.m., observation revealed S20Tech was sitting in the hallway observing a 1:1 patient when another staff called her down the hall to Patient #15's room. Upon entering the room S20Tech was observed to shake the patient to attempt to wake him. S20Tech then went to the nurses station to obtain a blood pressure cuff/machine and returned back to Patient #15's room to check his blood pressure. After checking the patient's blood pressure, S20Tech returned the cuff/machine back to the rolling cart in the nurses station without disinfecting it after use.

On 05/19/20 at 9:06 a.m., observation revealed S21Tech checked Patient #19's blood pressure with the automatic cuff/machine. S21Tech was then observed to return the cuff/machine to the rolling cart in the nurses station without disinfecting it after use on the patient.

6) Failure to ensure that the nurse followed proper infection control practices by taking medications of patients into the rooms of other patient during medication administation pass

On 05/19/2020 at 8:30 a.m., observation of S17LPN during medication administration revealed she put 5 med cups for 5 different patients and 5 cups of water into a plastic tray and went into the group therapy room, where Patient #17 was sitting at a table. S17LPN administered medications to Patient #17 from the cup labeled with her name and placed the basket of uncovered medications for the other 4 patients on the table in front of Patient #17, who did not have a face mask on. After administering the medications, S17LPN removed her gloves and performed hand hygiene with her hands positioned directly above the plastic tray of medications.

S17LPN then took the basket of medications for the other 4 patients into the room of Patient #18, where she administered her pills at the bedside and set the basket of uncovered medications down while she performed hand hygiene. The patient did not have a face mask on.

S17LPN then took the basket of meds for the remaining 3 patients and went into the room of Patient #16. She administered her medications and set the tray down to perform hand hygiene. The patient did not have a face mask on.
S17 picked up the tray of medications for the remaining 2 patients and continued to the room of Patient #15, but was unable to arouse him to take his medications. At one point, Patient #15 coughed as she tried to arouse him while holding the tray. He did not have a face mask on.

S17LPN proceeded down the hallway to Patient #19, who was sitting in a gerichair outside his room. She was unable to arouse him to take his medications. She then took the tray of medications for Patients #15 and #19, who were unable to take their medicaions, back to the medication room and placed the medication cups inside the medication cart, stating she would try to administer them later.

An interview with the LPN at that time confirmed she was aware that she should not predraw medications that she is not administering immediately, and should not administer medications to residents simultaneously.

On 05/19/20 at 2:00 p.m., an interview with S11DON confirmed that it is not the policy of the facility to pass medications to several patients at the same time.