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.

PINNACLE REGIONAL HOSPITAL, INC 12850 METCALF AVENUE OVERLAND PARK, KS 66213 June 14, 2018
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the hospital failed to ensure Registered Nurse Staff addressed the ongoing patient needs of one of 13 records reviewed (Patient 3) by failing to notify a supervisor or other practitioner when a physician ordered the discharge of a surgical patient with fever and pain requiring frequent dosing.

The hospital's failure to ensure nurses continually evaluate and address the needs of the patient has the potential to result in untreated pain, re-hospitalization , or even death.

Findings include:

Patient 3 was discovered unresponsive in bed at his home on 12/27/17, the morning after discharge from this hospital. Emergency medical services were notified and transported the patient to Hospital YY, where he was pronounced dead at 4:43 AM on 12/27/17.

Patient #3's autopsy report dated 12/28/17 showed that based on the circumstances surrounding death, the patient died as a result of acute bronchopneumonia (infection that inflames air sacs in one or both lungs which may fill with fluid), oxycodone intoxication, hypertensive (high blood pressure), atherosclerotic cardiovascular disease (damage or disease in the heart's major blood vessels), and recent lumbar fusion surgery for spondylolisthesis. Quantification studies performed on femoral blood revealed an oxycodone level of 190 mg/ml. The concentration of oxycodone is above the expected therapeutic range and within the potentially fatal range. Oxycodone causes respiratory depression, or a decreased drive to breath. This cause is increased risk of sudden death, which would exacerbate the risk of death with underlying pneumonia. Additionally, the respiratory depression can cause edema (fluid retention), which increases the risk of developing pneumonia. However, according to medical records, prior to Patient 3's release from the hospital following his surgery, chest radiographs and lab studies indicate a pneumonia was developing prior to discharge. Surgery is another risk factor for the development of pneumonia.

Review of Patient 3's medical record on 06/04/18 showed he was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. The patient has a history of Chronic Obstructive Pulmonary Disease (COPD) (a lung disease that blocks airflow and makes it difficult to breath), Hypertension (high blood pressure), Kidney Disease, Liver disease, Charcot-Marie-Tooth syndrome (a disease characterized by progressive loss of muscle tissue and touch sensation across various parts of the body), and his inability to walk has been precipitated by a "heat stroke" incident which left him with a prolonged hospitalization for recovery and now weakness in his lower extremities. The patient had complained of back pain for the last 15 years and received chiropractic care as well as three epidural injections (a steroid medication (to reduce inflammation) injected into the epidural space (the space around the spinal cord) to decrease pain). The patient's history and physical was completed on 12/22/17 by the surgeon, Physician Staff ?, who performed a Transforaminal Instrumented Fusion Minimally Invasive (the joining or fusing of two or more vertebrae together) on 12/22/17. The operative report showed the patient went to the recovery room in good condition where normal motor and sensory examination of the lower extremities was confirmed to be present.
The physician ordered a Respiratory consult on 12/22/17 that failed to be performed throughout the patient's hospitalization .

Patient 3 received the following pain medications on 12/22/17: Toradol (pain medication) 15 milligrams (mg) intravenous (IV) at 8:45 PM, Percocet (pain medication) 7.5/325 mg, 2 tablets at 8:46 PM, and Fentanyl 100mcg IV at 9:00 PM.

On 12/23/17, the patient's labs showed his white blood cell count (WBC) (indication of inflammation or infection in the blood) were 13.4 high (normal range is 3.4-10.8) with [DIAGNOSES REDACTED]s (part of the white blood cells) at 10.5 (normal range 1.4-7.0).

Patient 3 received the following pain medications on 12/23/17: Toradol (pain medication) 15 milligrams (mg) intravenous (IV) at 00:15 AM, 8:01 AM and 2:26 PM, Oxycodone (pain medication) 10mg tablets (2 tablets) at 8:02 AM, 12:10 PM, 4:08 PM, and 8:04 PM, Fentanyl (pain medication) 50 micrograms (mcg) IV injectable at 4:40 AM, and Morphine (pain medication) 2mg/ml, 2mg IV at 9:21 PM.

On 12/24/17, the WBC count at 5:00 AM was 15.5 high and [DIAGNOSES REDACTED] count 10.1 high and on 12/24/17 at 12:00 PM was 11.2 high and the [DIAGNOSES REDACTED] count was 6.7.

Normal temperature is 98.6. The patient had temperatures on 12/24/17 with readings throughout the day of 100.7, 99.5, 99, 99.1, and 99.1.

Patient 3 received the following pain medications on 12/24/17: Oxycodone (pain medication) 10mg tablets (2 tablets) at 00:20 AM, and 4:34 AM, 4:27 AM, 8:20 AM, and 11:51 AM, Hydromorphone (pain medication) 2mg tablets (2 tablets) at 6:16 AM and 10:08 AM, Fentanyl (pain medication) 50 micrograms (mcg) IV injectable at 2:28 AM, 7:20 PM and 10:32 PM, and Fentanyl 100mcg IV at 1:59 PM and 4:50 PM.

On 12/24/17, Physician, Staff N documented in his progress note that Patient 3 was "somewhat lethargic" and was complaining of pain in his back and legs. The nurse documented in the nursing notes "Decision made to hold discharge today."

The patient's record showed a chest x-ray was performed on 12/24/17 with results of reticulonodular opacities (the overlapping of reticular (connective tissues and fibers) shadowing and pulmonary nodules (a small mass in the lungs that is usually benign (lacks the ability to invade nearby tissues)) are seen in the left lower lobe of the lung suggestive of developing infiltrates (to cause something such as a liquid to permeate something by penetrating its pores, cells, or surrounding tissue), follow up recommended. The medical record lacked documentation of a follow up X-ray.

On 12/25/17, Patient 3's temperature continued to be elevated with readings of 100.7, 102, 100.1 99.4, and 100.4. Physician Staff N documented that the patient had a significantly low oxygen saturation of 87% on room air but improved to 90% with deep breathing.

Patient 3 received the following pain medications on 12/25/17: Dilaudid (pain medication) 1mg/ml, 1 mg IV at 00:30 AM and 3:31 AM, Oxycodone (pain medication) 10mg tablets (2 tablets) at 9:30 AM, 1:25 PM, 5:21 PM and 9:25 PM.

On 12/26/17 (day of discharge), Patient 3 had elevated temperatures of 101.5, 103 and 101 (at discharge).

Patient 3 received the following pain medications on 12/26/17 prior to discharge: Oxycodone (pain medication) 10mg tablets (2 tablets) at 4:27 AM, 8:20 AM, and 11:51 AM.

The patient's pain score ranged from 4/10 to 10/10 (10 being the worst pain) throughout his hospitalization .

The patient's pain upon discharge was a 5/10 and his goal was a 4/10. He was to follow up with the Surgeon, Staff DD in one week, have a walker delivered to his home, and he was given a prescription for Oxycodone with taper instructions and Flexeril (muscle relaxant). Prior to the surgery the documented home pain medications were Lyrica (nerve, muscle pain and fibromyalgia) 200mg one tablet three times a day and Norco (pain medication) 10mg tablet every 6 hours as needed.

On 12/26/17 at 8:10 AM registered nurse (RN), Staff L documented that the patient had an elevated temperature of 103 degrees Fahrenheit. At 9:16 AM, Physician, Staff N documented that he switched the patient to a form of oxycodone that did not contain Tylenol and discharged the patient despite the patient's significantly elevated temperature.

Review of the discharge instructions given to the patient and his significant other stated to notify your provider if any of the following occur - temperature over 101 (despite the fact that the patient's temperature was 101 at discharge and had been over 101 each time his temperature was taken that day).

The physician wrote the patient a prescription for a pharmacist to dispense 90 tablets of Oxycodone 10 mg with directions for the patient to take 1 or 2 tablets every 4 hours as needed, taper to 1 tablet every four hours in 3 days.

On the "Physician Orders" page of the medical record, RN, Staff K documented on 12/26/17 at 10:30 AM, "Ok to D/C home." The nurse did not indicate whether the order for discharge came from a practitioner with admitting privileges or whether the order was provided verbally or by telephone. Two weeks after the patient was discharged , a physician signed the order written by the nurse on the record.

On 12/29/17 at 12:17 PM, after Patient 3 expired, RN, Staff L entered the following in nursing notes: Late Entry: For care provided on 12/26/17. Patient still having intermittent high temperatures. Recheck prior to D/C patient at 101.0. Physician Staff N in to round on patient, discussed patient status, after seeing patient. OK to d/c/home.... Patient often asking for pain medication frequently or sooner than ordered.

The medical record lacked documentation that Staff L took her concerns about the patient's temperature or frequent need for pain medication prior to time for additional doses to any supervisor or other Practitioner prior to Patient 3's discharge.

Interview on 06/05/18 at 2:58 PM, Staff L, RN stated that it is not normal practice to discharge a patient with a temperature of 101.0. Staff L further stated that she did collaborate with Staff N, Physician the day of discharge concerning the fevers, but she did not have the final say on the patient's disposition.

Interview on 06/05/18 at 4:00 PM, Staff N, Physician stated that he was consulted to provided care for Patient 3 after he had surgery. He stated that he stayed at the hospital an additional day over Christmas to keep his pain controlled until he could have the prescription filled. Patient 3's elevated temperature and intermittent temperatures are very common with surgery. He stated that even though Patient 3 had a temp up to 103, and the WBC was elevated initially, there were no bands to indicate an acute infection. At discharge, "I looked at the labs to make sure he did not have an active infection." The autopsy showed Patient 3 had pneumonia. "I did not hear crackles (lung sounds which may indicate extra fluid in the lungs), he did not desaturate (have a lower oxygen level), and I did not think he had pneumonia. I have an ongoing conversation with the County Coroner and do not agree with the autopsy report. I don't know if I would have done anything different. I saw him the day of dismissal. He was totally non-symptomatic."

Interview on 06/05/18 at 9:58 AM, Staff M, Pharmacist, remembered "they" talked about Patient 3 in an administrative staff meeting. It was discussed that Patient 3 died of bronchopneumonia and oxycodone overdose and the hospital was negligent in their care. Staff M further stated that the hospital was fighting to have the reason for the cause of death changed. She stated that the patient had passed away in his home the morning following the discharge. Staff M stated that there is a lot of the blame game going on between Staff N, Physician and Staff L, the Registered Nurse, who cared for the patient prior to discharge home, and that Physician Staff M tried to change the documentation. The RN (Staff L) said that she reported to the doctor that Patient 3 had a fever, but the Physician (Staff N) said he didn't know about it. They were arguing back and forth. Staff M stated that the patient had a fever off and on since his surgery and that Staff N, Physician, failed to put in an order for a repeat chest x-ray.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, record review, and policy and procedure review the hospital failed to ensure contracted Registered Nurse (RN) staff, Staff S adhered to the hospital's Advanced Cardiac Life Support and Code Blue protocols for one of one patient (Patient 10) that required resuscitation, failed to ensure contracted Registered Nurse staff (Staff S) completed hospital required code and transfer documentation, and failed to ensure contracted Registered Nursing staff (Staff S) was appropriately experienced to provide independent care and recognize a potential opioid overdose in a patient receiving copious amounts of narcotics.

These deficient practices have the potential to cause ineffective resuscitation efforts and a failure to recognize a narcotic overdose which could lead to patient harm or death.

Findings include:

Patient 10 had right hip replacement surgery on 02/06/18 and within a short time developed a surgical site infection. Patient 10 returned to the hospital on [DATE] and was treated with pain medications, intravenous antibiotics, and a wound vacuum (therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds). He was discharged on [DATE]. Patient 10 was then re-admitted on [DATE] for the removal of the wound vacuum, irrigation and debridement of the wound, and application of new wound vacuum device. Patient 10 received pain medications and IV antibiotics during this hospitalization as well. Patient 10 was readmitted on [DATE] for a wash out (removal of unhealthy tissue from a wound to promote healing) of the right hip and received pain medications and IV antibiotics. On 03/30/18, an incision and drainage of the right hip with wound vacuum was performed. On 04/09/18, the surgeon performed and removed the right total hip implants and applied a wound vacuum to the right hip and during the procedure the right femur fractured.

Interview on 06/05/18 at 1:15 PM, Staff T, Surgeon stated that Patient 10 needed to have additional surgery at a hospital that provided a higher level of care. He further stated that he did not feel comfortable performing the surgery at this hospital and that Patient 10 needed to be transferred form this hospital to another facility.

The medical record further showed the 24 hours before the patient's death, nursing staff administered large quantities of narcotic pain medications to the patient including: a fentanyl (narcotic pain medication used to treat severe pain) patch (absorbed through the skin), fentanyl IV (through the vein), PO (by mouth) Oxycodone (narcotic pain medication used to treat severe pain), PO and IV Dilaudid (narcotic pain medication used to treat moderate to severe pain), and sedatives including PO Valium and PO Ativan.

Review of Patient 10's medical record on 06/07/18 showed that he received the following narcotic and sedative medications:

04/07/18: Fentanyl 100 mcg (micrograms)/hr (hour) transdermal (narcotic medication used to treat severe pain; released through the skin) film, extended release 100 mcg Transdermal
04/10/18: 12:10 AM - Fentanyl 100 mcg IV (through the vein)
04/10/18: 4:00 AM- Oxycodone Hydrochloride (narcotic used to treat moderate to severe pain) 10 mg oral tablet 2 PO (by mouth) tablet
04/10/18: 5:01 AM - Fentanyl 100 mcg IV
04/10/18: 7:30 AM - Fentanyl 100 mcg IV
04/10/18: 8:37 AM- Hydromorphone Hydrochloride (narcotic used to treat moderate to severe pain; 2 mg oral tablet) 2 PO tablets
04/10/18: 8:44 AM - Valium (diazepam - a sedative) 10 mg PO
04/10/18: 10:48 AM - Fentanyl 100 mcg IV
04/10/18: 10:52 AM - Ativan (lorazepam-a sedative) 1 mg PO
04/10/18: 11:40 AM - Dilaudid (hydromorphone - narcotic used to treat moderate to severe pain) 1 mg IV
04/10/18: 2:24 PM - Hydromorphone Hydrochloride 4 mg PO
04/10/18: 2:56 PM - Fentanyl 100 mcg/hr Transdermal patch
04/10/18: 4:17 PM- Dilaudid 1 mg IV
04/10/18: 6:38 PM - Fentanyl 100 mcg IV
04/10/18: 9:56 PM - Valium 10 mg PO tablet
04/10/18: 9:57 PM - Oxycodone Hydrochloride 20 mg PO
04/10/18: 11:00 PM - Ativan 1 mg PO

Mixing sedatives with narcotics can be risky as both classes of drugs can heighten the risk of respiratory depression, extreme sedation, and death.

On 04/11/18 at 12:00 AM, Staff S documented that Patient 10 had an oxygen saturation rate of 93% and was placed on two liters per minute of oxygen.

Review of the medical record showed Patient 10 had not routinely required oxygen therapy and had not required oxygen prior to his admission to the hospital.

On 04/11/18 at 3:52 AM Staff S documented the following information:

The patient was found unresponsive at about 3:50 AM. He was warm to the touch with a normal color. The patient's blood pressure 148/59 (average 120/80) , pulse was 110 beats per minute (normal = regular and 60 - 100), but was intermittent. The patient was taking deep intermittent breaths at that time approximately 10 seconds apart or 6 breaths per minute (normal 12-20). The patient was on oxygen and the oxygen saturation was at 89% (normal 90 - 100 on room air) on 2 Liters (L) of oxygen per minute. Oxygen was increased to 5 liters per minute. A sternal rub was performed three times with no response. CPR (cardio-pulmonary resuscitation) was started, and a colleague summoned EMS (Emergency Medical Services). The crash cart was availed, Ambu bag (a manual airway device used to deliver forced oxygen into the lungs) with oxygen was applied, while Staff S and colleague continued compressions. AED shock pads were attached on to the patient and the AED analyze the Rhythm. No shock was advised two times. We kept performing chest compressions until EMS arrived. EMS took over and continued compressions, secured the airway, suctioned the patient. Compressions were continued for 23 minutes. Pulse was regained at about 4:33 AM. Blood pressure was 84/49 and the pulse was 111. The patient was transferred to gurney by EMS and taken to Hospital ZZ at about 4:40 AM.
.
Review of hospital policy titled, "Code Blue Management," dated July 2017, showed Staff S failed to administer ACLS appropriate drugs as directed by the guidelines of the American Heart Association...and...At the end of the CODE BLUE the documentation will be reviewed, signed by the documenter, and the Physician directing the code. A code summary will be run form the monitor on the crash cart, mounted on a progress sheet and attached to the code blue summary sheet.

Review of the American Heart Association's Adult Cardiac Arrest Algorithm updated in 2015 and located on the crash cart showed the following: Step 1- Start CPR, give oxygen, attach monitor/defibrillator. If the rhythm is not shockable and the rhythm is Asystole/PEA the next step is to give CPR for two minutes and establish an IV/IO access, deliver Epinephrine every three to five minutes, and consider an advanced airway, capnography (carbon dioxide monitoring).

The record lacked any documentation that showed that Staff S recognized Patient 10's respiratory depression as a potential sign of opioid overdose or that the medication Naloxone, which is designed to rapidly reverse an opioid overdose was given. The record further showed that the Staff S did not follow Advanced Cardiac Life Support (ACLS) guidelines for a heart rhythm that is not shockable, in that they failed to administer the medication Epinephrine (adrenalin - a vasopressor used to treat pulseless electrical activity) every three to five minutes, during the approximate 50 minutes after Patient 10 was found unresponsive and he was taken to the other hospital. Staff S failed to deliver any ACLS medications during the code as directed by the algorithm and failed to recognize the potential for respiratory depression related to the large amount of narcotic medications and sedatives Patient 10 had received during the previous 24-hours. These deficient practices have the potential to diminish resuscitation attempts and could lead to death. .

During an interview on 06/06/18 at 12:22 PM Staff B, Director of Quality, stated she was unable to locate any code sheet documentation for Patient 10. Staff B also confirmed the hospital requires a transfer form to be completed with all transfers, but stated a transfer form was not located for Patient 10.

During an interview on 06/07/18 at 8:30 AM Staff M, Pharmacist, stated, I can tell you that after the code for Patient 10 I reviewed the crash cart to make sure I didn't need to replace any medications. The only thing that was used was a saline flush. No Narcan was used. No epinephrine was used. As a matter-of-fact no emergency drugs were taken from the crash cart. I would have expected at least one dose of Narcan or one dose of epinephrine would have been used. We gave Patient 10 a lot of narcotics and I believe anyone with experience would have recognized a potential for narcotic overdose and would have tried at least one dose of Narcan. I agree the ACLS algorithm shows that epinephrine should have been delivered while CPR was in progress.

During an interview on 06/05/18 at 12:00 PM Staff H, Registered Nurse, stated Patient 10's symptoms screamed of overdose to me. Patient 10 should have gotten Narcan. We do stock Narcan here, so it was available.

Review of the Autopsy report for Patient #10 on 06/07/18 showed the cause of death documented as coronary artery disease (a blockage in the coronary arteries) with Fentanyl intoxication as a contributing factor.

During an interview on 06/07/18 at 9:39 AM Staff FF, County Coroner, stated that coronary artery disease was the actual cause of death, but Fentanyl intoxication was a contributory cause. Staff FF indicated a therapeutic level for a Fentanyl patch is 1.9 to 3.8 and Patient 10's laboratory studies at autopsy showed his level was 18. Staff FF indicated this was six times the therapeutic level for a patient with a Fentanyl patch.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, record review, document review, and policy review the hospital failed to ensure nursing staff administered medications at the right time according to a prescribed frequency and time for six of 29 patients (Patients 2, 3, 5, 6, 7 and 10) with medication administration record (MAR) review, failed to ensure staff documented the disposal of a controlled substance for one of 10 patients (Patient 10), failed to ensure nursing staff followed standard of practice guidelines for administration limits of Acetaminophen (Tylenol) for one of 29 patients (Patient 29) with MAR review. These deficient practices have the potential to cause ineffective medication (antibiotic or pain) management, drug overdose, adverse drug reactions, and medication errors that could lead to harm or death.

Findings include:

- Document review of the hospital's Medication Administration Policies showed the hospital failed to provide a policy identifying time-critical and non-time critical medications and for the administration of time-critical and non-time critical medications.

According to the Institute for Safe Medication Practices (ISMP): Time-critical scheduled medications are those for which an early or late administration of greater than thirty minutes might cause harm or have significant, negative impact on the intended therapeutic or pharmacological effect. Accordingly, scheduled medications identified under the hospital's policies and procedures as time-critical must be administered within thirty minutes before or after their scheduled dosing time, for a total window of 1 hour. It is possible for a given medication to be time- critical for some patients, due to diagnosis, clinical situation, various risk factors, or therapeutic intent, but not time-critical for other patients. Therefore, hospital policies and procedures must address the process for determining whether specific scheduled medications are always time-critical, or only under certain circumstances, and how staff involved in medication administration will know when a scheduled medication is time-critical. Examples of time-critical scheduled medications/medication types may include, but are not limited to: Antibiotics; Anticoagulants; Insulin; Anticonvulsants; Immunosuppressive agents; Pain medication (non-IV);
Medications prescribed for administration within a specified period of time of the medication order;
Medications that must be administered apart from other medications for optimal therapeutic effect; or
Medications prescribed more frequently than every 4 hours.

Non-time critical scheduled medications are those for which a longer or shorter interval of time since the prior dose does not significantly change the medication's therapeutic effect or otherwise cause harm. For such medications greater flexibility in the timing of their administration is permissible. Specifically: Medications prescribed for daily, weekly or monthly administration may be within 2 hours before or after the scheduled dosing time, for a total window that does not exceed 4 hours; Medications prescribed more frequently than daily but no more frequently than every 4 hours may be administered within 1 hour before or after the scheduled dosing time, for a total window that does not exceed 2 hours.


Review of Patient 10's medical record on 06/05/18 showed the following:

Patient 10 had a hip replacement surgery at the hospital on [DATE].

During the 02/06/2017 date of service medication orders are as follows;

Fentanyl (a narcotic medication used to treat pain) - order for 100 micrograms (mcg) Intravenously (IV, into the vein) every two hours for four days:

Scheduled for administration on 02/06/18 at 4:56 PM and administered at 10:36 PM (five hours and 40 minutes late).

Scheduled for administration on 02/06/18 at 6:56 PM and administered on 02/07/18 at 4:45 AM (33 hours and 41 minutes late).

Scheduled for administration on 02/06/18 at 8:56 PM and administered on 02/07/18 at 9:38 AM (25 hours and 38 minutes late)

Scheduled for administration on 02/06/18 at 10:56 PM and administered on 02/07/18 at 9:38 AM (22 hours and 42 minutes late).

Patient 10's medical record showed no other documented doses of every two hour scheduled doses of Fentanyl 100 mcg's on the printed MAR provided by the facility on 06/05/2018 for the dates of 02/06/18, 02/07/18, 02/08/18 and 02/09/18.

Depakote 250 milligrams (mg) (unit of measure) by mouth (PO) administered twice daily for four days (medication used for mood stabilization, to treat seizure disorders, certain psychiatric conditions and to prevent migraine headaches. Medication directions include taking at the same time each day to maintain constant amounts of the medication in the blood stream.)

Scheduled for administration on 02/06/18 at 9:00 PM; however, Staff C, Registered Nurse, did not administer the medication and documentation showed, "Patient does not have medication with him. Uses it for sleep".

Scheduled for administration on 02/07/18 at 9:00 AM; however, Staff D, Registered Nurse, did not administer the medication and documentation showed, "Patient no longer taking. Did not bring medication from home.

Scheduled for administration on 02/07/18 at 9:00 PM; however, Staff E, Registered Nurse, did not administer the medication and documentation showed, "Patient is no longer taking".

Scheduled for administration on 02/08/18 at 9:00 AM; however, Staff F, Registered Nurse, did not administer the medication and documentation showed, "Patient refused".

History and Physical Progress Note signed by Staff G, Advanced Practice Registered Nurse, on 02/06/18 at 3:19 PM showed Patient 10 was currently taking Depakote for mood stabilization.

During an interview on 06/05/18 at 12:00 PM with Staff I, Registered Nurse, stated, "Patients are instructed to bring their home medications in with them and then we take them to the pharmacy, but if a patient forgot to bring it and it is something we don't carry we are supposed to get it from a local pharmacy usually by that afternoon".

During an interview on 06/06/18 at 4:45 PM, Staff M, Pharmacist, stated that if there is a medication on the patient's home medication list that they did not bring with them and we don't stock it, the nurses are supposed to let the pharmacy know so we can order it in for them. We can get most medications relatively quick.

Patient 10's medical record lacked communication from the nursing staff to the physician regarding the absence of the patient's home medication (Depakote). The record failed to show the nursing staff notified the pharmacy that the patient did not have this home medication with him.

After he was discharged from the facility, he developed a surgical site infection. Patient 10 went to a local emergency department where he received intravenous antibiotics (IV) and was advised to follow up with his surgeon. Patient 10 followed up at the clinic and was directed to go to the hospital on [DATE]. Patient 10 was treated with an increasing amount of pain medications, and intravenous antibiotics, a wound vacuum (a device used to promote wound healing). He was discharged on [DATE].

During the 02/19/2018 through 02/25/18 dates of service medication orders are as follows;

Fentanyl (narcotic pain medication) order for 50 micrograms (mcg) (unit of measure Intravenously (IV) every two hours for four days.

Scheduled for administration on 02/20/18 at 1:55 AM and administered on 02/20/18 at 3:15 AM (1 hour and 20 minutes late).

Scheduled for administration on 02/20/18 at 3:55 AM administered on 02/20/18 at 7:36 PM (10 hours and 5 minutes late).

Scheduled for administration on 02/20/18 at 5:55 AM and administered on 02/20/18 at 11:19 PM (16 hours and 24 minutes late).

Scheduled for administration on 02/20/18 at 7:55 AM and administered on 02/21/18 at 6:12 AM (22 hours and 17 minutes late).

Scheduled for administration on 02/20/18 at 9:55 AM and administered on 02/21/18 at 11:15 AM (23 hours and 20 minutes late).

Scheduled for administration on 02/20/18 at 11:55 AM and administered on 02/21/18 at 4:25 PM (28 hours and 30 minutes late).

Scheduled for administration on 02/20/18 at 1:55 PM and administered on 02/21/18 at 6:57 PM (29 hours and 5 minutes late).

Scheduled for administration on 02/20/18 at 3:55 PM and administered on 02/21/18 at 9:40 PM (29 hours and 45 minutes late).

Scheduled for administration on 02/20/18 at 5:55 PM and administered on 02/21/18 at 2:40 AM (33 hours and 45 minutes late).

Scheduled for administration on 02/20/18 at 7:55 PM and administered on 02/21/18 at 4:44 AM (33 hours and 49 minutes late).

Scheduled for administration on 02/20/18 at 9:55 PM and administered 02/21/18 at 7:04 AM (9 hours and 9 minutes late). Is this correct-it doesn't fit in line with the others.

Scheduled for administration on 02/20/18 at 11:55 PM and administered on 02/22/18 at 2:15 PM (38 hours and 20 minutes late).

Scheduled for administration on 02/21/18 at 1:55 AM and administered on 02/22/18 at 5:09 PM (39 hours and 14 minutes late).

Scheduled for administration on 02/21/18 at 3:55 AM and administered on 02/22/18 at 9:32 PM (41 hours and 37 minutes late).

Scheduled for administration on 02/21/18 at 5:55 AM and administered on 02/23/18 at 8:08 am (51 hours and 23 minutes late).

Scheduled for administration on 02/21/18 at 7:55 AM and administered on 02/23/18 at 12:42 PM (52 hours and 47 minutes late).

Scheduled for administration on 02/21/18 at 9:55 AM and administered on 02/23/ 18 at 8:29 PM (58 hours and 33 minutes late).

Scheduled for administration 02/21/18 at 11:55 AM and administered on 02/24/18 at 3:27 AM (63 hours and 32 minutes late).

Scheduled for administration on 02/21/18 at 1:55 PM and administered on 02/24/18 at 6:29 AM (104 hours and 34 minutes late).

During an interview on 06/05/18 at 10:10 AM with Staff I, stated "a fentanyl order should be written as needed (PRN), but if it is not, it will show up on the medical administration record (MAR) as a medication to be given on a schedule based on the frequency of administration in the order."

Vancomycin 1 gram (gm) (unit of measure) IV every eight hours for two days (antibiotic that leaves the body through the kidneys and has a half-life of four to six hours. Accumulation of the medication in the blood stream can result in permanent ototoxicity (damage to hearing) and nephrotoxicity (damage to the kidneys). The medication requires administration at predetermined times and monitoring blood stream residual levels between doses by obtaining trough levels) to avoid permanent damage.)

Scheduled for administration on 02/19/18 at 7:30 PM and administered on 02/19/18 at 8:46 PM (1 hour and 16 minutes late.)

Scheduled for administration on 02/20/18 at 11:30 AM and administered on 02/20/19 at 4:28 PM (4 hours late.)

During an interview on 06/05/18 at 10:10 AM with Staff I, stated scheduled medications are to be given within an hour of the scheduled time, but she was unsure if that meant a half hour either side of the scheduled time of administration or an hour either side of the scheduled time of administration. She also stated there was no policy she was aware of for reporting medications given outside of the scheduled time.

Interview on 06/07/18, Pharmacist Staff M stated that we don't have time dependant policies for medication administration (like Vancomycin). But I would expect it to be given within 30 minutes of the scheduled time because it's time-sensitive. I am available to answer questions all the time so if they had a question about the medication, if I wasn't here they could have called.


Depakote 250 milligrams (mg) (unit of measure) by mouth (PO) administered twice daily for eight days.

Scheduled for administration on 02/20/18 at 9:00 PM and administered 02/21/18 at 3:15 AM with documentation by Staff AA, Registered Nurse (RN) stating "held, not available."

Scheduled for administration on 02/21/18 at 9:00 AM and administered on 02/21/18 at 9:35 AM with documentation by Staff BB, RN, stating "the medication is not available."

Xanax 0.5 mg PO at bedtime for eight days (tranquilizer medication given for panic and anxiety disorders).

Scheduled for administration 02/20/18 at 9:00 PM and administered 02/21/18 at 3:19 AM with documentation by Staff AA, RN, stating "held, not available."

Scheduled for administration 02/21/18 at 9:00 PM and administered 02/21/18 at 9:36 PM with documentation by Staff BB, RN, stating "held, medication not available."

During an interview on 06/04/18 at 12:00 PM in the Pharmacy, Pharmacist, Staff U stated that the process for checking and providing continuation of essential home medications for patients includes instructing for them to bring the actual medications to the hospital with them at admission. Those medications are sent to the Pharmacy for review of accuracy by the Pharmacist. They are then placed in a baggy with the patient information label placed on the baggy and are placed into the Omnicell by the Pharmacist. Staff U, Pharmacist further stated that if a patient does not bring home medications to the hospital and they are ordered to be continued, then they are ordered from a local Pharmacy and made available to the patient normally within the same day. He further stated medications are reviewed daily by Pharmacy for new orders, that at no time are patients allowed to self-administer medications. Staff U stated medication errors included omissions and the RN making the error is responsible for completing the incident report which then goes to Pharmacy, Quality, and the Director of Nursing (DON) for review.

During an interview on 06/05/18 at 10:10 AM, Staff I, RN, stated that patients are instructed to bring home medications with them at the pre-operative phone call and if they do not bring them, the hospital will make arrangements to obtain them from a local pharmacy and provide them to the patient, usually by the afternoon of the same day. Staff I further stated, "we realize the psychiatric medications are an example of the medications frequently required for the patients that need to be continued during their hospital stay."

During an interview on 06/06/18 at 3:30 PM, Staff M, Pharmacist, stated that home medications that are non-formulary and not brought to the hospital by the patient are made available to the patient if ordered by obtaining them from a local Pharmacy, usually the same day.

Patient 10's medical record lacked communication from the nursing staff to the physician regarding the absence of the patient's home medications (Depakote and Xanax). The record failed to show the nursing staff notified the pharmacy that the patient did not have these home medications with him.


Gentamicin 100 mg IV Piggy Back (IVPB) administered twice daily for three days (antibiotic that leaves the body unchanged and has a half - life of two to three hours. Accumulation of the medication in the blood stream can result in in ototoxicity (toxic to the ear; can cause hearing loss and imbalance.) The medication requires administration at predetermined times and monitoring of blood stream levels before and after administration to avoid permanent damage.)

Scheduled for administration 02/21/18 at 3:30 AM and administered 02/21/18 at 4:29 AM (1 hour and 29 minutes late).

Scheduled for administration 02/21/18 at 3:30 PM and administered 02/21/18 at 6:03 PM (2 hours and 27 minutes late).

Scheduled for administration 02/22/18 at 3:30 AM and administered 02/22/18 at 4:34 AM (1 hour and 4 minutes late).


Vancomycin 1250 mg IV administered every eight hours for two days.

Scheduled for administration 02/22/18 at 11:30 AM and administered 02/22/18 at 3:22 PM (3 hours and 48 minutes late)

Vancomycin 1500 mg IV administered every eight hours for four days.

Scheduled for administration 02/23/18 at 7:30 PM and administered on 02/23/18 at 8:20 PM (50 minutes late).
Scheduled for administration on 02/25/18 at 11:00 PM and administered on 02/25/18 at 11:52 PM (52 minutes late).


Patient 10 was then re-admitted on [DATE] for the removal of the Prevena Plus Device (the wound vacuum device applied during the 02/19/18 admission), irrigation and debridement of the wound, and application of new wound vacuum device after it was discovered the Prevena device was not working appropriately.


During the 03/01/2017 date of service medication orders are as follows:

Fentanyl - order for 50 mcg IV every two hours for four days.

Scheduled for administration on 03/01/18 at 2:36 PM and administered on 03/02 at 7:35 AM (16 hours and 59 minutes late).

Scheduled for administration on 03/01/18 at 4:36 PM administered on 03/02/18 at 7:57 PM (15 hours and 21 minutes late).

Scheduled for administration on 03/01/18 at 6:36 PM and administered on 03/03/18 at 5:19 AM (10 hours and 43 minutes late).


Fentanyl ordered 100 mcg IV every two hours for four days.

Scheduled for administration on 03/01/18 at 2:35 PM and administered at 6:47 PM (4 hours and 12 minutes late).

Scheduled for administration on 03/01/18 at 4:35 PM and administered on 03/03/18 at 2:00 PM (45 hours and 25 minutes late)

Scheduled for administration on 03/01/18 at 6:35 PM and administered on 03/04/18 at 3:41 PM (68 hours and 6 minutes late).

During an interview on 06/05/18 at 3:50 PM Staff A, Director of Nursing, stated that there are several different reports showing the Medication Administration Record does not show that Fentanyl was scheduled every two hours as seen in the printed medical record. Staff A stated the computer system cut off the "as needed" verbiage in the printed medical record supplied for review. Staff A stated we do not schedule narcotic doses.

Review of alternate Medication Administration Record reports provided and printed on 06/05/18 showed "as needed" added to the end and "every two hours for four days" removed from the Fentanyl orders documented above.

Review of the Medication Error Report on 06/05/18 showed that on 12/29/17 a medication error was reported by Staff C, Registered Nurse involving Staff W, Registered Nurse with the following documentation, "Most of our Fentanyl orders are IV for every two hours. I obtained the order from (Staff V, Physician) who ordered fentanyl 50 mcg IV every four hours. I as in a constant rush and gave the medication at 2.5 hours after the last dose forgetting it was every four hours medication. The patient is still in pain and needing other medication. (Staff V, Physician) was contacted immediately, no new orders were obtained at this time".

During an interview on 06/06/18 at 4:45 PM Staff M, Pharmacist, stated that from the original printed view it does appear that there is not an area "cut off" and the order looks improperly written from the view displayed. Staff M stated that providers usually write an order for Fentanyl 100 mcg IV as an as needed (PRN) order. Staff M agreed that other medication orders on the example provided and like the Fentanyl order but were written with the "as needed" included had the "PRN" typed out and was not cut off so there would be not reason to believe that this particular order had "PRN" wording cut off.


Vancomycin order 1500 mg Intravenous piggyback (IVPB, an IV antibiotic given concurrently with another IV medication) administered every eight hours for four days.

Scheduled for administration on 03/02/18 at 6:30 AM and administered at 7:35 AM (one hour and five minutes late).

Scheduled for administration on 03/03/18 at 10:30 PM and administered at 11:23 PM (57 minutes late).

Scheduled for administration on 03/04/18 at 10:30 PM and administered on 03/05/18 at 12:21 AM (one hour and 51 minutes late).

Scheduled for administration on 03/05/18 at 6:30 AM and administered at 7:50 AM (one hour and 20 minutes late).

Xanax ordered 0.5 mg tablet at bedtime for four days.

Scheduled for administration on 03/01/18 at 9:00 PM; however, Staff E, Registered Nurse, did not administer the medication and documentation showed, "the patient did not have with him".

Scheduled for administration on 03/02/18 at 9:00 PM; however, Staff E, Registered Nurse, did not administer the medication and documentation showed, "the patient did bring".

Scheduled for administration on 03/03/18 at 9:00 PM; however, Staff C, Registered Nurse, did not administer the medication and documentation showed, "declined".

Scheduled for administration on 03/04/18 at 9:00 PM; however, Staff C, Registered Nurse, did not administer the medication and documentation showed, "the patient took valium instead".


Wellbutrin (medication used to treat major depressive disorder) XL ordered 300 mg tablet once daily for four days.
Scheduled for administration on 03/03/18 at 9:00 AM; however, Staff J, Registered Nurse, did not administer the medication and documentation showed, "not available".

Mobic (non-steroidal anti-inflammatory pain medication) ordered 15mg tablet once daily for four days.
Scheduled for administration on 03/03/18 at 9:00 AM; however, Staff J, Registered Nurse, did not administer the medication and documentation showed, "wound vac? Return to OR."

Cymbalta (It can treat depression, anxiety, diabetic peripheral neuropathy, fibromyalgia, and chronic muscle or bone pain) ordered 60 mg capsule once daily for four days.

Scheduled for administration on 03/02/18 at 9:00 AM; however, Staff J, Registered Nurse, did not administer the medication and documentation on 03/03/18 at 10:55 AM (25 hours and 55 minutes after the missed dose) showed, "medication not available".

Scheduled for administration on 03/03/18 at 9:00 AM; however, Staff J, Registered Nurse, did not administer the medication and documentation showed, "not available".


Ferrous Sulfate (iron supplement) ordered 325 mg capsule every 12 hours for six days.

Scheduled for administration on 03/03/18 at 9:00 AM and administered at 10:52 AM (one hour and 52 minutes late),

Scheduled for administration on 03/03/18 at 9:00 PM and administered at 10:12 PM (one hour and 12 minutes late).

Colace (a stool softener) ordered 100mg capsule twice daily for six days.

Scheduled for administration on 03/04/18 scheduled for 9:00 PM and Staff C, Registered Nurse, reported the medication was not given on 03/05/18 at 12:47 AM (three hours and 47 minutes after its scheduled administration time). The documentation showed, "declined."

During an interview on 06/06/2018 at 9:30 AM Staff B, Quality Director, stated that they do not have a current policy directing nursing staff what medications are critical for timing and which ones are non-critical. We will be developing a policy.

Patient 10 was again admitted on [DATE] for a wash out of the right hip. On 03/30/18 an incision and drainage of the right hip with wound vacuum was performed. On 04/09/18 Staff T, Physician, performed a removal of primary right total hip implants and applied a wound vacuum to the right hip. During the procedure the right femur fractured.

- During the 03/30/2018 through 04/10/18 dates of service medication orders are as follows;

Ancef 2 gm IVPB every eight hours for four days (antibiotic with a half - life of 1.8 hours and no laboratory monitoring for administration complications are required. Because of the short half-life, the medication is ordered to be administered at regularly scheduled intervals.)

Scheduled for 03/30/18 at 5:45 PM and administered 03/30/18 at 7:15 PM (1 hour and 30 minutes late).

Scheduled for 03/31/18 at 9:45 AM and administered on 03/31/18 at 10:31 AM (45 minutes late).

Scheduled for 04/01/18 at 9:45 AM and administered on 04/01/18 at 10:29 AM (45 minutes late).

Scheduled for 04/01/18 at 5:45 PM and administered on 04/01/18 at 5:30 PM (45 minutes late).

Scheduled for 04/02/18 at 9:45 AM and administered on 04/02/18 at 11:30 AM (1 hour and 45 minutes late).

Ceftriaxone 2 gm IVPB every 24 hours for four days (antibiotic with a half-life of 5.5 to 8.7 hours and laboratory monitoring for administration complications are required.)

Scheduled for 04/03/18 at 7:30 PM and administered on 04/03/18 at 8:10 PM (40 minutes late).

Scheduled on 04/07/18 at 7:30 PM and administered on 04/07/08 at 9:33 PM (2 hours late).

Vancomycin 1.5 gm IV every eight hours for four days.

Scheduled for 04/03/18 at 8:30 PM and administered 04/03/18 at 9:49 PM (1 hour and 19 minutes late).

Scheduled for 04/07/18 at 8:30 PM and administered on 04/07/18 at 9:34 PM (1 hour and four minutes late).

Scheduled for 04/10/18 at 12:30 PM and administered 04/10/18 at 1:10 PM (40 minutes late).

Scheduled for 04/10/18 at 8:30 PM and administered on 04/10/18 at 9:51 PM (1 hour and 19 minutes late).

Document review of the hospital's policy titled, "Controlled Substance Waste," dated 06/2017, showed, "All controlled substance waste in schedules II-V (CII-CV) will be wasted and documented appropriately ... and ... The waste must be witnessed by two licensed professionals (nurse, pharmacist, or nurse anesthetist), according to policy Medications 933.

Review of the Medication Administration Report (MAR) on 06/06/18 showed Fentanyl 100 mcg/hour transdermal (through the skin) film, extended release 100 mcg Transdermal Administered as needed. Staff J, RN documented administration of the patch on 04/07/18 at 9:17 AM and Staff D, RN documented application of the second patch on 04/10/18.

Review of Patient #10's medical record on 06/06/18 showed nursing staff failed to document removal and disposal of the 100 mcg Fentanyl patch applied on 04/07/18 when the new patch was applied on 04/10/18.

Throughout Patient 10's multiple admissions he was treated with antibiotics that were not delivered according to acceptable standards of practice to include timing of critical medication administration. This failure to deliver scheduled antibiotic medications as ordered has the potential to cause them to be ineffective in killing the infectious organism because there are sub-therapeutic levels of the antibiotic in the patient's system.


Review of Patient 2's medical record on 06/05/18 showed the following medication administration information:

- During the 12/12/17 date of service medication orders are as follows:

Ancef (cefazolin, an antibiotic) 2 grams Intravenous Piggy Back (IVPB, a secondary infusion) administered every 8 hours for 4 days

Scheduled for administration on 12/12/17 at 10:10 PM and administered 12/12/17 at 11:07 PM (57 minutes late).

Scheduled for administration on 12/13/17 at 6:10 AM and administered 12/13/17 at 6:59 AM (49 minutes late).

Cipro (ciprofloxacin, an antibiotic) 400 milligrams Intravenous Piggy Back (IVPB, a secondary infusion) administered every 12 hours for 4 days

Scheduled for administration 12/14/17 at 9:00 AM and administered 12/14/17 at 10:14 AM (1 hour and 14 minutes late).

The hospital staff failed to administer two different time-critical antibiotics for Patient 2 within 30 minutes of their scheduled dosing times.


Review of Patient 3's medical record on 06/05/18 showed the following medication administration schedule:
During the 12/22/17 through 12/26/17 dates of service medication orders are as follows:

Ancef (antibiotic) order for 1 gram (g) Intravenous Piggy Back (IVPB) (an IV solution hung in conjunction with another IV solution) administer every eight hours for two days.

Scheduled for administration on 12/22/17 at 9:30 PM and administered on 12/22/17 at 8:44 PM (46 minutes early).

Toradol (pain medication) 15 mg IV Injectable Solution administer every six hours for four times

Scheduled for administration on 12/22/17 at 6:00 PM and administered on 12/22/17 at 8:45 PM (2 hours and 45 minutes late).

Scheduled for administration on 12/23/17 at 6:00 AM and administered on 12/23/17 at 8:01 AM (2 hours and 1 minute late).

Scheduled for administration on 12/23/17 at 12:00 PM and administered on 12/23/17 at 2:26 PM (2 hour and 26 minutes late).

The hospital staff failed to administer two different time-critical medications (an antibiotic and scheduled pain medication) for Patient 3 within 30 minutes of their scheduled dosing times.


Review of Patient 5's medical record on 06/05/18 showed the following medication administration information:

During the 11/29/17 date of service medication orders are as follows;

Ancef (cefazolin) 1gm Intravenous Piggy Back (IVPB, a secondary infusion) administered every 8 hours for 2 times.

Scheduled for administration on 11/30/17 at 1:40 AM and administered 11/30/17 at 8:06 AM (6 hours and 26 minutes late).

The hospital staff failed to administer a time-critical antibiotic for Patient 5 within 30 minutes of its scheduled dosing time.


Review of Patient 6's medical record on 06/05/18 showed the following medication administration schedule:

Lovenox (medication for prevention of deep vein blood clots) (enoxaparin 40 mg/0.4 ml) subcutaneous solution administer 40 mg subcutaneously, pre-operative, ordered 03/15/18 at 9:12 AM by Staff V, Physician.

Review of the medication administration record showed no documentation of Lovenox administration in the pre-operative area.

Document "Omnicell Report", date range of 03/15/18, 12:00 AM through 03/05/18, 11:59 PM showed the medication was dispensed from the Omnicell to Staff X, RN on 03/15/18 at 5:55 AM.

Document "Comprehensive Surgical Checklist" for Patient 6 date of service 03/15/18, showed a check mark located in the box under the preprinted notation "Include in pre-procedure check in per institutional custom: Venous thromboembolism prophylaxis ordered."

Patient 6's medical record lacked documentation that a critical medication (anticoagulant) was given as ordered prior to their surgical procedure or any other time during their hospitalization .


Review of Patient 7's medical record on 06/05/18 showed the following medication administration schedule:

Lovenox (enoxaparin 40 mg/0.4 ml) subcutaneous solution administer 40 mg subcutaneously pre-operatively, ordered 02/20/18 at 2 AM by Staff Y, Physician.

Review of the medication administration record showed no documentation of Lovenox administration in the pre-operative area.

Document "Omnicell Report" date range 02/20/18 12:00 AM through 02/20/18 11:59 PM showed the medication was dispensed from the Omnicell to Staff X, RN on 02/20/18 at 5:55 AM.

Document "Comprehensive Surgical Checklist" for Patient 7, date of service 02/20/18, showed a check mark in the box under the preprinted notation "Include in pre-procedure check in per institutional custom: Venous thromboembolism prophylaxis ordered."

Patient 7's medical record lacked documentation that a critical medication (anticoagulant) was given as ordered prior to their surgical procedure or any other time during their hospitalization .


During an interview on 06/05/18 at 10:50 AM, Staff B, Director of Quality Management stated that the "only way Pharmacy knows medications are not given is to review the records every day. The computer system does not alert Pharmacy or the nurse of missed or late medications." She also stated the Hospital has no policy related to missed medications or late administration.

During an interview on 06/06/18 at 12:45 PM, Staff B, Director of Quality Management, stated that she was confident the medication was given because of the Omnicell report of the drug removal and the check mark documentation on the surgical checklist, but Staff X, RN definitely did not document the medication was administered on the medication administration record (MAR) for either Patient 6 or Patient 7.


- Review of Patient 29's Medication Administration report on 06/07/18 showed that on 02/15/18 at 1:51 PM the patient received one Acetaminophen (APAP) 10mg/1 ml as a 100 ml injection (this is equal to 1000 mg of Acetaminophen), on 02/15/18 at 6:38 PM the patient received two tablets of Oxycodone/APAP 7.5/325 mg each (this equals 650 mg of Acetaminophen), on 02/15/18 at 11:01 PM the patient received two tablets of Oxycodone/APAP 7.5/325 mg each (this equals 650 mg of Acetaminophen), on 02/16/18 at 3:28 AM the patient received two tablets of Oxycodone/APAP 7.5/325 mg each (this equals 650 mg of Acetaminophen), on 02/16/18 at 8:37 AM the patient received two tablets of Oxycodone/APAP 7.5/325 mg each (this equals 650 mg of Acetaminophen), on 02/16/18 at 12:07 PM the patient received two tablets of Oxycodone/APAP 7.5/325 mg each (this equals 650 mg of Acetaminophen), on 02/16/18 at 12:27 PM the patient received one Acetaminophen (APAP) 10 mg/1 ml as a 100 ml injection (this is equal to 1000 mg of Acetaminophen). The total amount of Acetaminophen Patient #29 received in a 24-hour timeframe was 5,250 mg.

During an intervie
VIOLATION: USE OF VERBAL ORDERS Tag No: A0407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interviews, and document review the hospital failed to limit the number of verbal orders and failed to ensure verbal orders were authenticated by the provider within 48 hours for six out of 13 patient medical records reviewed (Patients 1, 3, 4, 5, 7, and 8). The hospital's failure to ensure the authentication of verbal orders within 48 hours and to limit the use of verbal orders has the potential for an increased risk of miscommunication that could contribute to a medication or other error, resulting in an adverse patient event.

Findings include:

Document review of the hospital policy titled, "Verbal and Telephone Orders," dated September 2017, showed the prescribing practitioner, or another practitioner responsible for the patient's care, must sign the written record of the verbal/telephone order within 48 hours of giving the order.


Review of Patient 1's medical record on 06/04/18 showed it failed to have the following verbal orders signed within 48 hours:

Flexeril (a muscle relaxant, can treat pain and stiffness caused by muscle spasms) 10 milligrams (a unit of measurement), by mouth three times a day; verbal order given 12/06/17 at 8:00 PM. The order was approved and signed 12/18/17 3:04 PM (12 days later).

Gaboarone (gabapentin, used to treat seizures and pain caused by neuropathy) 300 milligram (a unit of measurement), by mouth three times a day; verbal order given 12/06/17 at 8:00 PM. The order was approved and signed 12/18/17 3:04 PM (12 days later).

Sertraline (an antidepressant) 25 milligram (a unit of measurement), one daily verbal order given 12/06/17 at 8:00 PM. The order was approved and signed 12/18/17 3:04 PM (12 days later).


Review of Patient 3's medical record on 06/04/18 showed it failed to have the following verbal orders signed within 48 hours:

Remove the Foley catheter (a tube that drains urine from the bladder into a collection bag); verbal order given 12/23/17 at 2:55 AM. The order was approved and signed on 01/17/18 at 10:30 AM (25 days later).

Sodium Chloride Injectable (a saline and water solution) 125 milliliters (ml, a unit of measurement) via Intravenous (IV, a small tube placed into a vein to administer the fluids) every eight hours for four 4 doses; verbal order given on 12/24/17 at 10:30 AM. The order was approved and signed on 01/17/18 at 10:30 AM (24 days later).

Ok to leave IV out at 5:30 PM verbal order given on 12/25/17 at 5:30 PM. The order was approved and signed on 01/17/18 at 10:30 AM (23 days later).

Straight catheter (a straight tube placed into the bladder to drain urine into a basin and remove) every six hours as needed if greater than 300 ml after urination (the discharge of urine from the body); verbal order given on 12/25/17 at 5:30 PM. The order was approved and signed on 01/17/18 at 10:30 AM (23 days later).

Discontinue IV fluids and discontinue Foley catheter; verbal order given on 12/25/17 at 5:30 PM. The orders were approved and signed on 01/17/18 at 10:30 AM (23 days later).

Miralax (a laxative) administer one -17 gram (a unit of measurement) packet by mouth twice daily for three doses for constipation; verbal order given on 12/25/17 at 5:30 PM. The order was approved and signed on 01/17/18 at 10:30 AM (23 days later).

Cyclobenzaprine (a muscle relaxant) administer 10 milligrams (a unit of measurement), tablet by mouth every six hours as needed for muscle spasms; verbal order given on 12/25/17 at 5:30 PM. The order was approved and signed on 01/17/18 at 10:30 AM (23 days later).

During an interview on 06/04/18 at 3:53 PM, Staff K, Clinical Documentation Registered Nurse (RN) stated that the medical record for Patient #3 showed that the seven verbal orders for the hospitalized from [DATE] to 12/26/17 failed to be authenticated within 48 hours after the verbal order was received.


Review of Patient 4's medical record on 06/05/18 showed it failed to have the following verbal orders signed within 48 hours:

Toradol (a nonsteroidal anti-inflammatory, can treat pain) 30 milligrams (a unit of measurement) intravenous (IV) every six hours for four doses as needed for pain; verbal order given on 11/22/17 at 11:41 AM. The order was approved and signed on 11/29/17 at 3:30 PM (7 days later).

Ofirmev (acetaminophen, an analgesic can treat minor aches and pains, reduces fever) 1000 milligrams (a unit of measurement) every six hours as needed for four doses as needed for fever or pain; verbal order given on 11/23/17 at 9:00 PM. The order was approved and signed on 11/29/17 at 3:30 PM (6 days later).


Review of Patient 5's medical record on 06/05/18 showed it failed to have the following verbal orders signed within 48 hours:

Lopressor (metoprolol, can treat high blood pressure, chest pain and heart failure) 5 milligram (a unit of measurement), Intravenous (IV) once give for systolic blood pressure greater than 180 millimeters of mercury (a unit of measurement); verbal order given on 11/29/17 at 2:04 PM. The order was approved and signed 12/05/17 at 10:09 AM (6 days later).

Hydralazine (can treat high blood pressure and heart failure) 10 milligrams (a unit of measurement) Intravenous (IV) every four hours for systolic blood pressure greater than 160 millimeters of mercury (a unit of measurement); verbal order 11/29/17 at 2:19 PM. The order was approved and signed 12/05/17 at 10:09 AM (6 days later).

Toradol (ketorolac, a nonsteroidal inti-inflammatory, can treat pain) 30 milligram (a unit of measurement), Intravenous (IV) every six hours for two days; verbal order 11/30/17 at 4:04 PM. The order was approved and signed 12/05/17 at 10:09 AM (5 days later).

Compazine (prochlorperazine, antipsychotic, can treat nausea and vomiting) 25 milligrams (a unit of measurement) suppository administer per rectum every eight hours as needed; verbal order given on 11/30/17 at 4:00 PM. The order was approved and signed 12/05/17 at 10:09 AM (5 days later).

Benadryl (diphenhydrAMINE, an antihistamine can treat pain and itching or severe allergic reactions) 25 milligrams (a unit of measurement) Intravenous (IV) every eight hours verbal order given on 11/30/17 at 11:45 AM. The order was approved and signed 12/05/17 at 10:09 AM (5 days later).


Review of Patient 7's medical record on 06/05/18 showed it failed to have the following verbal orders signed within 48 hours:

Toradol (ketorolac, a non-steroidal anti-inflammatory) 30 milligrams (a unit of measurement) intravenous (IV) every six hours as needed (PRN) for pain; verbal order given on 02/20/18 at 12:00 PM. The order was approved and signed on 02/27/18 at 1:31 PM (7 days later).

Dilaudid (hydromorphone, a narcotic pain medication) 4 milligrams (a unit of measurement) tablet by mouth every six hours PRN for four doses; verbal order given on 02/21/18 at 5:13 PM. The order was approved and signed on 02/27/18 at 1:31 PM (6 days later).


Review of Patient 8's medical record on 06/05/18 showed it failed to have the following verbal order signed within 48 hours:

Cefazolin (antibiotic) 1 gram (a unit of measurement), IV every eight hours for two doses; verbal order given on 01/25/18 at 2:40 PM. The order was approved and signed 02/22/18 at 9:30 AM (28 days later).


During an interview on 06/05/18 at 4:25 PM, Staff Z, Health System Administrator, stated that its my fault verbal orders are not approved and signed within in 48 hours. "Amkia, our electronic medical record system does not flag or identify in any way verbal orders which need a signature." She also stated that it was a process improvement issue.

During an interview on 06/05/18 at 4:00PM, Staff N, Physician, stated that this electronic medical record system does not identify verbal orders for me to sign. He stated that other systems, which he had worked with, have a way of prompting me to sign verbal orders or it doesn't let me sign in to the patient's chart. "I am getting pretty good at opening the medical administration record, checking the verbal orders and signing them."