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.

FREEDOM BEHAVIORAL HOSPITAL OF TOPEKA, LLC 1334 SW BUCHANAN STREET TOPEKA, KS 66604 Dec. 24, 2019
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, policy review, and interview the hospital failed to reassess the appropriateness of the discharge plan for one of 14 patients reviewed (Patient 12) and discharged her to an environment in which she previously failed to safely care for herself resulted in a police arrest and immediate involuntary rehospitalization .

Failure of the hospital to reassess and consider the risks and appropriateness of returning a patient to an environment in which they were previously unsuccessful in safely caring for themselves, places them at risk for exposure to an unsafe environment, harm, rehospitalization and an inability to meet post hospitalization needs.


Findings Include:

Document review of the Hospital's policy titled, "Plan for Clinical Services: Discharge Planning," effective 11/2018 and revised 10/2019, shows the rationale for discharge planning is to reduce or eliminate the risk of hospital readmission in some cases. The goal is to improve the quality of discharge transition, reduce readmissions, promote continuity of care, ensure patient safety, and ensure the active involvement of the patient and/or representatives in the plan.


Review of Patient 12's medical record showed her date of birth (DOB) as 11/05/1956 ([AGE] years old). She was an involuntary inpatient admission to the above named psychiatric hospital on [DATE] with a psychiatric diagnosis of schizoaffective (mental disorder characterized by abnormal thought processes and an unstable mood) disorder with delusions and paranoia (mental condition characterized by delusions of persecution, unwarranted jealousy, or exaggerated self- importance). She was admitted as a danger to herself, others, and property, was unable to provide self-care, experienced hallucinations, delusions, agitation, anxiety, and depression. She was isolating herself in her home, not taking medications, and missing community mental health appointments. Estimated length of stay at admission was 12-14 days.

Review of a physician progress note dated 08/24/19 showed, Staff J, Psychiatrist, documented he was working with the team to get her discharged , but she had no insurance, "the nursing home cannot take psychiatric patients, and trying to have her screen by the state [psychiatric] hospital because they were holding her as an overflow patient for the state hospital."

Review of a physician progress note dated 08/28/19 showed Staff J, Psychiatrist documented Patient 12 remained paranoid and the treatment team was, "still of opinion not to release her" to her home.

Review of a document titled, "Treatment Review Conference and Patient Response to Plan of Care" dated 08/21/19, and signed on 08/28/19 by Staff J Psychiatrist, showed the discharge criteria included decreased delusions and to show reality-based thoughts and behaviors ... The document also showed that Patient 12's continued stay criteria was "Disorganization of Thought Process Impedes Functionality in Social, Vocational, Daily Living Skills and Exhibits impoverished life/coping skills to effectively manage disease process." Patient 12 did not agree with the individualized plan of care.

Review of a physician progress note dated 08/30/19, showed Staff M, Medical Doctor (MD) documented Patient 12 engaged in bizarre behavior, bathing while clothed, and accusing staff of taking pictures of her and sending them to satan.

Review of the Multi-Disciplinary note dated 09/02/19, no time documented, showed Staff R, Case Manager, Discharge Planner, documented Patient 12 assaulted staff, refused to take clothes off in the shower and showed that Patient 12 stated that demons were taking pictures of her and selling them.

Review of a document titled "Contact Log" showed Staff R documented on 09/04/19 at 3:50 PM, that she contacted Patient 12's step son and informed him Patient 12 would discharge on 09/06/19. On 09/05/19 at 11:00 AM, Staff R, documented that Patient 12's step son called and is sending a nursing home to assess Patient 12. On 09/05/19 at 2:30 PM, Staff R, documented nursing home staff here to assess patient. Due to patient's behaviors, patient is denied. On 09/06/19, at 9:35 AM, noted as a late entry, showed Staff R, documented that she spoke to the step son about discharge and he would like Patient 12 to be private pay to have time to look for a nursing home. On 09/06/19 at 4:00 PM, also noted as a late entry, showed Staff R, documented that contacted the step son and told him that Staff J, Psychiatrist would not allow Patient 12 to stay private pay.

Review of a physician progress note dated 09/05/19, showed Staff J, Psychiatrist documented a team meeting was scheduled on 09/06/19, to discuss Patient 12's discharge. Further review of the progress note showed Staff J, Psychiatrist, documented that Patient 12 had, "No agitation, no aggression, or combative behavior." The progress notes also showed, "We will have a team meeting in the morning and we will discharge her to her home with follow-up with psychiatrist or psychiatrist nurse practitioner for medication management, case management and therapist for therapy as arranged by our social worker and discharge planner.

There was no evidence a team meeting or a "Treatment Review Conference and Patient Response to Plan of Care" meeting was held on 09/06/19, to discuss Patient 12's discharge, found in the medical record.

Review of a Multi-Disciplinary note dated 09/06/19, and not timed, showed Staff R, Spoke with Staff J, Psychiatrist about Patient 12's step son wanting her to stay private pay until placement can be found, and Staff J said no, the patient will discharge today.

Review of a document titled "Freedom to Choose" dated 09/06/19 showed, "Freedom Behavioral would like to assist you the patient in obtaining community resources" ..., The document showed choices of Home Health, Hospice, Nursing Home, Assisted Living, Personal Care, Durable Medical Equipment, Respiratory Services, and Other. Not Applicable (N/A) was written on the line by the word other. The document had an illegible signature and was initialed by Staff I, RN.

Review of a document titled "Discharge Continuing Care Plan, Patient Stay Treatment Summary, Treatment Summary & Patient Response to Treatment, (Clinical Services)," Patient 12 attended groups and developed some coping skills to help with reality. Staff R, signed the document on 08/05/19, Staff J, Psychiatrist signed the document on 09/13/19 and Patient 12, Staff I, RN, and Staff BB, Licensed Medical Social Worker (LMSW), all signed the document on 09/06/19. The "Discharge Continuing Care Plan, Patient Stay Treatment Summary," "Treatment Summary & Patient Response to Treatment, (Clinical Services)," lacked evidence Patient 12 specifically met the discharge criteria of decreased delusions and to show reality-based thoughts and behaviors.

Review of the "Contact Log" dated 09/06/19 at 4:45 PM (late entry) showed that Staff R, spoke to a case manager from a county mental health and they were waiting for Patient 12 to arrive.

The "Discharge Continuing Care Plan, Patient Stay Treatment Summary," failed to show assessment of the risks associated with returning Patient 12 to her previous home environment, failed to show the county mental health contact information and failed to show reassessment of the appropriateness of the discharge plan.

Review of the Hospital Complaint and Grievance form dated 09/07/19 at 9:00 AM, showed Staff A, Administrator documented Patient 12's step son stated that he had issues with only having two days to find placement after the state hospital declined her and that she was "dropped off at a burger place across the street."

Further documentation dated 09/10/19, attached to the Hospital Complaint and Grievance, showed Staff A, interviewed Staff MM (unknown title), who along with Staff NN (unknown title), transported Patient 12 to her apartment. When they arrived, Staff MM stated that Staff NN and Patient 12 went upstairs to her apartment and were gone for approximately 15 minutes. When they returned Patient 12 told Staff MM that she could not get into her apartment and that she would meet someone across the street at the restaurant. Staff MM took her to over to the restaurant and when she got out of the van she gave an unknown person a big hug like she knew them and started talking to them. Staff MM and Staff NN then left her with that person.

Review of the "Contact Log" dated 09/07/19 at 1:00 PM (late entry) showed that Staff R, spoke with Patient 12's step son, who stated that Patient 12 had been arrested at the restaurant she was dropped off at, for delusional behaviors and was admitted to another hospital.

During an interview on 12/24/19 at 8:30 AM, Staff R, Case Manager/Discharge Planner (CM), Social Service Designee (SSD), stated that Patient 12 remained delusional and unchanged during the hospitalization and her step son requested she be discharged somewhere besides her home. He started pursuing nursing homes, however none would accept her as a patient. She stated she explained to Staff J, Psychiatrist that her step son requested to keep Patient 12 in longer and would private pay until placement at a facility was made available. Staff R stated she told Staff J that Patient 12 still met criteria, qualifying her for continued inpatient care. Staff R then stated, "since we were still getting certification for continued stay and there was no change in her condition, Patient 12 should not have been discharged ."
VIOLATION: DISCHARGE PLANNING Tag No: A0799
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, and interview the hospital failed to ensure staff reassessed the discharge plan and appropriately discharged a patient to a safe environment by: failing to ensure the psychiatrist took into consideration the treatment teams opinion that the patient should not be released back to her home, failing to show evidence of a team meeting to discuss the patient discharge plan on the day of discharge; failing to show evidence the patient met documented discharge criteria, failing to arrange community service for the patient once discharged , failing to show evidence in the discharge plan and instructions that county mental health services had been contacted and their contact information provided; by failing to show evidence in the medical record that the county mental health staff were at the patient's apartment when she arrived home; by failing to show evidence the transportation staff ensured the safety of the patient when they left her at the restaurant across the street from her apartment; and by failing to show evidence in the medical record that the transportation staff reported back to the hospital that they had left the patient at a restaurant.

The cumulative effect of the hospital's failure to reassess and consider the risks and appropriateness of returning a patient to an environment in which they were previously unsuccessful in safely caring for themselves, resulted in the immediate arrest and rehospitalization .

Findings Include:

Review of a [AGE]-year-old patient's medical record showed she was admitted to the hospital as a danger to herself, others, and property, was unable to provide self-care, experienced hallucinations (seeing things that aren't there), delusions (firm belief in something that is not true), agitation, anxiety, and depression. She was isolating herself in her home, not taking medications, and missing community mental health appointments. She was in the hospital from 06/13/19 and discharged on [DATE] back to her home and previous environment. The patient was arrested shortly after her discharge from this hospital for delusional behavior after the hospital transportation staff dropped her off at a restaurant. She was immediately rehospitalized as a result. Refer to A-0821.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview, record review, document review and policy review the hospital failed to ensure nursing services provided safe and effective nursing care by failing to ensure a registered nurse evaluated the nursing care for each patient; by failing to ensure nursing staff develops and keeps a nursing care plan up-to-date for each patient; and by failing to ensure medications were administered in accordance with the hospitals policies and procedures.

The cumulative effect of the hospital's failure to provide safe and effective nursing care placed patients at risk for falls, injury, unmet needs, and medications errors.

Findings Include:

The hospital failed to ensure nursing staff implemented new interventions to reduce the likelihood of additional falls that resulted in patient injury and emergency room visits; failed to ensure nursing staff completed fall intervention assessments per policy; failed to ensure nursing staff completed post fall assessments; failed to ensure nursing staff documented patient education; failed to ensure all patients who were assessed as a fall risk had a yellow falls wrist band per policy; and failed to ensure a yellow star was placed outside the doors and above the beds of patients assessed as fall risk. Refer to A-0395.

The hospital failed to ensure nursing staff developed, reassessed, and kept a nursing care plan up-to-date for all patients. The nursing staff failed to reassess interventions and document progress toward the patients' goals. Refer to A-0396.

The hospital failed to ensure medications were administered in accordance with policies and procedures by failing to follow physician's orders; by failing to ensure medication overrides (override allows a nurse to remove a medication from an automated dispensing machine before a pharmacist reviews the order) were less than the five percent targeted goal set as one of the Pharmacy Performance Indicators; by failing to educate staff regarding medication errors and overrides; by failing to handle and store a narcotic medication appropriately; by failing to ensure proper identification of a patient prior to medication administration; and by failing to maintain medication integrity when splitting pills. Refer to A-0405.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, document review and policy review the hospital failed to ensure nursing staff implemented any new interventions to reduce the likelihood of subsequent falls for five of five patients who had more than one fall (Patient 1, 2, 3, 7, and 13) and for two of two patients with one fall (Patient 4 and 5) that resulted in emergency room visits for five of these seven patients (Patient 1, 2, 3, 4, and 5); failed to ensure nursing staff completed the fall precautions intervention form each shift per policy for seven of seven patients reviewed who were assessed as a moderate or a high fall risk (Patients 1, 2, 3, 4, 5, 7, and 13); failed to ensure nursing staff completed the Post Fall Assessments for seventeen of nineteen falls involving these seven patients (Patients 1, 2, 3, 4, 5, 7, and 13); failed to ensure nursing staff documented fall education for six of seven fall patients reviewed (Patients 1, 3, 4, 5, 7, and 13); failed to ensure one of 12 current patients assessed as a fall risk on 12/18/19 had a yellow wrist band per policy (Patient 19); failed to ensure a yellow star was placed outside the doors and above the beds of patients identified as fall risk for nine of 12 current patients (Patients 1, 15, 16, 17, 18, 19, 20, 21, and 22); and failed to ensure nursing staff provided immediate toileting needs for one of 11 current patients (Patient 20) after she told staff that she was wet and had a strong urine odor about her. These deficient practices have the potential to place all patients at risk for harm, serious injury, and even death.

Findings Include:

1. Falls

Review of the Hospital's policy titled, "Hospital Wide - Fall Prevention," dated 12/2016, showed ...all patients will be assessed on admission and continuing throughout the stay using the fall assessment guidelines. History of falls prior to or during the hospitalization shall be documented on the care plan ...patient/family will be instructed about safety measures and rational, including to call for assistance before getting out of bed, rise slowly, keep necessary items within reach and the proper use of canes, walkers, wheelchairs and crutches...ambulatory patients shall wear proper foot gear, regular shoes or well-fitting slippers.

Review of the Hospital's policy titled, "Assessment - Fall," dated 03/2017, showed...to alert multidisciplinary team members that a patient is a fall risk, to prevent a patient from falling during hospitalization , to provide appropriate interventions for patients identified as a fall risk, to provide a safe environment for all patients during hospitalization ...an initial screen for AT RISK FOR FALLS (ARF) will be completed on all patients upon admission...the form will be performed weekly thereafter... "patient's that are identified as a high-risk level will have a shift fall risk intervention form implemented by the nursing staff...to ensure that all applicable interventions are be applied and to assist with a concurrent evaluation...the post fall assessment will be completed after a patient has fallen...an incident report completed".

Review of the "At Risk for Falls" Score Sheet showed the "Total Scoring Guide" as 0-7 Low Risk; 8-24 Moderate Risk (initiate fall precautions); 25-35 High Risk (Initiate Fall Precautions & Utilization of Low Pro beds). FALL PRECAUTIONS for Moderate/High Risk: Place Fall Precaution Indicator on Patient Chart, Place Fall Precaution on Patient Board List, Place Fall Precaution on Report Sheet, Fall Risk Identified on Treatment Plan, Teach Fall Prevention/Precautions To Patient, Identify Fall Precaution on Close Observation Sheet, Patient Is Not Left Unattended During Activities That Place Him / Her at Increased Risk of Falling, Place Yellow Arm Band on Patient.


Patient 1

Review of Patient 1's current medical record showed his date of birth (DOB) as 04/24/1946 ([AGE] years old). He was admitted on [DATE] with a diagnosis of Impulse control disorder (failure to resist temptation, an urge, an impulse, or the inability to not speak on a thought), reported risk of harm to self and others, assaultive behaviors within 24 hours of admission, paranoia (an unrealistic distrust of others or a feeling of being persecuted), and delusions (a belief or altered reality that is persistently held despite evidence or agreement to the contrary). Patient 1's medical diagnosis included hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD) (damage to the lungs that cannot be reversed). Patient 1 had an impairment with his walking, used a cane, and needed assistance with showering. He was confused at times and liked to walk when under stress. Patient 1's ARF showed an initial fall risk score of 11 placing him at a moderate risk for falls.

Review of Patient 1's treatment team goals for fall precautions showed, "1. Verbalize Need to Request Assistance to Prevent Falls within 7 days. 2. Demonstrate Proper Transfer Techniques Within 7 days and 3. Demonstrate Use of Call Bell Within 7 days". Nursing Interventions on the treatment plan included: 1. Initiate Fall Assessment Protocols Per Guidelines ...2. Fall Risk After All Falls and Weekly 3. Assign MHT to Assist With AL's (activities of daily living) and Baths Daily 4. Assess Level of Sedation Each Shift and Document 5. Assure Patient has Appropriate Clothing and Footwear 6. Educate on Rising Slowly From Sitting / Lying Position, Dangling Feet on Side of Bed Before Rising 7. Assess and Document Side Effects of Medication 8. Educate Patient to Request Assistance Prior to Getting Out of Bed 9. Other: Due to Aggression cane use will be monitored closely 10: Other Assess need for wheelchair".

Review of Patient 1's Master treatment plan for fall precautions showed the goals and nursing interventions above were initiated on admission on 11/02/19. The interdisciplinary team continued the same goals on 11/09/19, 11/16/19, 11/19/19, 11/26/19, and 12/23/19. However, the treatment plan lacked any evidence that these nursing interventions were reassessed, updated, or revised at any point during his hospitalization even though Patient 1 experienced seven falls in a 35-day period (11/03/19 to 12/07/19).

Fall 1
Review of the multidisciplinary notes showed Patient 1 was standing at the nurse's station, fell asleep, slipped to his knees and then to the floor on 11/03/19 at 7:45 PM.

Review of the medical record lacked evidence that nursing staff completed a post fall assessment form (includes vital signs, notification to family, neurological, musculoskeletal, pain, respiratory cardiovascular, gastrointestinal, genitourinary, and skin assessments) and review of the nurse's notes failed to show any additional education to the patient or nursing staff put any new interventions into place to prevent another fall.

Fall 2
Review of physician's progress notes and the treatment team care plan showed Patient 1 fell on [DATE] at 11:37 AM. The multidisciplinary notes showed the patient was found on the floor and complained of pain to his right hip. Patient 1 was taken to an emergency room (ER). The psychiatric hospital was notified by the receiving ER that a CT scan was done to his head, x-rays were done to his neck, back, chest, right hip, ankle and knee with all radiology showing negative results and that he will return at 6:30 PM.

Review of the medical record lacked evidence that nursing staff completed a post fall assessment form and review of the nurse's notes failed to show any additional education to the patient or nursing staff put any new interventions into place to prevent another fall. Nursing staff also failed to complete the ARF score sheet after the patient's fall on 11/5/19 to assess his new fall risk score since he fell .

Fall 3
Review of the multidisciplinary notes showed the patient was standing at the nurse's station with his arms crossed, he appeared to fall asleep and lost his balance and slid to the floor on 11/11/19 at 10:00 PM. Review of medications given on 11/11/19 showed Patient 1 received Seroquel (an antipsychotic with side effects can include dizziness, sleepiness, unusual drowsiness, faintness and lightheadedness) at 9:00 PM and the fall occurred one hour later.

Review of the medical record lacked evidence that nursing staff completed a post fall assessment form and review of the nurse's notes failed to show any additional education to the patient or nursing staff put any new interventions into place to prevent another fall.


Fall 4
Review of the multidisciplinary notes and treatment team care plan showed the patient fell at the nurse's station on 11/19/19 at 2:40 AM. Patient 1 complained of back and hip pain with movement. The Patient was taken to the ER for evaluation. The patient was back from the ER at 8:00 AM and no injuries were noted.

Review of the medical record lacked evidence that nursing staff completed a post fall assessment form and review of the nurse's notes failed to show any additional education to the patient or that nursing staff put any new interventions into place to prevent another fall.. Nursing staff also failed to complete the ARF score sheet after the patient's fall on 11/19/19 to assess his new fall risk score since he fell .

Fall 5
Review of the multidisciplinary notes showed the patient was walking down the hallway to his room and a staff member saw him staggering backwards and she went to help him, and he pushed her away and he fell into the wall and door on 11/20/19 at 6:20 PM. Patient 1 had a scrape to his lower back and skin tear to his left elbow. Patient 1 stated that his first two fingers on his left hand hurt. No new orders were given when the physician was notified.

Review of the medical record lacked evidence any additional education was provided to the patient or that nursing staff put any new interventions into place to prevent another fall. Nursing staff also failed to complete the ARF score sheet after the patient's fall on 11/20/19 to assess his new fall risk score since he fell .

Fall 6
Review of the multidisciplinary notes showed Patient 1 fell in the hallway on 12/06/19 at 11:32 PM. The fall was unwitnessed by the staff and he was found on the floor lying on his right side with his eyes closed. The notes show the patient stated, "I'm just a little sleepy." Patient 1 shared he had pain in his right shoulder. The staff documented the right clavicle looked different in appearance compared to the left. The physician was called and ordered Patient 1 be taken to the ER. Review of medications given prior to the 12/06/19 fall showed Zyprexa (antipsychotic with side effects that can include change in walking and balance and clumsiness or unsteadiness) 5 mg was given at 10:18 PM and the fall occurred about an hour and fifteen minutes later.

Review of the medical record lacked evidence that nursing staff completed a post fall assessment form and review of the nurse's notes failed to show any additional education to the patient or that nursing staff put any new interventions into place to prevent another fall.

Fall 7
Review of incident/accident reports showed Patient 1 fell on [DATE] at 1:30 PM. Patient 1 stood up in the dining room area and fell . A post fall assessment was completed stating the patient had refused his blood pressure medications this morning. Review of the Fall Prevention Intervention form showed the nursing staff failed to complete the form on the shift prior to Patient 1's seventh fall. Review of medications given prior to the fall on 12/07/19 showed Seroquel 25 mg was given at 12:00 PM and the fall occurred one and a half hours later.

Review of the medical record lacked evidence any additional education was provided to the patient or that nursing staff put any new interventions into place to prevent another fall. Nursing staff also failed to complete the ARF score sheet after the patient's fall on 12/07/19 to assess his new fall risk score since he fell .

During an interview on 12/18/19 at 4:07 PM, Staff DD, Agency Registered Nurse (RN) stated that if a patient had multiple falls she is not aware of any changes they do in the interventions to prevent further falls.

Review of the "Fall Precautions Intervention" form showed nursing staff also failed to document any nursing assessment or interventions to prevent the patient from falling on the following shifts: 11/13/19 day and night shifts, 11/28/19 day shift, 11/29/19 night shift, 12/02/19 day shift, 12/03/19 day shift, 12/07/19 night shift, 12/12/19 day shift, 12/16/17 night shift, 12/19/19 night shift, and 12/21/19 day shift.


Patient 2

Review of Patient 2's discharged medical record showed his DOB 12/04/1963 ([AGE] years old). He was an involuntary admission to the hospital on [DATE] with a psychiatric diagnosis of impulse control disorder (a condition in which a person has trouble controlling emotions or behavior), unspecified intermittent explosive disorder (a disorder characterized by hostility, impulsivity, and recurrent aggressive outbursts), risk of harm to others, and assaultive behaviors with a high risk of reoccurrence. His medical history included seizures (a sudden, uncontrolled electrical disturbance in the brain). Further documentation shows he presented with a physical impairment requiring transfer assist and assistance with toileting, grooming, and dressing. Documentation showed difficulty with comprehension, experienced a knowledge deficit, exhibited difficulty with swallowing and was at high risk of injury. His total fall risk assessment was 27 placing him at high risk for falls.

Review of Patient 2's treatment team goals for fall precautions showed, "1. Verbalize Need to Request Assistance to Prevent Falls within 7 days. 2. Demonstrate Proper Transfer Techniques Within 7 days and 3. Demonstrate Use of Call Bell Within 7 days". Nursing Interventions on the treatment plan included: 1. Initiate Fall Assessment Protocols Per Guidelines ...2. Fall Risk After All Falls and Weekly 3. Assign MHT to Assist With AL's (activities of daily living) and Baths Daily 4. Assess Level of Sedation Each Shift and Document 5. Assure Patient has Appropriate Clothing and Footwear 6. Educate on Rising Slowly From Sitting / Lying Position, Dangling Feet on Side of Bed Before Rising 7. Assess and Document Side Effects of Medication 8. Educate Patient to Request Assistance Prior to Getting Out of Bed 9. Other: Use Geri-Chair for mobility.


Review of Patient 2's Master treatment plan for fall precautions showed the goals and nursing interventions above were initiated on 11/06/19. The interdisciplinary team continued the same goals on 11/09/19, 11/12/19, and 11/19/19. However, the treatment plan lacked any evidence that these nursing interventions were reassessed, updated, or revised at any point during his hospitalization even though Patient 2 experienced two falls during his 16-day admission with one being on a day the treatment team met (11/12/19).

Fall 1
Review of an incident/accident report on 11/01/19 at 4:30 AM showed, "Pt stated he was going to hurt himself & trying to hit staff, increase in agitation & combative behavior. Pt put himself on the floor without injury".

Review of the multidisciplinary untimed nursing note dated 11/01/19 showed, Patient 2 had "multiple near falls despite multiple attempts at redirecting patient, 1 to 1 care, and talking to patient."

Review of the medical record lacked evidence that nursing staff completed a post fall assessment form and review of the nurse's notes failed to show that nursing staff put any new interventions into place to prevent another fall. Nursing staff also failed to complete the ARF score sheet after the patient's fall on 11/01/19 to assess his new fall risk score since he fell .

Fall 2
Review of an incident/accident report on 11/12/19 at 6:46 AM showed Patient 2 stood up from his wheel chair at the nursing station and immediately fell down hitting the right side of his head on the station. Nursing staff notified the physician and gave orders to send the patient to the ER to be evaluated for head trauma

Review of the medical record lacked evidence that nursing staff completed a post fall assessment form and review of the nurse's notes failed to show any additional education to the patient or that nursing staff put any new interventions into place to prevent another fall. Nursing staff also failed to complete the ARF score sheet after the patient's fall on 11/12/19 to assess his new fall risk score since he fell .


Patient 3

Review of Patient 3's discharged medical record showed his DOB as 07/23/1941 ([AGE] years old). He was a voluntary admission to the hospital on [DATE] at 10:15 PM with a psychiatric diagnosis of impulse control disorder, unspecified identified by reports from his living facility of verbal aggression toward staff and threatening behavior toward other residents. Symptom onset was approximately two weeks with increased intensity. His medical history included Parkinson's (degenerative disorder of the central nervous system that affects the motor system) disease, dementia (memory and judgement loss), and diabetes. Documentation showed he needed a walker with a history of falls due to weakness requiring assistance with toileting, grooming, dressing, and shower. The fall risk factor assessment score of 20 placed him as a moderate risk of falls on admission. The at risk for falls (ARF) document dated 10/21/19 and 10/26/19 showed total scores of 27 and 32 placing him at high risk for falls.

Review of Patient 3's treatment team goals dated 10/22/19 for fall precautions showed, "1. Demonstrate Proper Transfer Techniques Within 7 days and 2. Demonstrate Use of Call Bell Within 7 days". Nursing Interventions on the treatment plan included: 1. Initiate Fall Assessment Protocols Per Guidelines ...2. Fall Risk After All Falls and Weekly 3. Assign MHT to Assist With AL's (activities of daily living) and Baths Daily 4. Assess Level of Sedation Each Shift and Document 5. Assure Patient has Appropriate Clothing and Footwear 6. Assess and Document Side Effects of Medication 7. Educate Patient to Request Assistance Prior to Getting Out of Bed 8. Other: Monitor/educate walker safety.

Review of Patient 3's Master treatment plan for fall precautions showed the goals and nursing interventions above were initiated on 10/22/19. The interdisciplinary team continued the same goals on 10/29/19. However, the treatment plan lacked any evidence that these nursing interventions were reassessed, updated, or revised at any point during his hospitalization even though Patient 3 experienced four falls during his 12-day admission.

Fall 1
Review of the incident/accident report on 10/22/19 at 5:30 AM showed the patient was found in his room on the floor with a left forearm skin tear and an abrasion of the right side of his face.

Review of the medical record lacked evidence that nursing staff completed a post fall assessment and review of the nurse's notes failed to show any additional education to the patient or that nursing staff put any new interventions into place to prevent another fall. Nursing staff also failed to complete the ARF score sheet after the patient's fall on 10/22/19 at 5:30 AM to assess his new fall risk score since he fell .


Fall 2
Review of the incident/accident report dated 10/22/19 at 9:45 PM showed patient was combative, agitated, and uncooperative. Patient took his walker and was walking fast with an unsteady gait, hit the hallway door and fell on his left side hitting his forehead. Patient had large hematoma and laceration on his forehead. Nursing staff notified the physician who gave orders to have the patient transferred to the ER for evaluation.

Review of the medical record lacked evidence that nursing staff completed a post fall assessment and review of the nurse's notes failed to show any additional education to the patient or that nursing staff put any new interventions into place to prevent another fall. Nursing staff also failed to complete the ARF score sheet after the patient's fall on 10/22/19 at 9:45 PM to assess his new fall risk score since he fell .


Fall 3
Review of an incident/accident report undated and untimed showed Patient put himself on the floor. Witnessed by roommate. Sutures on forehead intact with blood dripping from suture site. No other injuries noted.

Review of the medical record lacked evidence that nursing staff completed a post fall assessment and review of the nurse's notes failed to show any additional education to the patient or that nursing staff put any new interventions into place to prevent another fall.


Fall 4
Review of the incident/accident report dated 10/29/19 at 7:00 PM showed per Staff I, RN, patient was witnessed slipping out of chair, non injury.

Review of the medical record lacked evidence that nursing staff completed a post fall assessment and review of the nurse's notes failed to show any additional education to the patient or that nursing staff put any new interventions into place to prevent another fall. Nursing staff also failed to complete the ARF score sheet after the patient's fall on 10/29/19 to assess his new fall risk score since he fell .


Review of Patient 3's Fall Prevention Intervention forms showed nursing staff also failed to document any nursing assessment or interventions implemented to prevent falls on 10/27/19, 11/01/19, and 11/02/19 on the day shift.


Patient 4

Review of Patient 4's discharged medical record showed her DOB as 01/15/1951 ([AGE] years old). She was admitted on [DATE] with a diagnosis of Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Suicide attempt, Overdose, and Dementia (thinking and social symptoms that interfere with daily functioning). Her medical diagnosis included hypertension (high blood pressure), type 2 diabetes, and chronic obstructive pulmonary disease (damage to the lungs that cannot be reversed). Patient 4 had gross motor and walking impairment, she uses a wheel chair, has weakness, and is independent with her shower. Patient 4 had a fall risk score of 22 indicating a moderate risk for falls. When she was reassessed on 11/29/19 and 11/30/19 it showed a score of 27 placing her at a high risk for falls.

Review of the nurse's note dated 11/29/19 at 8:20 PM showed Patient 4 stated, "If I don't get my way I am going to throw myself on the floor." The nurse's note showed the patient was requesting pain medications at 12:00 AM and the patient was informed she would be getting her next dose at 12:40 AM.

Review of incident/accident form dated 11/29/19 showed that Patient 4 fell at 12:35 AM in her room. Staff found the patient on the floor, she had hit her head with blood coming from her nose. She was taken to an ER by ambulance. The medical record failed to show any results, treatments or changes after the hospital visit.

Review of the medical record lacked evidence that nursing staff completed a post fall assessment and review of the nurse's notes failed to show any additional education to the patient or that nursing staff put any new interventions into place to prevent another fall.

Review of Patient 4's Fall Precaution Intervention Forms showed nursing staff also failed to document any nursing assessment or interventions to prevent falls on 11/23/19 day shift, 11/25/19 night shift, 11/27/19 night shift, and 12/02/19 night shift.


Patient 5

Review of Patient 5's discharged medical record showed her DOB as 03/30/1934 ([AGE] years old). She was admitted on [DATE] with a diagnosis of Dementia (a decline in mental ability severe enough to interfere with independence and daily life) and cognitive impairment. Her medical diagnosis include hypertension (an abnormally high blood pressure). She was independent and did not need help with her activities of daily living. The initial nursing assessment showed a fall score of 8 which qualified her to be a moderate fall risk. Patient 5 experienced one fall during her 11-day admission.

Review of multidisciplinary notes showed that on 11/28/19 at 6:03 PM Patient 5 fell in the hallway and hit her head on the right side of her forehead causing a laceration and bleeding. She was sent to the ER. Review of nurse's notes showed on 11/28/19 patient returned from the ER at 10:50 PM.

Review of the medical record lacked evidence that nursing staff completed a post fall assessment form and review of the nurse's notes failed to show any additional education to the patient or that nursing staff put any new interventions into place to prevent another fall.


Patient 7

Review of Patient 7's discharged medical record showed her DOB as 07/14/1931 ([AGE] years old). She was admitted on [DATE] with a diagnosis of depressive disorder (all-encompassing low mood accompanied by low self-esteem and loss of interest in activities, and major neurocognitive disorder with behavioral disturbances (dementia, a decline in mental ability severe enough to interfere with independence and daily life. Patient 7 was also admitted for a risk of harm to self, suicide attempts, physical aggression and feeling hopeless. Patient 7's medical diagnoses are many and include some of the following: heart failure, hypertension, pulmonary embolism (one or more arteries in the lungs become blocked by a blood clot). She had an impaired ability to walk, transferred with an assist, was weak, uses a wheel chair, is fair with performing her own independent activities and needs assistance with toileting, grooming, and showering. Document review of the initial nursing assessment shows an initial fall score of 18 placing her at a moderate risk for falls. Review of the ARF showed a fall risk score of 27 on 10/16/19 placing her at a high risk for falls.

Review of Patient 7's treatment team goals dated 10/08/19 for fall precautions showed, "1. Verbalize Need to Request Assistance to Prevent Falls within 7 days. 2. Demonstrate Proper Transfer Techniques Within 7 days and 3. Demonstrate Use of Call Bell Within 7 days". Nursing Interventions on the treatment plan included: 1. Initiate Fall Assessment Protocols Per Guidelines ...2. Fall Risk After All Falls and Weekly 3. Assign MHT to Assist With AL's (activities of daily living) and Baths Daily 4. Assess Level of Sedation Each Shift and Document 5. Assure Patient has Appropriate Clothing and Footwear 6. Educate on Rising Slowly From Sitting / Lying Position, Dangling Feet on Side of Bed Before Rising 7. Assess and Document Side Effects of Medication 8. Educate Patient to Request Assistance Prior to Getting Out of Bed 9. Other: Safety.

Review of Patient 7's Master treatment plan for fall precautions showed the goals and nursing interventions above were initiated on admission on 10/08/19. The interdisciplinary team continued the same goals on 10/15/19 and 11/01/19. However, the treatment plan lacked any evidence that these nursing interventions were reassessed, updated, or revised at any point during her hospitalization even though Patient 7 experienced two falls in 14 days.

Fall 1
Review of the multidisciplinary notes dated 10/11/19 at 1:45 PM showed Patient 7 leaned over to get something off the table and slid to the floor. She had no injuries.

Review of the medical record lacked evidence that nursing staff completed a post fall assessment was completed by nursing staff and review of the nurse's notes failed to show any additional education to the patient or that nursing staff put any new interventions into place to prevent another fall.


Fall 2
Review of an Incident/Accident Report dated 10/11/19 at 4:10 PM showed that the patient was in the hallway when the writer of the incident form heard a noise and found the patient on the floor. She had a small abrasion to the right forehead with no bleeding. Review of the Multi-Disciplinary notes failed to show documentation of the fall that occurred at 4:10 PM.

Review of the medical record lacked evidence that nursing staff completed a post fall assessment and review of the nurse's notes failed to show any additional education to the patient or that nursing staff put any new interventions into place to prevent another fall.


Review of Patient 7's Fall Precaution Intervention forms showed nursing staff also failed to document any nursing assessment or interventions to prevent falls on 10/09/19 day shift, 10/10/19 day shift, 10/11/19 day and night shift (day of her falls), 10/21/19 day shift, and 10/22/19 day shift.


Patient 13
Review of Patient 13's discharged medical record showed her DOB as 07/22/1935 ([AGE] years old). She was a voluntary admission to the hospital on [DATE] at 5:00 PM with a psychiatric diagnosis of major neurocognitive disorder (dementia) with behavioral disturbance. Family reported increased agitation and aggression toward her husband, hearing voices and noises, and has made statements about self-injury without a stated plan. Her past psychiatric history includes Alzheimer's dementia (a progressive disease that destroys memory and other important mental functions). She also is post stroke (damage to the brain from interruption of its blood supply) and is diabetic (too much sugar in the blood). On admission she required a walker with ambulation and documentation shows fair independence with activities of daily living requiring no assistance. The fall risk assessment on admission showed a score of 16 placing her in the moderate fall risk category and the ARF dated 10/09/19, 10/15/19, and 10/19/19 showed the total fall risk score of 23 keeping her at a moderate risk of falls although she had two documented falls during her 13-day admission. When requested, the hospital failed to provide documentation that Patient 13's Master treatment Plan of Care included goals related to fall precautions or any nursing interventions for the nurses to assess/reassess although she scored a moderate fall risk on admission and the treatment team should have implemented a falls precaution plan.


Fall 1
Review of the untimed nurse's notes dated 10/13/19 showed, Patient 13 was walking the hallways, pushing another resident and was observed at the end of the hallway turning and falling without hitting her head.

Review of the incident/accident report dated 10/13/19 at 10:20 PM showed, "Pt was walking down hallway, turned to run and put herself on the floor. There was no documented evidence nursing staff notified the family of the fall.

Review of Patient 13's Fall Prevention Intervention form showed nursing staff failed to document any nursing assessment or interventions to prevent falls on either shift 10/13/19; the day of this fall.

Review of the medical record lacked evidence that a post fall assessment was completed by nursing staff and review of the nurse's notes failed to show any additional education to the patient or that nursing staff put any new interventions into place to prevent another fall.

Fall 2
Review of the nurse's notes dated 10/18/19 at 6:30 PM showed Patient 13 fell in room with no injuries noted.

Review of the medical record lacked evidence that a post fall assessment was completed by nursing staff and review of the nurse's notes failed to show any documentation that nursing staff put any new interventions into place to prevent another fall.

Review of Patient 13's Fall Prevention Intervention form showed nursing staff also failed to document any nursing assessment or interventions to prevent falls on 10/10/19 day shift, 10/11/19 day and night shifts.


Miscellaneous Fall Information

1. Observation on 12/18/19 at 1:50 PM, showed incomplete Fall Precaution Intervention assessments for current Patients 18 and 20.

Review of Patient 18's Fall Prevention Intervention forms showed nursing staff failed to document any nursing assessment or interventions to prevent falls on 11/22/19 night shift, 11/27/19 night shift, 11/28/19 night shift, 12/03/19 day and evening shift, 12/11/19 night shift, and 12/12/19 day shift.

Review of Patient 20's Fall Prevention Intervention forms showed nursing staff failed to document any nursing assessment or interventions to prevent falls on 12/04/19 day shift, 12/12/19 night shift, and 12/14/19 day shift.


During an interview on 12/18/19 at 5:11 PM, Staff B, DON stated that we are looking at wireless alarms that clip on the staff and patient to alert them when there is a fall. We ordered them a month ago and have not implemented them yet. The DON state
VIOLATION: Condition of Participation: Pharmaceutical Se Tag No: A0489
Based on observation, interview, record review, document review and policy review the hospital failed to ensure pharmaceutical services was staffed and able to provide services that safely and effectively met the needs of their patients.

The cumulative effect of the hospital's failure to provide safe and effective pharmaceutical services placed patients at risk for adverse outcomes, delayed symptom management, and additional medication errors.


Findings Include:


The hospital failed to ensure pharmaceutical staff provided supervision and oversight of pharmaceutical services ensuring accurate, timely medication delivery and safe medication administration by: 1. failing to ensure nursing staff administered medications in accordance with physician's orders; 2. failing to provide education to nurses to reduce the number of overrides and to reduce the potential for medication errors regarding overrides (The override function allows a nurse to remove a medication from the automated dispensing machine before a pharmacist reviews the order); 3. failing to ensure staff follow policy and procedure in handling and storage of a narcotic medication brought from home; 4. failing to ensure a patients identification band was legible; and 5. failing to ensure staff follow hospital policy to maintain medication integrity when splitting tablets. Refer to A-492

The hospital failed to ensure adequate pharmaceutical staff to provide quality pharmaceutical services ensuring accurate, timely medication delivery and safe medication administration by: 1. failing to ensure nursing staff administered medications in accordance with physician's orders; 2. failing to provide education to nurses to reduce the number of overrides and to reduce the potential for medication errors regarding overrides (The override function allows a nurse to remove a medication from the automated dispensing machine before a pharmacist reviews the order); 3. failing to ensure staff follow policy and procedure in handling and storage of a narcotic medication brought from home; 4. failing to ensure a patients identification band was legible; and 5. failing to ensure staff follow hospital policy to maintain medication integrity when splitting tablets. Refer to A-493

The hospital staff failed to follow policy and procedure in handling and storage of a narcotic medication brought from home resulting in the loss of the narcotic. Refer to A-503

The hospital staff failed to ensure that they notified the attending physician immediately of medication errors and missing doses. Refer to A-508
VIOLATION: PHARMACIST RESPONSIBILITIES Tag No: A0492
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, document review and policy review the hospital failed to ensure pharmaceutical staff provided supervision and oversight of pharmaceutical services ensuring accurate, timely medication delivery and safe medication administration by: 1. failing to ensure nursing staff administered medications in accordance with physician's orders for nine of 14 patients records reviewed (Patients 1, 4, 5, 6, 7, 8, 9, 10, and 11); 2. failing to provide education to nurses to reduce the number of overrides and to reduce the potential for medication errors regarding overrides (The override function allows a nurse to remove a medication from the automated dispensing machine before a pharmacist reviews the order); 3. failing to ensure staff follow policy and procedure in handling and storage of a narcotic medication brought from home for one of 14 patients records reviewed resulting in the loss of the narcotic (Patient 8); 4. failing to ensure one of twelve current patients identification band was legible on 12/18/19 (Patient 23); and 5. failing to ensure staff follow hospital policy to maintain medication integrity when splitting tablets for three of four medications passes observed (Patient 1, 16, and 17). The hospital's failure to ensure pharmaceutical staff provided supervision and oversight of pharmaceutical services places patients at risk to receive medications in error possibly causing sedation, serious side effects, falls, injury and harm.



Findings Include:


Review of a hospital policy titled, "Decreasing Medication Errors," revised 11/2016, showed, ...Pharmacist will make daily rounds on all patient care units."

During an interview on 12/17/19 at 8:08 AM, Staff K, Pharmacist stated that she is at the hospital two times a week usually during the days and in 2020 she is planning to be there three times a week. She stated that her responsibilities include: stocking medications into the Pyxis (an automated medication dispensing system), reviewing and updating policies and procedures, completing audits for quality concerning medication overrides, and performing medication tracers through the Pyxis and medication administration record (MAR) from beginning to end for diversion control. She stated that the data is recorded on excel sheets and she reviews and evaluates the results with another pharmacist. She stated that she has quarterly pharmacy and therapy (P&T) meetings to address all regulatory compliance. She explained she does orientation training with the new nurses concerning: dispensing medications, policies and procedures, and documentation. She shared the crash cart has a sign off sheet for nursing that should be checked every day and she signs off on it once a week. She stated that the pharmacy and therapy (P&T) meetings are combined with med exec for meeting minutes. Concerning quality issues/initiatives she is looking at medication reconciliation's, overrides, adverse drug reactions, medication errors, and the use of multiple antipsychotic medications upon discharge. She stated that she is sent a spreadsheet with Pyxis override data two times a day Monday thru Friday and once on the weekends. As part of the review process, Staff K looks to see if the right medication was pulled for the right patient and if there is an order written for the medication. If an error is found during this review process, Staff K is to share it with the DON and CEO. If this resulted in a medication error, the nurses have a medication variance report form they can fill out to give to the DON and CEO. Once a month the medication variances are reconciled and reported to pharmacy. Adverse drug reactions (ADRs) mostly come from nursing on an incident form and a few things come from the Pyxis if a stat (immediate) medication is given. The process after awareness of medication errors is to perform education with the specific staff it occurred with and we put the educations forms in their files. The variances and errors are discussed in the monthly quality meetings. With a lot of agency staff coming and going the last three to four months we have not been able to keep up with the training/education and follow up. The DON's responsibility is to train agency staff on medications. She stated that a few patients bring their own meds from home and we have a policy on checking them in and administration of home medications. She stated that as far as she knew there are no medication reviews of patient charts. The process if a medication is a read back verbal order (RBVO) is that the RN takes the order and then hand writes it in the medical record. All medication orders are then to be scanned to the pharmacy and flagged in the chart for review. The RN handwrites the order on the MAR (paper) from the handwritten order on the chart after it is received. The pharmacy reviews the order and after it is approved it will be entered electronically into the Pyxis. Staff K stated that all meds are in the Pyxis. The controlled medication report is usually run one time a month for review.



1. Document review of the hospital's policy titled, "Medication Management," dated 11/2016, showed...The individual administering the medication will verify the medication selected for administration is the correct medication based on the medication order and the medication product label. The individual administering the medication will be aware of the following information concerning each medication before administration...appropriate timing of medication administration, normal dosage and maximum safe dosage...the medication nurse will assure that the correct medication is administered by checking the physician's order and the medication label... ...errors in medications...a notification form will be sent to nursing administration and the pharmacy department by the end of the shift in which the error was committed...each dose of medication administered is to be properly recorded in the patient's record.

Document review of the hospital policy titled, "Decreasing Medication Errors," revised 11/2016, showed, ...Pharmacist will make daily rounds on all patients."

Document review of the hospital's Medication Variance Report form (discrepancy between the order and the medication administration) showed the following areas to be completed by staff:

Who was involved?
When occurred?
What occurred?
Risk Level:
Level 1: non-medication variance occurred
Level 2: A variance occurred that did not result in patient harm.
Level 3: A variance occurred that resulted in the need for increased patient monitoring by no change in vital signs and no patient harm.
Level 4: A variance occurred that resulted in the need for increased patient monitoring with a change in vital signs, labs, etc. but no ultimate patient harm.
Level 5: A variance occurred that resulted in the need for treatment with another drug or an increased length of stay.
Level 6: A variance occurred that resulted in permanent patient harm
Level 7: A variance occurred that resulted in patient death.
Type of Variance: Wrong Patient, Wrong Route, Wrong Dose, Wrong Medication, Wrong time, Misinterpretation of order, Transcription, Order Written incorrectly, Other.
Outcome: What effect (if any) did this incident have on the person?
Physician Notified? Name, Date/Time notified.
Pharmacist Notified? Name, Date/Time notified.
Sign off.

During an interview on 12/19/19 at 10:03 AM, Staff K, Pharmacist stated that the medication variance report can be filled out by the pharmacy, nursing, administration or whoever discovers the medication error.

The facility failed to provide a policy regarding "Medication Variance Report" when requested.

Review of the Medication Variance Reports showed a total of three medication variance forms were completed for medication errors from June 2019 to December 24, 2019.

Review of the following medical records showed that there were many more medication variances than Medication Variance Reports completed:



Patient 1

Review of Patient 1's current medical record showed his date of birth (DOB) as 04/24/1946. He was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. Patient 1's medical diagnosis included hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD) (damage to the lungs that cannot be reversed).

Document review of Patient 1's Medication Administration Record (MAR) showed the following medication errors/missing doses and tests not completed:

The medical record lacked any evidence Staff FF, Agency RN completed finger sticks to check blood sugar levels on 11/05/19 and 11/07/19 at 4:00 PM as ordered.

The medical record lacked any evidence Staff U, Agency Registered Nurse (RN), administered Lantus 25 units (insulin for high blood sugars) at hour of sleep (HS) on 11/07/19 as ordered.

The medical record lacked any evidence Staff DD, Agency RN completed finger sticks to check blood sugar levels on 11/08/19, 11/12/19, and 11/14/19 at 4:00 PM as ordered.

The medical record lacked any evidence Staff V, Agency Registered Nurse (RN), administered Lantus 25 units (insulin for high blood sugars) at hour of sleep (HS) on 11/10/19 as ordered.

The medical record lacked any evidence Staff HH, Agency RN administered Vitamin D3, 1000 units once a day on 11/10/19 as ordered.

The medical record lacked any evidence Staff HH, Agency RN administered Prozac 40 milligrams (mg) (medication used to treat depression) once a day on 11/10/19 as ordered.

The medical record lacked any evidence Staff HH, Agency RN administered Folic acid 1 mg (supplement) once a day on 11/10/19 as ordered.

The medical record lacked any evidence Staff U, Agency RN administered Quetiapine 100 mg (a medication used to treat psychosis) at HS on 11/13/19 and 11/14/19 as ordered.

The medical record lacked any evidence Staff II, Agency RN administered Metformin (oral medication to help control high blood sugar) 750 mg on 11/27/19 at 5:00 PM as ordered.

The medical record lacked any evidence that either of the two RNs (Staff DD, Agency RN or Staff JJ, Agency RN) working the day shift (7:00 AM to 7:00 PM) on 11/29/19 administered any medications that the patient had ordered including Tylenol 500 mg (for chronic pain) at 9:00 AM and 5:00 PM, Aspirin 81 mg at 9:00 AM, Atenolol 25 mg (treats high blood pressure), Vitamin D3, 1000 units once a day at 9:00 AM, Vitamin B12 1000 mcg (supplement) once a day at 9:00 AM, Prozac 40 mg once a day at 9:00 AM, Flonase 50 mcg (relieves allergy symptoms like nasal congestion, sneezing, runny nose) once a day at 9:00 AM, Folic acid 1 mg once a day at 9:00 AM, Lisinopril 10 mg (treats high blood pressure) once a day at 9:00 AM, Namenda 10 mg (treats dementia) once a day at 9:00 AM, Metformin 750 mg twice a day at 9:00 AM and 5:00 PM, Multivitamin once a day at 9:00 AM, Potassium Chloride 20 mEq once a day at 9:00 AM, Seroquel 25 mg (treats aggression) twice a day at 9:00 AM and 12:00 PM, Risperdal 0.25 mg (antipsychotic medication used to treat paranoia) twice a day at 8:00 AM and 2:00 PM, Exelon 4.6 mg/24 Transdermal (through the skin medication used to treat dementia) once a day at 9:00 AM, and Zoloft 100 mg (used to treat depression) once a day at 9:00 AM.

The medical record lacked any evidence Staff II, Agency RN administered Exelon 9.5 mg/24 Transdermal (through the skin medication used to treat dementia) once a day or Aspirin 81 mg (used to prevent blood clots) once a day on 12/10/19 as ordered.

Review of the record showed that nursing staff failed to complete a 24-hour chart check on 11/02/19, 11/05/19, and 11/07/19.

During an interview on 12/23/19 at 4:42 PM, Staff B, DON stated that concerning medication reviews of the chart, the night RNs are required to perform a 24-hour chart check for medication accuracy. She stated that there has been such a turn over with agency nurses and it has been difficult to perform any kind of education.

There was no evidence any hospital staff completed Medication Variance Reports for the above medication errors/missed doses and blood glucose tests on 11/05/19, 11/07/19, 11/08/19, 11/10/19, 11/12/19, 11/13/19, 11/14/19, 11/27/19, 11/29/19, and 12/10/19.



Patient 4



Review of Patient 4's discharged medical record showed her DOB as 01/15/1951. She was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED].

Review of Patient 4's MAR showed the following medication errors/missing doses:

The medical record lacked any evidence that either of the two RNs (Staff DD, Agency RN or Staff JJ, Agency RN) working the day shift administered Norvasc 10 mg (medication used to treat high blood pressure), Cymbalta 90 mg (a medication used to treat depression), or a Multivitamin, daily in the morning on 11/29/19 as ordered.

The medical record lacked any evidence that either of the two RNs (Staff I, RN or Staff DD, Agency RN) working the day shift administered Protonix 40 mg (used to decrease the amount of acid produced in the stomach) daily in the morning on 12/05/19 as ordered.

Review of the record showed that nursing staff failed to complete a 24-hour chart check on 11/24/19, 11/25/19, and 12/05/19.

There was no evidence any hospital staff completed Medication Variance Reports for the above medication errors/missed doses on 11/29/19 and 12/05/19.



Patient 5

Review of Patient 5's discharged medical record showed her DOB as 03/30/1934, she was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient 5's MAR showed the following medication errors/missing doses:

The medical record lacked any evidence that either of the two RNs (Staff DD, Agency RN or Staff JJ, Agency RN) working the day shift on 11/29/19 administered Abilify 2 mg (a medication used to treat psychosis) once a day at 9:00 AM or Zestril 10 mg (a medication used to treat high blood pressure) once a day at 9:00 AM as ordered, Namenda 5 mg (a medication used to treat dementia) twice a day at 9:00 AM, and Exelon 4.6 mg/ 24 hour once a day at 9:00 AM.

Review of the record showed that nursing staff failed to complete a 24-hour chart check on 11/27/19, 11/28/19, 12/01/19, and 12/05/19.

There was no evidence any hospital staff completed Medication Variance Reports for the above medication errors/missed doses on 11/29/19.


Patient 6

Review of Patient 6's discharged medical record showed her DOB as 07/04/1942. She was admitted on [DATE] at 12:50 PM with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient 6's MAR showed the following medication errors/missing doses:

The medical record lacked any evidence that either of the two RNs (Staff DD, Agency RN or Staff II, Agency RN) working the day shift on 12/06/19 administered Diltiazem (a medication used to treat high blood pressure) 30 mg at 5:00 PM as ordered or Namenda 5 mg at 5:00 PM as ordered.

The medical record lacked any evidence that either of the two RNs (Staff N, Agency RN or Staff EE, Agency RN) working the night shift (7:00 PM to 7:00 AM) on 12/06/19 administered Melatonin (a medication used for sleep) 6 mg oral at bedtime as ordered.

Review of the record showed that nursing staff failed to complete a 24-hour chart check on 12/06/19.

There was no evidence any hospital staff completed Medication Variance Reports for the above medication errors/missed doses on 12/06/19.



Patient 7

Review of Patient 7's discharged medical record showed her DOB as 07/14/1931. She was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. She was discharged on [DATE].

Review of Patient 7's MAR showed the following medication errors/missing doses:

The medical record lacked any evidence Staff KK, Agency RN administered Desyrel 25 mg (medication used for sleep) at HS on 10/12/19 as ordered.

The medical record lacked any evidence Staff N, Agency RN administered Desyrel 25 mg (medication used for sleep) at HS on 10/13/19 as ordered.

The medical record lacked any evidence Staff LL, Agency RN administered Timoptic Ocumeter (eye drop used to treat glaucoma) 1 drop once a day on 10/15/19 at 9:00 PM as ordered.

The medical record lacked any evidence Staff V, Agency RN administered Desyrel 25 mg (medication used for sleep) at HS on 10/15/19 as ordered.

The medical record lacked any evidence Staff DD, Agency RN administered Prilosec (a medication used to treat acid reflux) 20 mg daily at 7:00 AM on 10/16/19 as ordered.

The medical record lacked any evidence Staff N, Agency RN administered Xalatan (eye drop used to treat glaucoma) 1 drop at HS on 10/16/19 at 9:00 PM as ordered.

The medical record lacked any evidence either of the two RNs working day shift on 10/18/19 (Staff I, RN and Staff II, Agency RN) administered any of the medications the patient had ordered including Eliquis 5 mg twice a day (a medication used to thin the blood) at 9:00 AM and 5:00 PM, Amoxicillin 500 mg three times a day at 9:00 AM, 1:00 PM, and 5:00 PM, Aspirin 81 mg once a day at 9:00 AM, Celexa 20 mg (a medication used to treat anxiety and depression) once a day at 9:00 AM, Prilosec 20 mg daily at 7:00 AM, Miralax (a stool softener) 17 gms every other day at 9:00 AM, Potassium Chloride 10 mEq once a day at 9:00 AM, Risperdal 0.125 mg twice a day at 8:00 AM and 2:00 PM, and Timoptic Ocumeter one drop once a day at 9:00 AM.

The medical record lacked any evidence either of the two RNs working night shift on 10/18/19 (Staff V, RN and Staff N, Agency RN) administered any of the medications the patient had ordered including Xalatan 1 eye drop each eye at HS and Desyrel 50 mg at HS.

An unidentified person indicated on the Medication Administration Record that the MAR was missing on 10/18/19.

Review of the record showed that nursing staff failed to complete a 24-hour chart check on 10/09/19, 10/10/19, 10/12/19, 10/14/19, 10/15/19, 10/17/19, 10/18/19, and 10/21/19.

There was no evidence any hospital staff completed Medication Variance Reports for the above medication errors/missed doses on 10/12/19, 10/13/19, 10/15/19, 10/16/19, and 10/18/19.



Patient 8

Review of Patient 8's discharged medical record showed his DOB as 04/10/1962. He was admitted on [DATE] with a psychiatric diagnosis of [DIAGNOSES REDACTED]

Review of Patient 8's record showed that Staff J, Psychiatrist ordered Oxcarbazepine (a medication used to treat seizures) 300 mg every AM and 600 mg every PM on 09/30/19 at 10:00 PM.

Review of an incident/accident report dated 10/01/19 showed an unidentified night nurse did an override for Carbamazepine (a medication used to treat seizures, nerve pain, and bipolar disorder) 600 mg and so Patient 8 received the incorrect medication at 1:58 AM.

Review of the daily staffing schedules showed Staff B, RN, DON, was working the night of the medication error on 10/01/19.

Review of the Medication Variance Report dated 10/02/19 by Staff L, RN, showed Staff B, DON as the nurse involved and that the wrong medication was given to Patient 8. The Risk Level and Outcome section of the form was not completed.



Patient 9

Review of Patient 9's discharged medical record showed her DOB as 12/15/1966. She was admitted on [DATE] at 5:40 PM with a psychiatric diagnosis of [DIAGNOSES REDACTED].

Review of the physician orders showed Pantoprazole (a medication used to treat acid reflux) 20 mg and Levothyroxine 50 micrograms (mcg), both to be given daily at 6:30 AM.

Review of Patient 9's MAR showed Staff KK, Agency RN, failed to administer medications as ordered:

11/01/19 Pantoprazole 40 mg oral (Staff KK documented that she gave this medication at 6:30 AM even though the patient was not admitted until 5:40 PM).
11/02/19 Pantoprazole 40 mg oral at 6:30 AM (Staff KK gave two times the ordered dose of 20 mg daily).
11/02/19 Levothyroxine 25 mcg (Staff KK gave 1/2 the ordered 50 mcg dose).
11/03/19 Pantoprazole 40 mg oral at 6:30 AM (Staff KK gave two times the ordered dose of 20 mg daily).
11/03/19 Levothyroxine 25 mcg (Staff KK gave 1/2 the ordered 50 mcg dose).

Review of the record showed no evidence that Staff KK completed a 24-hour chart check on the night shift of 11/01/19 or 11/02/19.

Review of the medication variance report completed by Staff S, Agency RN on 11/04/19 at 12:11 AM failed to show evidence that nursing staff notified the ordering Physician, Staff M of the medication errors.

During an interview on 12/19/19 at 12:00 PM, Staff M, Physician stated that he is notified of medication errors but not the overrides and he assumes verbal orders are written as he instructs the nurses and he does not pick up on the orders that are written incorrectly when he signs the verbal order.


Patient 10

Review of Patient 10's discharged medical record showed her DOB as 04/08/1950. She was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. Her medical diagnoses included [DIAGNOSES REDACTED]] (a problem in the brain caused by a chemical imbalance in the blood caused by an illness or organs that are not working as they should).


Review of the MAR showed Staff HH, Agency RN, gave Zyprexa 5 mg (a medication given for agitation and aggression) to Patient 10 on 11/03/19.

Review of the physician's orders lacked evidence of an order to give Zyprexa to Patient 10.

Review of the nurse's notes lacked evidence that nursing staff documented the medication error that occurred on 11/03/19.


Review of Patient 10's MAR showed the following medication errors/missing doses:

The medical record lacked any evidence Staff U, Agency RN administered Protonix 40 mg once a day at 6:30 AM on 11/01/19 as ordered.

The medical record lacked any evidence Staff II, Agency RN administered Risperidone (medication used to treat paranoia/agitation) 0.125 mg every morning on 11/04/19 as ordered.

The medical record lacked any evidence that either of the two RNs (Staff II, Agency RN or Staff N, Agency RN) working the night shift administered Levothyroxine (medication used to treat low thyroid levels) 75 mcg once a day at 6:30 AM or Protonix 40 mg once a day at 6:30 AM on 11/07/19 as ordered.

The medical record lacked any evidence Staff HH, Agency RN administered Vitamin B1 100 mg once a day on 11/10/19 as ordered.

The medical record lacked any evidence Staff V, Agency RN administered Protonix 40 mg once a day on 11/11/19 as ordered.

The medical record lacked any evidence Staff EE, Agency RN administered Namenda 5 mg at 5:00 PM on 11/12/19 as ordered.

The medical record lacked any evidence Staff EE, Agency RN administered Namenda 5 mg at 5:00 PM on 11/14/19 as ordered.

Review of the record showed that nursing staff failed to complete a 24-hour chart check on 10/31/19, 11/02/19, 11/03/19, and 11/10/19.

There was no evidence any hospital staff completed Medication Variance Reports for the above medication errors/missed doses on 11/01/19, 11/03/19, 11/04/19, 11/07/19, 11/10/19, 11/11/19, 11/12/19, and 11/14/19.



Patient 11

Review of Patient 11's discharged medical record showed her DOB as 03/28/1955. She was admitted on [DATE] at 1:00 AM with a diagnosis of [DIAGNOSES REDACTED].

Review of Patient 11's MAR showed the following medication errors/missing doses:

Review of the physician's orders showed MiraLAX (a medication used to treat constipation) 17 g daily was ordered 09/28/19, however, this order was not faxed to the pharmacy until 10/01/19. Therefore, Patient 11 failed to receive this medication on 09/28/19, 09/29/19, and 09/30/19.

The medical record lacked any evidence Staff B, DON administered Mirtazapine (a medication used to treat psychosis) 15 mg at bedtime or Tamsulosin (a medication used to treat urinary retention) 0.4 mg at bedtime on 09/30/19 as ordered.

The medical record lacked any evidence Staff I, RN administered Amantadine (a medication used to treat tremors) 50 mg on 10/02/19 at 9:00 AM as ordered.

Review of the record showed that nursing staff failed to complete a 24-hour chart check on 09/24/19, 09/25/19, 09/27/19, 09/29/19, 10/01/19, and 10/06/19.

There was no evidence any hospital staff completed Medication Variance Reports for the above medication errors/missed doses on 09/28/19, 09/29/19, 09/30/19, and 10/02/19 or for the failure to fax the MiraLAX order to the pharmacy resulting in delay in the start of the medication administration on 10/01/19.


During an interview on 12/23/19 at 4:42 PM, Staff B, DON verified there were only three medication variance forms completed from June thru December 2019. She stated that she thought Staff K, Pharmacist was doing the medication variances. She stated that they have not done any education concerning medication errors. She further stated that there has been such a turn over with agency nurses and it has been difficult to perform any kind of education. Staff B stated that if a nurse forgets to give a medication it is hard to track as there is not a system in place to track it. She and Staff K, Pharmacist initiated a once a week meeting with Staff A, Chief Executive Officer (CEO) to look at medication errors, but they are having difficulty meeting and there are no notes to reflect when they met and what they discussed.

During an interview on 12/19/19 at 10:03 AM, Staff K, Pharmacist stated that she is only budgeted for 10-15 hours a week and that sometimes it is difficult to get everything done. Staff K does not feel like she gets med errors as they happen. She stated that she feels the med errors are not reported timely or at all as she can see the reports verses the actual med error sheets. She stated chart checks getting done appropriately is the number one problem between pharmacy and nursing (the night RNs are required to perform a 24-hour chart check for medication accuracy). She stated that is has been discussed but not resolved. When the staff fail to complete a timely chart check it leads to medication issues. She stated she feels like her recommendations for policy or care changes are not acted upon and she does not believe she receives an accurate report of all medication errors. Staff K did not clarify what recommendations were made or to whom or when she made the recommendations. Staff K stated that Staff M, Physician wanted her to start an audit to track on random patients admitted after 3:00 PM to see if they are getting their medications the same night of the admission. Staff K stated that she was not able to get the audit started at this time due to her limited hours.



2. Review of the hospital's policy titled, "Automated Dispensing Machines (ADM) - Access To," dated 11/2016, showed ...nursing services and pharmacy department staff will follow the policies and procedures for the automated dispensing machine(s) to ensure the safe and accurate dispensing of medications, accountability of controlled substances and other medications.

Review of the hospital's policy titled, "Automated Dispensing Machine - Removing Medications," dated 11/2016, showed...medications may only be removed from the ADM after the medication order has been verified by the Pharmacist, unless in an emergency.

Review of the hospital's policy titled, "Automated Dispensing Machine - Audit and Quality Control," dated 11/2016, showed...the pharmacy and nursing services will jointly review reports of the automated dispensing system transactions for all users of the system monthly ...areas that may be tracked...removal of medications for approval...frequency and reasons for medication override in the ADM... reporting/documentation of discrepancies and resolution of those discrepancies.

Review of a document titled "Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes" showed: The override function allows a nurse to remove a medication from the machine before a pharmacist reviews the order. The purpose of the override function is to allow access to medications in urgent/emergent situations. The override function is frequently utilized in clinical settings with non-24-hour pharmacies, emergency departments, and most procedural locations. Inappropriate uses of the override function are often based on practice patterns and perceptions that the pharmacy cannot process orders as quickly as needed. It might also occur if staff has a verbal order and acts upon it, or if a physician demands that a medication be given stat. Administering medications prior to a pharmacist review increases the risk of medication errors.


Review of an untitled document dated 06/02/19 through 12/06/19 showed a total of 46 medication errors and 33 (72%) of those errors were related to overrides of the ADM. Although the document identified that nurses were responsible for each error, it does not identify the nurses by name.

Review of the hospital's incident/accident reports showed Staff J, Psychiatrist ordered Oxcarbazepine (a medication used to treat convulsions) 300 mg every AM and 600 mg every PM on 09/30/19 for Patient 8. Review of an incident/accident report dated 10/01/19 showed an unidentified night nurse did an override for Carbamazepine (a medication used to treat seizures, nerve pain, and bipolar disorder) 600 mg and so Patient 8 received the incorrect medication at 1:58 AM. The untitled document dated 06/02/19 through 12/06/19 showed this medication error was directly related to overriding the medication ADM.

Review of a hospital document titled "Department of Pharmacy Performance Indicators-Monthly Reporting" dated Nov. 2019 showed the percent of Overrides of Net (total) Dispensed at 7.00%. The target percent is less than 5%. The report showed override percentages for May through November 2019 as follows:

May 2019 - 110 total overrides, 3.18%
June 2019 - 317 total overrides, 8.39%
July 2019 - 372 total overrides, 10.11%
August 2019 - 252 total overrides, 6.82%
September 2019 - 259 total overrides, 7.20%
October 2019 - 220 total overrides, 5.50%
November 2019 - 167 total overrides, 7.00%

Th
VIOLATION: CONTROLLED DRUGS KEPT LOCKED Tag No: A0503
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, record review and staff interview the hospital staff failed to follow policy and procedure in handling and storage of a narcotic medication brought from home for one of 14 patients records reviewed resulting in the loss of the narcotic (Patient 8). Failure of the hospital staff follow policy and procedure in handling and storage of narcotics has the potential for abuse and loss of the narcotic.

Findings Include:

Review of the hospital's policy titled, "Medication Administration," dated 11/2016, showed...Medications from home that the patient brings to the hospital will be disposed of in one of two ways: 1. Sent home with an immediate relative 2. Sent to the hospital Pharmacy to be stored until the patient is discharged . Medications are placed in a labeled bag and sent to the Pharmacy. If the patient expires, all personal medication will be destroyed.

Review of the Hospital's policy titled, "Medication Storage - Controlled Substances," dated 11/2016, showed...the pharmacy department is responsible for the procurement and usage of controlled drugs within the hospital...patient care areas: scheduled drugs will be kept in limited access drawers in the dispensing cabinet.

Document review of the Hospital's policy titled, "Narcotics," dated 11/2016, showed...the patient care unit nurse manager/nursing supervisor shall assist the nurses in determining what happened to the controlled substance, by following these steps: review controlled substance drawer, review patient records, review controlled substance records...the completed Controlled Substance Discrepancy Form/Notification Form shall be completed by the charge nurse or his/her designee prior to reporting off duty...the controlled substance discrepancy form and the notification form shall be submitted to: pharmacy, patient care unit nurse manager, nursing office...the patient care unit manager (DON)/Nursing Supervisor shall be accountable for preventing the loss of controlled substances and requiring that the Controlled Substance Discrepancy Form be completed prior to the team leader reporting off duty. Nursing management shall hold team leader and staff nurses accountable for preventing the loss of controlled substances and for the completion of the forms prior to the team leader reporting off duty...nursing quality teams/peer review teams shall be held as directed by the DON when needed to determine methods to prevent losses that occur and formulate policy.

Review of Patient 8's discharged medical record showed his DOB as 04/10/1962 ([AGE] years old). He was admitted on [DATE] with a psychiatric diagnosis of major depressive disorder. His history includes one suicide attempt and anxiety. Documented reasons for admission were risk of harm to self, suicidal ideations with no plan, and hopelessness. On the Nursing Admission Assessment completed 09/27/19, Patient 8 rated his pain 8/10 on a 0 (no pain) -10 (worst pain) pain scale, indicating that his back pain is constant, sharp, aching and that he has had for years.

Review of the form titled, "Inventory of Patient's Possessions," completed on 09/27/19 showed under Personal Belongings that the patient had a Red Cooler w/meds.

Review of the "Reconcile Home Medication and Physician Order Form," dated 09/27/19 at 10:30 PM, completed by Staff N, Agency RN showed Patient 8 brought the following medications from home: duloxetine (medication for depressive disorder and anxiety) 60 mg twice daily (BID), lithium (medication used to treat manic-depressive disorder) 600 mg, oxcarbazepine 300 mg BID, oxycodone (narcotic pain medication) 10 mg as needed (PRN) BID, dicyclomine (medication for irritable bowel disease) 10 mg, four times per day (QID), flecainide (anti-arrhythmic) 100 mg BID, fluticasone (steroid anti-inflammatory) 200-25 every day, furosemide (diuretic medication) 80 mg daily, Jantoven (medication for blood clot prevention) 1 mg daily on Tuesday, Thursday, Saturday, and Sunday, Jantoven 5 mg Monday, Wednesday, and Friday, losartan (antihypertensive medication) 25 mg daily, Lubiprostone (for constipation) 8 mcg BID, mesalamine (medication for ulcerative colitis) 4.8 gm daily, metoprolol (antihypertensive) 25 mg BID, Montelukast (medication for the treatment of asthma) 10 mg daily, Pancrelipase (pancreatic enzyme) 2 capsules three times daily (TID), potassium chloride (potassium replacement) 20 mEq daily, Simvastatin (medication to lower lipid levels) 10 mg daily, Aldactone (diuretic) 25 mg daily, Tamsulosin (medication for the treatment of difficult urination) 0.4 mg daily, trazadone (antidepressant) 100 mg daily, and Valbenazine (medication to treat tardive dyskinesia, involuntary repetitive body movements) 80 mg daily. The form had a box checked indicating that the patient's home meds were stored on site and showed that no one was available to take the medications home.

Review of Physician's Orders dated 09/27/19 at 10:30 PM showed that Physician Staff M ordered Oxycodone 5 mg QID PRN for pain.

Review of Patient 8's medical record showed that he discharged on [DATE].

Review of the Contact Log for Patient 8, dated 10/11/19 Before 12:00 showed Staff I, RN stated "she had seen there was Oxycodone in the home medications and had asked Staff B, DON if it should be placed in the medication room safe, but Staff B stated "no."

Review of the Contact Log for Patient 8, dated 10/11/19 at 12:08 PM showed, "Patient's wife called and said that the patient made it home and she looked through the red bag of the patient's home medications and stated that the patient's pain medication, oxycodone is missing. Staff O, Licensed Practical Nurse (LPN), Discharge Planner told the patient's wife that she would give Staff B, DON her phone number." Staff O, LPN further documented "Staff B, DON stated that she didn't know what to do and told me (case manager) to handle it because I am the discharge planner."

An unusual occurrence report was not completed. However, a written statement from Staff I, RN showed that on 09/29/19 she discovered a red bag on the counter with a bottle of Oxycodone 10 mg instant release (IR) in it. She reported it to the DON stating it was in an unsecured area. She then wrote on 10/11/19 she was responsible for the discharge of Patient 8 and returned his home medications to him, however the Oxycodone was not in the red bag.

During an interview on 12/17/19 at 4:00 PM Staff B, DON stated she did remember the incident and provided the following additional documentation.

Undated written documentation by Staff P, Mental Health Technician (MHT) stated she helped admit Patient 8 and inventoried his possessions. She "did not know what to do with the cooler of meds so I gave it to Staff L, RN." She additionally wrote at the end of shift she noticed the cooler behind the nursing station and told Staff L, RN what was in the cooler and Staff L, RN said, "she would take care of it."

Review of the 10/12/19 unsigned incident investigation document showed, that the writer called Patient 8's wife regarding the missing medication and confirmed with her that the medication was brought to the psychiatric hospital when her husband, Patient 8 was admitted and a MHT and two nurses verified the medication. Further documentation showed the charge nurse administered some of the home medications to Patient 8 and the pain medication was still with the other medications at that time. The charge nurse also stated she passed the box onto the night charge nurse at the end of shift and it was placed in the medication room. The night charge nurse no longer works at the psychiatric hospital. Finally, documentation shows, "going forward everyone will be trained, and signed training acknowledgements will be in the employees file of the procedure about how to handle this type of situation."

The nursing staff failed to follow policy by not securing Patient 8's narcotics in a limited access drawer in the dispensing cabinet and failed to prevent the loss of a controlled substance.

During an interview on 12/19/19 at 10:00 AM, Staff K, Pharmacist, stated that her expectation is that home narcotics brought in by patients are to be counted, documented and locked in the safe in the medication room. She stated that she does not have access to the safe in the medication room.

Staff B, DON did not provide evidence of staff education following the loss of Patient 8's narcotics.
VIOLATION: REPORTING ADVERSE EVENTS Tag No: A0508
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, record review, and staff interview, the hospital staff failed to ensure that they notified the attending physician immediately of medication errors and missing doses for eight of 14 patients reviewed (Patients 1, 4, 5, 6, 7, 9, 10, and 11). This deficient practices places patients at risk for adverse outcomes, delayed symptom management, and additional medication errors.

Findings Include:

Document review of the Hospital's policy titled, "Medication Management," dated 11/2016, showed...The individual administering the medication will verify the medication selected for administration is the correct medication based on the medication order and the medication product label. The individual administering the medication will be aware of the following information concerning each medication before administration...appropriate timing of medication administration, normal dosage and maximum safe dosage...the medication nurse will assure that the correct medication is administered by checking the physician's order and the medication label... ...errors in medications...a notification form will be sent to nursing administration and the pharmacy department by the end of the shift in which the error was committed...each dose of medication administered is to be properly recorded in the patient's record.

Document review of the hospital's Medication Variance Report form (discrepancy between the order and the medication administration) showed staff were to complete the following information:

Who was involved?
When occurred?
What occurred?
Risk Level:
Level 1: non-medication variance occurred
Level 2: A variance occurred that did not result in patient harm.
Level 3: A variance occurred that resulted in the need for increased patient monitoring by no change in vital signs and no patient harm.
Level 4: A variance occurred that resulted in the need for increased patient monitoring with a change in vital signs, labs, etc. but no ultimate patient harm.
Level 5: A variance occurred that resulted in the need for treatment with another drug or an increased length of stay.
Level 6: A variance occurred that resulted in permanent patient harm
Level 7: A variance occurred that resulted in patient death.
Type of Variance: Wrong Patient, Wrong Route, Wrong Dose, Wrong Medication, Wrong time, Misinterpretation of order, Transcription, Order Written incorrectly, Other.
Outcome: What effect (if any) did this incident have on the person?
Physician Notified? Name, Date/Time notified.
Pharmacist Notified? Name, Date/Time notified.
Sign off.

During an interview on 12/19/19 at 10:03 AM, Staff K, Pharmacist stated that the medication variance report can be filled out by the pharmacy, nursing, administration or whoever discovers the medication error.

The facility failed to provide a policy regarding "Medication Variance Report" when requested.

Review of the Medication Variance Reports showed a total of three medication variance forms were completed for medication errors from June 2019 to December 24, 2019.



1. Review of the following medical records showed that there were many more medication variances than Medication Variance Reports completed:


Patient 1

Review of Patient 1's current medical record showed his date of birth (DOB) as 04/24/1946. He was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. Patient 1's medical diagnosis included hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD) (damage to the lungs that cannot be reversed).

Document review of Patient 1's Medication Administration Record (MAR) showed the following medication errors/missing doses:

The medical record lacked any evidence Staff U, Agency Registered Nurse (RN), administered Lantus 25 units (insulin for high blood sugars) at hour of sleep (HS) on 11/07/19 as ordered.

The medical record lacked any evidence Staff V, Agency Registered Nurse (RN), administered Lantus 25 units (insulin for high blood sugars) at hour of sleep (HS) on 11/10/19 as ordered.

The medical record lacked any evidence Staff HH, Agency RN administered Vitamin D3, 1000 units once a day on 11/10/19 as ordered.

The medical record lacked any evidence Staff HH, Agency RN administered Prozac 40 milligrams (mg) (medication used to treat depression) once a day on 11/10/19 as ordered.

The medical record lacked any evidence Staff HH, Agency RN administered Folic acid 1 mg (supplement) once a day on 11/10/19 as ordered.

The medical record lacked any evidence Staff U, Agency RN administered Quetiapine 100 mg (a medication used to treat psychosis) at HS on 11/13/19 and 11/14/19 as ordered.

The medical record lacked any evidence Staff II, Agency RN administered Metformin (oral medication to help control high blood sugar) 750 mg on 11/27/19 at 5:00 PM as ordered.

The medical record lacked any evidence that either of the two RNs (Staff DD, Agency RN or Staff JJ, Agency RN) working the day shift (7:00 AM to 7:00 PM) on 11/29/19 administered any medications that the patient had ordered including Tylenol 500 mg (for chronic pain) at 9:00 AM and 5:00 PM, Aspirin 81 mg at 9:00 AM, Atenolol 25 mg (treats high blood pressure), Vitamin D3, 1000 units once a day at 9:00 AM, Vitamin B12 1000 mcg (supplement) once a day at 9:00 AM, Prozac 40 mg once a day at 9:00 AM, Flonase 50 mcg (relieves allergy symptoms like nasal congestion, sneezing, runny nose) once a day at 9:00 AM, Folic acid 1 mg once a day at 9:00 AM, Lisinopril 10 mg (treats high blood pressure) once a day at 9:00 AM, Namenda 10 mg (treats dementia) once a day at 9:00 AM, Metformin 750 mg twice a day at 9:00 AM and 5:00 PM, Multivitamin once a day at 9:00 AM, Potassium Chloride 20 mEq once a day at 9:00 AM, Seroquel 25 mg (treats aggression) twice a day at 9:00 AM and 12:00 PM, Risperdal 0.25 mg (antipsychotic medication used to treat paranoia) twice a day at 8:00 AM and 2:00 PM, Exelon 4.6 mg/24 Transdermal (through the skin medication used to treat dementia) once a day at 9:00 AM, and Zoloft 100 mg (used to treat depression) once a day at 9:00 AM.

The medical record lacked any evidence Staff II, Agency RN administered Exelon 9.5 mg/24 Transdermal (through the skin medication used to treat dementia) once a day or Aspirin 81 mg (used to prevent blood clots) once a day on 12/10/19 as ordered.

Review of the record showed that nursing staff failed to complete a 24-hour chart check on 11/02/19, 11/05/19, and 11/07/19.

During an interview on 12/23/19 at 4:42 PM, Staff B, DON stated that concerning medication reviews of the chart, the night RNs are required to perform a 24-hour chart check for medication accuracy. She stated that there has been such a turn over with agency nurses and it has been difficult to perform any kind of education.

There was no evidence any hospital staff completed Medication Variance Reports (which includes notification to the physician of the date/time of the medication error) for the above medication errors/missed doses on 11/07/19, 11/10/19, 11/13/19, 11/14/19, 11/27/19, 11/29/19, and 12/10/19.



Patient 4


Review of Patient 4's discharged medical record showed her DOB as 01/15/1951. She was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED].

Review of Patient 4's MAR showed the following medication errors/missing doses:

The medical record lacked any evidence that either of the two RNs (Staff DD, Agency RN or Staff JJ, Agency RN) working the day shift administered Norvasc 10 mg (medication used to treat high blood pressure), Cymbalta 90 mg (a medication used to treat depression), or a Multivitamin, daily in the morning on 11/29/19 as ordered.

The medical record lacked any evidence that either of the two RNs (Staff I, RN or Staff DD, Agency RN) working the day shift administered Protonix 40 mg (used to decrease the amount of acid produced in the stomach) daily in the morning on 12/05/19 as ordered.

Review of the record showed that nursing staff failed to complete a 24-hour chart check on 11/24/19, 11/25/19, and 12/05/19.

There was no evidence any hospital staff completed Medication Variance Reports (which includes notification to the physician of the date/time of the medication error) for the above medication errors/missed doses on 11/29/19 and 12/05/19.



Patient 5

Review of Patient 5's discharged medical record showed her DOB as 03/30/1934, she was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient 5's MAR showed the following medication errors/missing doses:

The medical record lacked any evidence that either of the two RNs (Staff DD, Agency RN or Staff JJ, Agency RN) working the day shift on 11/29/19 administered Abilify 2 mg (a medication used to treat psychosis) once a day at 9:00 AM or Zestril 10 mg (a medication used to treat high blood pressure) once a day at 9:00 AM as ordered, Namenda 5 mg (a medication used to treat dementia) twice a day at 9:00 AM, and Exelon 4.6 mg/ 24 hour once a day at 9:00 AM.

Review of the record showed that nursing staff failed to complete a 24-hour chart check on 11/27/19, 11/28/19, 12/01/19, and 12/05/19.

There was no evidence any hospital staff completed a Medication Variance Report (which includes notification to the physician of the date/time of the medication error) for the above medication errors/missed doses on 11/29/19.


Patient 6

Review of Patient 6's discharged medical record showed her DOB as 07/04/1942. She was admitted on [DATE] at 12:50 PM with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient 6's MAR showed the following medication errors/missing doses:

The medical record lacked any evidence that either of the two RNs (Staff DD, Agency RN or Staff II, Agency RN) working the day shift on 12/06/19 administered Diltiazem (a medication used to treat high blood pressure) 30 mg at 5:00 PM as ordered or Namenda 5 mg at 5:00 PM as ordered.

The medical record lacked any evidence that either of the two RNs (Staff N, Agency RN or Staff EE, Agency RN) working the night shift (7:00 PM to 7:00 AM) on 12/06/19 administered Melatonin (a medication used for sleep) 6 mg oral at bedtime as ordered.

Review of the record showed that nursing staff failed to complete a 24-hour chart check on 12/06/19.

There was no evidence any hospital staff completed a Medication Variance Report (which includes notification to the physician of the date/time of the medication error) for the above medication errors/missed doses on 12/06/19.



Patient 7

Review of Patient 7's discharged medical record showed her DOB as 07/14/1931. She was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. She was discharged on [DATE].

Review of Patient 7's MAR showed the following medication errors/missing doses:

The medical record lacked any evidence Staff KK, Agency RN administered Desyrel 25 mg (medication used for sleep) at HS on 10/12/19 as ordered.

The medical record lacked any evidence Staff N, Agency RN administered Desyrel 25 mg (medication used for sleep) at HS on 10/13/19 as ordered.

The medical record lacked any evidence Staff LL, Agency RN administered Timoptic Ocumeter (eye drop used to treat glaucoma) 1 drop once a day on 10/15/19 at 9:00 PM as ordered.

The medical record lacked any evidence Staff V, Agency RN administered Desyrel 25 mg (medication used for sleep) at HS on 10/15/19 as ordered.

The medical record lacked any evidence Staff DD, Agency RN administered Prilosec (a medication used to treat acid reflux) 20 mg daily at 7:00 AM on 10/16/19 as ordered.

The medical record lacked any evidence Staff N, Agency RN administered Xalatan (eye drop used to treat glaucoma) 1 drop at HS on 10/16/19 at 9:00 PM as ordered.

The medical record lacked any evidence either of the two RNs working day shift on 10/18/19 (Staff I, RN and Staff II, Agency RN) administered any of the medications the patient had ordered including Eliquis 5 mg twice a day (a medication used to thin the blood) at 9:00 AM and 5:00 PM, Amoxicillin 500 mg three times a day at 9:00 AM, 1:00 PM, and 5:00 PM, Aspirin 81 mg once a day at 9:00 AM, Celexa 20 mg (a medication used to treat anxiety and depression) once a day at 9:00 AM, Prilosec 20 mg daily at 7:00 AM, Miralax (a stool softener) 17 gms every other day at 9:00 AM, Potassium Chloride 10 mEq once a day at 9:00 AM, Risperdal 0.125 mg twice a day at 8:00 AM and 2:00 PM, and Timoptic Ocumeter one drop once a day at 9:00 AM.

The medical record lacked any evidence either of the two RNs working night shift on 10/18/19 (Staff V, RN and Staff N, Agency RN) administered any of the medications the patient had ordered including Xalatan 1 eye drop each eye at HS and Desyrel 50 mg at HS.

An unidentified person indicated on the Medication Administration Record that the MAR was missing on 10/18/19.

Review of the record showed that nursing staff failed to complete a 24-hour chart check on 10/09/19, 10/10/19, 10/12/19, 10/14/19, 10/15/19, 10/17/19, 10/18/19, and 10/21/19.

There was no evidence any hospital staff completed Medication Variance Reports (which includes notification to the physician of the date/time of the medication error) for the above medication errors/missed doses on 10/12/19, 10/13/19, 10/15/19, 10/16/19, and 10/18/19.



Patient 9

Review of Patient 9's discharged medical record showed her DOB as 12/15/1966. She was admitted on [DATE] at 5:40 PM with a psychiatric diagnosis of [DIAGNOSES REDACTED].

Review of the physician orders showed Pantoprazole (a medication used to treat acid reflux) 20 mg and Levothyroxine 50 micrograms (mcg), both to be given daily at 6:30 AM.

Review of Patient 9's MAR showed Staff KK, Agency RN, failed to administer medications as ordered:

11/01/19 Pantoprazole 40 mg oral (Staff KK documented that she gave this medication at 6:30 AM even though the patient was not admitted until 5:40 PM).
11/02/19 Pantoprazole 40 mg oral at 6:30 AM (Staff KK gave two times the ordered dose of 20 mg daily).
11/02/19 Levothyroxine 25 mcg (Staff KK gave 1/2 the ordered 50 mcg dose).
11/03/19 Pantoprazole 40 mg oral at 6:30 AM (Staff KK gave two times the ordered dose of 20 mg daily).
11/03/19 Levothyroxine 25 mcg (Staff KK gave 1/2 the ordered 50 mcg dose).

Review of the record showed no evidence that Staff KK completed a 24-hour chart check on the night shift of 11/01/19 or 11/02/19.

Review of the medication variance report completed by Staff S, Agency RN on 11/04/19 at 12:11 AM failed to show evidence that nursing staff notified the ordering Physician, Staff M of the medication errors.


Patient 10

Review of Patient 10's discharged medical record showed her DOB as 04/08/1950. She was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. Her medical diagnoses included [DIAGNOSES REDACTED]] (a problem in the brain caused by a chemical imbalance in the blood caused by an illness or organs that are not working as they should).


Review of the MAR showed Staff HH, Agency RN, gave Zyprexa 5 mg (a medication given for agitation and aggression) to Patient 10 on 11/03/19.

Review of the physician's orders lacked evidence of an order to give Zyprexa to Patient 10.

Review of the nurse's notes lacked evidence that nursing staff documented the medication error that occurred on 11/03/19 or that the physician was notified of the medication given to Patient 10 without a physician's order.


Review of Patient 10's MAR showed the following medication errors/missing doses:

The medical record lacked any evidence Staff U, Agency RN administered Protonix 40 mg once a day at 6:30 AM on 11/01/19 as ordered.

The medical record lacked any evidence Staff II, Agency RN administered Risperidone (medication used to treat paranoia/agitation) 0.125 mg every morning on 11/04/19 as ordered.

The medical record lacked any evidence that either of the two RNs (Staff II, Agency RN or Staff N, Agency RN) working the night shift administered Levothyroxine (medication used to treat low thyroid levels) 75 mcg once a day at 6:30 AM or Protonix 40 mg once a day at 6:30 AM on 11/07/19 as ordered.

The medical record lacked any evidence Staff HH, Agency RN administered Vitamin B1 100 mg once a day on 11/10/19 as ordered.

The medical record lacked any evidence Staff V, Agency RN administered Protonix 40 mg once a day on 11/11/19 as ordered.

The medical record lacked any evidence Staff EE, Agency RN administered Namenda 5 mg at 5:00 PM on 11/12/19 as ordered.

The medical record lacked any evidence Staff EE, Agency RN administered Namenda 5 mg at 5:00 PM on 11/14/19 as ordered.

Review of the record showed that nursing staff failed to complete a 24-hour chart check on 10/31/19, 11/02/19, 11/03/19, and 11/10/19.

There was no evidence any hospital staff completed Medication Variance Reports (which includes notification to the physician of the date/time of the medication error) for the above medication errors/missed doses on 11/01/19, 11/03/19, 11/04/19, 11/07/19, 11/10/19, 11/11/19, 11/12/19, and 11/14/19.



Patient 11

Review of Patient 11's discharged medical record showed her DOB as 03/28/1955. She was admitted on [DATE] at 1:00 AM with a diagnosis of [DIAGNOSES REDACTED].

Review of Patient 11's MAR showed the following medication errors/missing doses:

Review of the physician's orders showed MiraLAX (a medication used to treat constipation) 17 g daily was ordered 09/28/19, however, this order was not faxed to the pharmacy until 10/01/19. Therefore, Patient 11 failed to receive this medication on 09/28/19, 09/29/19, and 09/30/19.

The medical record lacked any evidence Staff B, DON administered Mirtazapine (a medication used to treat psychosis) 15 mg at bedtime or Tamsulosin (a medication used to treat urinary retention) 0.4 mg at bedtime on 09/30/19 as ordered.

The medical record lacked any evidence Staff I, RN administered Amantadine (a medication used to treat tremors) 50 mg on 10/02/19 at 9:00 AM as ordered.

Review of the record showed that nursing staff failed to complete a 24-hour chart check on 09/24/19, 09/25/19, 09/27/19, 09/29/19, 10/01/19, and 10/06/19.

There was no evidence any hospital staff completed Medication Variance Reports (which includes notification to the physician of the date/time of the medication error) for the above medication errors/missed doses on 09/28/19, 09/29/19, 09/30/19, and 10/02/19 or for the failure to fax the MiraLAX order to the pharmacy resulting in delay in the start of the medication administration on 10/01/19.


During an interview on 12/23/19 at 4:42 PM, Staff B, DON verified there were only three medication variance forms completed from June thru December 2019. She stated that she thought Staff K, Pharmacist was doing the medication variances. She stated that they have not done any education concerning medication errors. She further stated that there has been such a turn over with agency nurses and it has been difficult to perform any kind of education. Staff B stated that if a nurse forgets to give a medication it is hard to track as there is not a system in place to track it. She and Staff K, Pharmacist initiated a once a week meeting with Staff A, Chief Executive Officer (CEO) to look at medication errors, but they are having difficulty meeting and there are no notes to reflect when they met and what they discussed.

During an interview on 12/19/19 at 10:03 AM, Staff K, Pharmacist stated that she is only budgeted for 10-15 hours a week and that sometimes it is difficult to get everything done. Staff K does not feel like she gets med errors as they happen. She stated that she feels the med errors are not reported timely or at all as she can see the reports versus the actual med error sheets. She stated chart checks getting done appropriately is the number one problem between pharmacy and nursing (the night RN's are required to perform a 24-hour chart check for medication accuracy). She stated that is has been discussed but not resolved. When the staff fail to complete a timely chart check it leads to medication issues. She stated she feels like her recommendations for policy or care changes are not acted upon and she does not believe she receives an accurate report of all medication errors. Staff K did not clarify what recommendations she made or to whom or when she made the recommendations.