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Based on observations, interviews, record reviews and policy reviews, the facility failed to ensure that medications were administered safely and accurately and nursing was notified of medication errors in a timely manner for:
- One patient (#5) of one patient observed whose identity was not confirmed before medication was administered and when medication was ordered to be administered by G-Tube (a tube surgically inserted into the stomach to deliver medications or nutrition) but was administered by mouth.
- Two current patients (#8 and #12) of seven current patients whose medications were left at the patients' bedside and self-administered medications without a physicians order.
-Two current patients (#19 and #13) and one discharged patient (#20) when the nurse was not notified in a timely manner of the medication error to prevent reoccurrence.
This had the potential to place all patients at risk for harm or compromised treatment when medications were not appropriately administered, secured, and notification of the physician and staff was not timely to prevent reoccurrence. There were 16 patients at the Lindell Campus (LC) and 28 patients at the Kennerly Campus (KC).

Findings included:

1. Record review of the facilities policy titled, "Medication Management", release date 05/2015, showed the following:
-Rational: Establish a system by which medications will be administered to patients safely, accurately and efficiently by qualified personnel.
Components:
-Prior to medication administration, a patient must be positively identified by two forms of identification on the wristband issued at admission: never room number.
-Procedure:
The 7 "R's" of administer medications well be followed with each medication administration.
-"Right" patient
-"Right" medication
-"Right" dose
-"Right" time
-"Right" route
-"Right" reason
- "Right" documentation
- Medications must be properly stored and secured at all times prior to administration and must never be left unattended.

2. Observation on 06/22/16 at 9:00 AM showed Staff R, Registered Nurse (RN), entered Patient #5's room and did not ask his name or check his arm band before she administered Metoprolol Tartrate (a medication used to treat chest pain or high blood pressure) 100 milligrams (measurement equal to 1/1000 of a gram) to Patient # 5 by mouth. The Medication Administration Record (MAR) showed that the medication was ordered by the physician to be given "by tube". The patient previously had a feeding tube (a tube placed through the skin into the stomach).

Record review of the Patient #5's MAR showed the patient had been given the medication by the wrong route from 06/06/16 through 06/22/16 at 9:00 AM.

During an interview on 06/22/16 at 10:12 AM, Staff R, RN, stated that she had not noticed the route was incorrect and did not ask his name or check his arm band because she had just been in his room and knew who he was.

3. Record review of the facility's policy titled, "Self-Administered Medications," dated 08/2014, showed that the physician must write an order for each medication that may be self-administered and indicate on each order that the patient may self-administer medication. If the medication is to be stored in the patient's room where the patient has access to the medication, there must be a physician's order stating that the medication can be stored at the bedside.

4. Observation on 06/22/16 at 11:00 AM, showed current Patient #8 with three medications at the bedside; Nystatin (antifungal) powder, Flonase nasal spray (medication used to relieve allergy symptoms) and Ocean nasal spray (saline/salt solution). Patient #8 stated that he administered the medications to himself.

Record review of Patient #8's physician orders showed an order dated 05/19/16 for sodium chloride nasal spray, one spray each nostril every 12 hours, and orders dated 05/25/16 for fluticasone propionate nasal spray (Flonase), one spray each nostril at 9:00 AM daily, and Nystatin topical powder to groin area.

The orders failed to show that the patient could self-administer the medications and that the medications could be stored at bedside.

Record review of Patients #8's MAR from 05/30/16 to 06/22/16 documented several RN notes that the medications were not administered because the patient administered them himself.

During an interview on 06/22/16 at 11:20 AM, Staff X, KC Nurse Supervisor, stated that Patient #8 was able to self-administer the medications. A nurse left the medication at the bedside at the time the medication was due and returned later to check that the patient administered the medications to self. She did not know if there was a physician order for self-administration or not.

During an interview on 06/22/16 at 11:45 AM, Staff U, KC Director of Quality Management, stated that there were no orders for Patient #8's self-administration of medications. The medications should have been administered by a nurse and stored in the locked cabinet in the patient's room unless there was an appropriate physician order.

5. Record review of current Patient #12's medical record, showed a physician order dated 06/21/16 for fluticasone propionate nasal spray, two sprays daily. The order failed to show that the patient could self-administer the medications and that the medications could be stored at bedside

Observation with concurrent interview on 06/22/16 at 2:35 PM, showed Patient #12's fluticasone propionate nasal spray was sitting on the patient's bedside table, unattended by nursing staff. Staff LL, LC Wound Care Nurse/DQM, verified the medication was not secured, and stated that medications should be not be left at the patient's bedside.

During an interview on 06/23/16 at 1:27 PM, Staff P, LC Director of Pharmacy, stated that facility did not have any patients with a physician's order to self-administer medications, and therefore, medications were not allowed to be left at patients' bedsides.

6. Record review of the facility's policy titled, "Adverse Drug Events," dated 08/2014, showed that:
- An adverse drug event is a collective term for a medication error or an adverse drug reaction.
- A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm.
- Investigated immediately by the involved department's supervisor, clinician's supervisor, pharmacist, and DQM for appropriate corrective action.

7. Record review of a facility record titled, "Event Log Report," documented that on 06/18/16 current Patient #19 had a medication variance (errors). DQM documentation showed that the employee received education.

8. The facility's investigation report documented that Patient #19 had a physician order to start piperacillin/tazobactam (antibiotic) Intravenous (IV, into the vein) three times per day and stop the medication on 06/19/16 at 12:30 AM. On 06/20/16 the IV medication [labeled with the date of 06/18/16] was discovered in the medication room and documentation showed a nurse administered the medication at 12:00 PM.

During a telephone interview on 06/23/16 at 3:05 PM, Staff HH, Licensed Practical Nurse, stated that she thought for sure that she administered Patient #19's IV medication on 06/18/16 because she remembered that the medication was later discontinued and did not administer it on 06/19/16. She stated that she was not notified of a medication error.

During an interview on 06/24/16 at 10:00 AM, Staff C, LC Nurse Manager, stated that she spoke with Staff HH about the medication error on 06/23/16.

9. Record review of a facility record titled, "Event Log Report," documented that on 05/01/16 discharged Patient #20 had two medication errors and DQM documentation that the employees received education.

10. A facility's investigation report documented that a nurse supervisor found [documented on a control substance sign out sheet] that on 05/01/16 at 9:45 AM and at 8:30 PM, two nurses administered the medication, Ativan, by IV instead of by mouth.

Record review of Patient #20's physician's orders showed that on 04/30/16 at 6:34 PM, a physician ordered lorazepam (anti-anxiety medication, also known as Ativan), one mg tablet by mouth every two hours as needed for severe anxiety.

Record review of Patient #20 medication administration record documented on 05/01/16 that lorazepam one mg tablet was administered by mouth and not by IV.

During an interview on 06/24/16 at 10:20 AM, Staff C, LC Nurse Manager, stated that she discussed the medication errors with Staff II and Staff HH. She had no record of the discussions.

During a telephone interview on 06/24/16 at 11:30 AM, Staff HH, LC RN, stated that on 05/01/16 she was the day shift nurse for Patient #20. She was not notified that she made a medication error and administered lorazepam incorrectly by IV instead of by mouth. She did not recall, was not notified, and received no specific education to prevent a recurrence.

During a telephone interview on 06/24/16 at 11:20 AM, Staff II, LC RN, stated that on 05/01/16 she was the evening shift nurse for Patient #20. She was not notified that she made a medication error and administered the lorazepam incorrectly by IV instead of by mouth. She did not recall, was not notified, and received no specific education to prevent a recurrence.

11. Record review of current Patient #13's medical record showed:
- The History and Physical (H&P) indicated that the patient had a post-operative wound infection (infection that occurs in a wound, after surgery) and dehiscence (where a wound that was surgically closed, re-opened) with multidrug-resistant bacteria (infection where many typical drugs used to treat the infection don't work).
- The MAR for ceftazidime/avibactam (antibiotic) IV, indicated that the 06/19/16 at 6:00 AM dose of medication was administered as scheduled.
- The MAR for colistimethate (drug used to reduce the development of drug-resistant bacteria) indicated that the 06/18/16 and 06/21/16 9:00 AM doses were administered as scheduled.

Record review of the facility's medication error investigation report showed that the (identified by facility administration as the 06/19/16 6:00 AM) dose of ceftazidime/avibactam was not administered.

During a telephone interview on 06/29/16 at 9:35 AM, Staff MM, LC RN, stated that he was not notified of the 06/19/16 6:00 AM medication error until 06/27/16, even though he had worked several shifts since the medication error was found.

Record review of the facility's medication error investigation report showed that the 06/18/16 9:00 AM dose of colistimethate was found in the refrigerator on 06/20/16, and had not been administered.

During a telephone interview on 06/29/16 at 10:07 AM, Staff NN, LC RN, stated that she was not notified of the 06/18/16 at 9:00 AM medication error, even through she had worked several shifts since the medication error was found.

Observation and concurrent interview on 06/21/16 at 3:25 PM, showed that Patient #13's 06/21/16 9:00 AM dose of colistimethate was still in the patient's room, and was not administered. Staff J, LC Nursing Supervisor, verified that the medication was not administered, and confirmed it was a medication error.

During a telephone interview on 06/23/16 at 4:40 PM, Staff D, LC RN, stated that she was unsure how the medication error occurred. Staff D stated that she started the medication administration and believed that another staff member came into the room and stopped the medication before the medication administration was completed because the infusion pump (pump that is programmed to administer IV medications) alarmed. Staff D stated that she did not have a chance to discuss the medication error or find out what happened, because she was asked to leave the facility and not return.






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