HospitalInspections.org

Based on review of records and interview, the facility's registered nurse did not supervise and evaluate the nursing care for 1 of 1 patient who was admitted on 10/15/15 with a primary diagnosis of "s/p heart transplant" in that:

1-A nurse administered wrong doses of anti-rejection medications twice on 10/16/15;

2-A nurse did not give Patient #1's second dose of anti-rejection medication on 10/19/15;

3-A nurse administered the patient's anti-rejection medication 4 hours and 36 minutes past the scheduled time on 10/20/15; and

4-A nurse did not ensure that there was a physician's order in the medical record to use Patient #1's own medication instead of the hospital's medications.



Findings included:

Patient #1 was admitted on 10/15/15 for "s/p heart transplant," with secondary diagnoses that included hypertension (HTN) and idiopathic cardiomyopathy.

1-On 10/16/15 Patient #1 was given anti-rejection medications named "Astagraf XL cap ER 5 mg patient's own medication" at 7:39 AM and 5:54 PM. The physician's order was for "8 milligrams" twice daily.

2-On 10/19/15 Patient #1 was given "Astagraf XL cap ER 8 mg patient's own medication" at 5:50 AM. The second dose scheduled at 6:00 PM was not administered.

3-On 10/20/15 nurses' notes indicated "Astagraf XL cap ER 8 mg pt own med" was administered at 10:36 AM (4 hours and 36 minutes past the scheduled time).

4-Nurses' notes indicated they were using Patient #1's own anti-rejection medications from 10/16/15 to 10/24/15. There was no physician's order in the medical record to use Patient #1's own medications instead of the hospital's medication.

In an interview with Personnel #2 on 2/1/16 at approximately 11:30 AM, she was informed of the above findings and she confirmed the findings. Personnel #2 stated that according to their policy, nurses may administer scheduled medications 1 hour before or after the scheduled time. She confirmed it was still 3 hours and 36 minutes past the scheduled time.
Personnel #2 was asked if a nurse could administer medicines owned by a patient. She stated the facility's policy allowed the nurses to administer patients' own medications if there was a physician's order for it. Personnel #2 confirmed there was no physician's order to use Patient #1's anti-rejection medications.

Policy "Timely Administration of Scheduled Medication" effective 3/2014 reviewed 6/2014 required "In an effort to enhance safety...the following...has been developed...Definitions...Time-critical scheduled medications-medications that if administered greater than 30 minutes before or after the scheduled dose may cause harm or result in sub-optimal therapy or pharmacologic effect..."

Policy "Patient's Own Medication Use in the Hospital" dated 6/2014 required "It is the policy of the hospital that patients will be allowed to take their own medications with a physician order."

Based on record review and interview, the facility's nursing staff failed to administer anti-rejection medications according to physician's order, citing 1 of 1 patient (Patient #1) who was admitted on 10/15/15 with a primary diagnosis of "s/p heart transplant" on 9/10/15.

Findings included:

Patient #1 was admitted on 10/15/15 for "s/p heart transplant," with secondary diagnoses that included hypertension (HTN) and idiopathic cardiomyopathy.

On 10/16/15 Patient #1 was given "Astagraf XL cap ER 5 mg" at 7:39 AM and 5:54 PM. The order was for "Astagraf XL cap ER 8 mg" twice daily.

In an interview on 2/1/16 at approximately 11:30 PM, Personnel #2 was informed of the above findings and she confirmed the findings. She stated the order was not followed.

Based on record review and interview, the facility's pharmacist failed to identify a drug administration error for 1 of 1 patient (Patient #1) and did not report the error to the physician or the hospital's quality assessment and performance improvement program, in that:

1-The patient was given wrong doses of anti-rejection medications twice on 10/16/15;

2-The patient was not given his scheduled second dose of anti-rejection medication on 10/19/15;

3-A nurse administered the patient's anti-rejection medication 4 hours and 36 minutes past the scheduled time on 10/20/15; and

4-There was no physician's order in the medical record to use Patient #1's own medication.

Findings included:

Patient #1 was admitted on 10/15/15 for "s/p heart transplant," with secondary diagnoses that included hypertension (HTN) and idiopathic cardiomyopathy.

1-On 10/16/15 the patient was given anti-rejection medications named "Astagraf XL cap ER 5 mg patient's own medication" at 7:39 AM and 5:54 PM. The physician's order was for "8 milligrams" twice daily.

2-On 10/19/15 the patient was given "Astagraf XL cap ER 8 mg patient's own medication" at 5:50 AM. The second dose scheduled at 6:00 PM was not administered.

3-On 10/20/15 nurses' notes indicated "Astagraf XL cap ER 8 mg pt own med" was administered at 10:36 AM (4 hours and 36 minutes past the scheduled time).

4-Nurses' notes indicated they were using Patient #1's own medications from 10/16/15 to 10/24/15. There was no physician's order to use the anti-rejection medications of Patient #1.

In an interview on 2/1/16 at 10:45 AM, Personnel #3 was asked if pharmacy monitor and track medication errors. He stated "no" and that it was a nursing responsibility. Personnel #3 was asked what pharmacy quality indicators they monitor. He replied he did not know since he works part time. Personnel #3 was asked what his duties and responsibilities were. He replied one of his duties was to ensure that the correct patient, correct drugs, correct doses were entered in the computer. Personnel #3 was asked why Patient #1 received incorrect doses of his anti-rejection medications on 10/16/15. He replied that it was a pharmacy error.

Policy "Timely Administration of Scheduled Medications" last reviewed 6/2014 required "Missed doses due to omission will be considered a medication error..."

"Patient's Own Medication Use in the Hospital" dated 6/2014 required "It is the policy of the hospital that patients will be allowed to take their own medications with a physician order."