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Based on record review and interview, the hospital failed to follow the quality process to track medical errors and adverse patient events, analyze their causes, and implement preventive actions for 1 of 10 inpatients (Patient #1) who was found to have a missing 100 mcg Fentanyl patch on 11/26/13, in that, Patient #1 experienced symptoms of withdrawal on 11/26/13, within 24 hours after the administration of a Fentanyl patch on 11/25/13 resulting in a dose of a 100 mcg Fentanyl patch administered to the patient on 11/26/13.


Findings Included:
The electronic medical record (EMR) for Patient #1 contained the "History and Physical" dated 11/07/13. It reflected Patient #1 was admitted 11/06/13 for abdominal pain.

The "Patient Care Notes" for 11/26/13 by Personnel #14 reflected, "2:00 PM...jittery and not herself...feels like she is going through withdrawal...she does not think her Fentanyl patch is on. Nurse examined and did not find patch. Linen checked and no patch found...Charge nurse advised...contacted pharmacy...new RX from doctor needed..." and "3:00 PM new order received...placed Fentanyl patch left upper back."

The paper medical record for Patient #1, contained the "Medication Administration Record" (MAR) printed from the EMR, for 11/25/13. It reflected the Fentanyl patch 100 mcg, every 72 hours, administration due at 10:00 AM. Personnel #13 documented the old patch was not present at 10:00 AM and new patch was not placed. Personnel #13 later charted the patch was found and placed in the sharps container in the room, without a time designated. Personnel #16 documented as the witness, without a time. Personnel #13 documented the administration of the Fentanyl patch on 11/25/13 at 1:30 PM, without a location of placement. The "Medication Administration Record" for 11/26/13 reflected the Fentanyl patch was hand written in and documented as given at 3:00 PM by Personnel #14.


The "Incident Report Log" was reviewed from November 2013 through January 2014. There was no medication occurrence logged for the missing Fentanyl patch from the 11/25/13 documented administration which triggered the dose of a Fentanyl patch on 11/26/13.


The "Complaint/Grievance Log" was reviewed from November 2013 through January 2014. There was no logged complaint for the patient's complaint of withdrawal symptoms on 11/26/13 from not having her Fentanyl patch that was documented administered on 11/25/13 on the MAR.

During an interview on 02/20/14 at 12:42 PM, Personnel #3 was informed of there being no complaint or incident filed for the issue with the 11/25/13 administered Fentanyl patch missing and the 11/26/13 patient complaint of symptoms of withdrawal. Personnel #3 confirmed the incident was not reported. Personnel #3 confirmed it should have been a patient complaint per the complaint policy and the nurse should have completed an incident report for the medication occurrence.

During an interview on 02/20/14 at 1:48 PM, Personnel #6 stated he remembered the incident with the Fentanyl Patch with Personnel #14. Personnel #6 stated he received the call about the missing patch and advised the nurse on the need for a new order from the doctor since it was not due until 11/28/13. Personnel #6 said once the order was received, the medication was administered to the patient. When asked about filing an incident report for the medication occurrence, Personnel #6 stated, "It didn't cross his mind." When asked about a possible drug diversion investigation, Personnel #6 stated, "I took it at face value...we have had no diversions in the year I have been here..."

During an interview on 02/20/14 at 2:55 PM, Personnel #2 was shown the above medical records findings. Personnel #2 confirmed the findings. When asked about the medication incident report, Personnel #2 stated a report should have been filed. When asked about pulling records from Medi-systems (medication containment device), Personnel #2 stated reports can't be pulled after 30 days.

During an interview on 02/21/14 at 9:00 AM, Personnel #7 reviewed the documented notes and MAR for 11/26/13 administration of the Fentanyl patch. Personnel #7 stated she did not recall if she spoke to the nurse about completing an incident report.

During a telephone interview on 03/05/14 at 8:28 AM, Personnel #14 called the surveyor. When asked if Personnel #14 reviewed the "Patient Care Notes" and "MAR" for the 11/26/13 issue. Personnel #14 said yes and confirmed the above findings. When asked about the medication incident report policy, Personnel #14 stated she did not have to complete a report; she just had to notify the charge nurse. When asked about the patient complaint policy, Personnel #14 stated she did not have to complete a complaint; she just had to notify the charge nurse.

The "Medication Error Reporting" policy, effective 05/31/08, required, "Drugs administered in error and doses omitted shall be reported and reviewed in accordance with the policy...A medication error is defined as any deviation from established policies and/or procedures during the prescribing, transcribing, dispensing, administering, and monitoring of a drug...types of error...extra dose...in addition to a regularly scheduled dose...the person who discovers the error shall prepare a drug administration error report..."

The "Complaint and Grievance Policy" revised 03/01/12, required, "...to provide a process to review, investigate and resolve a patient s complaint within a reasonable timeframe and provide a standardized format to document patient complaints...complaint...issues brought to the attention of the staff present which can be resolved timely by the staff..."

The Quality Assurance meeting minutes for November 2013 through January 2014 were reviewed. These was no documentation of the patient's complaint of withdrawal symptoms on 11/26/13 or the missing Fentanyl patch from the 11/25/13 administration and subsequent dose of Fentanyl given on 11/26/13.

Based on record review and interview, the facility failed to develop a plan of care for each patient which addressed the patient's needs for 10 of 10 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10), in that,

A) Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 had no required physician signature on the Interdisciplinary Team Care Conference (IDT CC) report,

B) Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 had blank sections on the IDT CC report,

C) Patient #1, #4, #5, and #6 had no date designating when the IDT CC report had been completed, and

D) Patient #1, #3, #4, and #5 had one missing IDT CC report each during their hospitalization.



Findings Included:



A) The Medical Record for Patient #1 contained two IDT CC reports. The first was dated 11/13/13. The second reflected no date. Neither report had the required physician signature.

The Medical Record for Patient #2 contained two IDT CC reports. The first was dated 11/06/13. The second was dated 11/13/13. Neither report had the required physician signature.

The Medical Record for Patient #3 contained three IDT CC reports. The first was dated 11/27/13. The second was dated 12/05/13. The third was dated 12/12/13. None of the three reports had the required physician signature.

The Medical Record for Patient #4 contained two IDT CC reports. The first was dated 12/04/13. The second reflected no date. Neither report had the required physician signature.

The Medical Record for Patient #5 contained two IDT CC reports. The first was dated 12/04/13. The second reflected no date. Neither report had the required physician signature.

The Medical Record for Patient #6 contained two IDT CC reports. The first was dated 12/30/13. The second reflected no date. Neither report had the required physician signature.

The Medical Record for Patient #7 contained four IDT CC reports. The first was dated 01/29/14. The second was dated 02/03/14. The third was dated 02/12/14. The fourth was dated 02/19/14. None of the four reports had the required physician signature.

The Medical Record for Patient #8 contained three IDT CC reports. The first was dated 02/03/14. The second was dated 02/12/14. The third was dated 02/19/14. None of the three reports had the required physician signature.

The Medical Record for Patient #9 contained two IDT CC reports. The first was dated 02/20/14. The second was dated 02/27/14. Neither report had the required physician signature.

The Medical Record for Patient #10 contained one IDT CC report. It was dated 02/19/14. This report did not have the required physician signature.


B) The Medical Record for Patient #1 contained two IDT CC reports. The first was dated 11/13/13. The "Nutrition," and "Wound" sections were left blank. The "Nursing," "Respiratory," and "Pharmacy" sections had no goal, plan of care or action noted. The second reflected no date. The "Pharmacy" section had no goal, plan of care or action noted.

The Medical Record for Patient #2 contained three IDT CC reports. The first was dated 11/06/13. The "Nursing," "Respiratory," and "Pharmacy" sections were left blank. The second was dated 11/13/13. The "Nursing," "Respiratory," and "Pharmacy" sections had no goal, plan of care or action noted. The third was dated 11/20/13. The "Nursing," and "Pharmacy" sections had no goal, plan of care or action noted. The "Respiratory," and "Wound Care" sections were left blank.

The Medical Record for Patient #3 contained three IDT CC reports. The first was dated 11/27/13. The "Nursing," and "Therapies" sections had no goal, plan of care or action noted. The second was dated 12/05/13. The "Respiratory," and "Wound Care" sections were left blank. The "Pharmacy" section had no goal, plan of care or action noted. The third was dated 12/12/13. The "Respiratory" section was left blank. The "Infection Control" section had no required signature.

The Medical Record for Patient #4 contained two IDT CC reports. The first was dated 12/04/13. The "Respiratory," and "Pharmacy" sections had no goal, plan of care or action noted. The second reflected no date. The "Nursing," "Therapies," and "Pharmacy" sections had no goal, plan of care or action noted. The "Respiratory" section was left blank.

The Medical Record for Patient #5 contained two IDT CC reports. The first was dated 12/04/13. The "Respiratory" section was left blank. The "Pharmacy" sections had no goal, plan of care or action noted. The second reflected no date. The "Nursing," and "Pharmacy" sections had no goal, plan of care or action noted. The "Respiratory" section was left blank.

The Medical Record for Patient #6 contained two IDT CC reports. The first was dated 12/30/13. The "Respiratory," and "Pharmacy" sections were left blank. The "Nursing," and "Therapies" sections had no goal, plan of care or action noted. The second reflected no date. The "Nursing," and "Therapies" sections had no goal, plan of care or action noted and no required signatures. The "Respiratory," "Pharmacy," "Wound Care," and "Discharge Plan" sections were left blank.

The Medical Record for Patient #7 contained four IDT CC reports. The first was dated 1/29/14. The "Respiratory," "Pharmacy," "Therapies," and "Infection Control" sections were left blank. The "Nursing," and "Pharmacy" sections had no goal, plan of care or action noted. The second was dated 02/03/14. The "Respiratory" section was left blank. The "Nursing," and "Pharmacy" sections had no goal, plan of care or action noted. The third was dated 02/12/14. The "Respiratory" section was left blank. The "Nursing," "Pharmacy," and "Discharge Plan" sections had no goal, plan of care or action noted. The fourth was dated 02/19/14. The "Respiratory" section was left blank. The "Nursing," "Therapies," "Pharmacy," and "Discharge Plan" sections had no goal, plan of care or action noted.

The Medical Record for Patient #8 contained three IDT CC reports. The first was dated 02/03/14. The "Respiratory," and "Therapies" sections were left blank. The "Nursing," and "Pharmacy" sections had no goal, plan of care or action noted. The second was dated 02/12/14. The "Respiratory" section was left blank. The "Nursing," and "Pharmacy" sections had no goal, plan of care or action noted. The third was dated 02/19/14. The "Respiratory" section was left blank. The "Nursing," "Pharmacy," and "Discharge Plan" sections had no goal, plan of care or action noted.

The Medical Record for Patient #9 contained two IDT CC reports. The first was dated 02/20/14. The "Respiratory" section was left blank. The "Nursing," and "Pharmacy" sections had no goal, plan of care or action noted. The second was dated 02/27/14. The "Pharmacy" section had no goal, plan of care or action noted.

The Medical Record for Patient #10 contained one IDT CC report. The report was dated 02/19/14. The "Nursing," "Nutrition," "Pharmacy," and "Discharge Plan" sections had no goal, plan of care or action noted. The "Respiratory," and "Therapies" sections were left blank. The "Nutrition" section had no assessment documented.


C) The Medical Record for Patient #1 contained two IDT CC reports. The first was dated 11/13/13. The second reflected no date.

The Medical Record for Patient #4, contained two IDT CC reports. The first was dated 12/04/13. The second reflected no date.

The Medical Record for Patient #5 contained two IDT CC reports. The first was dated 12/04/13. The second reflected no date.

The Medical Record for Patient #6 contained two IDT CC reports. The first was dated 12/30/13. The second reflected no date.


D) The Medical Record for Patient #1 contained two IDT CC reports dated 11/13/13 and the second one had no date. The "History and Physical" reflected the admit date was 11/06/13. The discharge date was 11/27/13, a 21 day admission with 2 IDT CC reports. The third IDT CC report was not completed.

The Medical Record for Patient #3, contained three IDT CC reports dated 11/27/13, 12/05/13 and 12/12/13. The "History and Physical" reflected the admit date was 11/20/13. The discharge date was 12/18/13, a 28 day admission with 3 IDT CC reports. The fourth IDT CC report was not completed.

The Medical Record for Patient #4, contained two IDT CC reports dated 12/04/13 and the second had no date. The "History and Physical" reflected the admit date was 11/26/13. The discharge date was 12/17/13, a 21 day admission with 2 IDT CC reports. The first IDT CC report was late and the third IDT CC report was not completed.

The Medical Record for Patient #5 contained two IDT CC reports dated 12/04/13 and the second one had no date. The "History and Physical" reflected the admit date was 11/29/13. The discharge date was 12/23/13, a 25 day admission with 2 IDT CC reports. The third IDT CC report was not completed.


During an interview on 02/20/14 at 1:45 PM, Personnel #2 was shown and confirmed chart findings of each medical record's IDT CC missing dates, signatures and sections not addressed appropriately. Personnel #2 supplied the surveyor with each patient's discharge date.

During an interview on 02/20/14 at 2:14 PM, Personnel #4 was asked about the IDT CC issues found. Personnel #4 stated the issues had been identified within the last week and the hospital has not had a quality meeting to discuss the issues as yet. Personnel #4 stated the hospital's process of concurrent active chart audits had not been followed.

The "Interdisciplinary Team Care Conference Meeting" policy, revised October 2013, required "...meet at least once, within 7 calendar days of patient's admission and then at least weekly...team members have a role in participating in the IDT meeting and to assure patient care is delivered according to each patient's unique needs...Medical Staff have a role in documenting their review of the noted plan of care, and certifying that the patient meets medical necessity for continued LTAC inpatient stay...Patient care goals are identified, prioritized and directed toward the next appropriate level of care and are discussed at each session...each disciple identifies discipline specific goals...Disciplines are responsible to document and update goals...patient care plan and the care plan goal dates..."

Based on record review and interview, the pharmacist failed to immediately report the medication occurence to the hospital's quality assessment and performance improvement program for 1 of 10 reviewed inpatients (Patient #1), in that, Patient #1 experienced symptoms of withdrawal on 11/26/13, within 24 hours after the administration of a Fentanyl patch on 11/25/13 resulting in a replacement dose of 100 mcg Fentanyl patch administered to the patient on 11/26/13.

Findings Included:

The electronic medical record (EMR) for Patient #1 contained the "History and Physical" dated 11/07/13. It reflected Patient #1 was admitted 11/06/13 for abdominal pain.

The "Patient Care Notes" for 11/26/13 by Personnel #14 reflected, "2:00 PM...jittery and not herself...feels like she is going through withdrawal...she does not think her Fentanyl patch is on. Nurse examined and did not find patch. Linen checked and no patch found...Charge nurse advised...contacted pharmacy...new RX from doctor needed..." and "3:00 PM new order received...placed Fentanyl patch left upper back."

The paper medical record for Patient #1, contained the "Medication Administration Record" (MAR) printed from the EMR, for 11/25/13. It reflected the Fentanyl patch 100 mcg, every 72 hours, administration due at 10:00 AM. Personnel #13 documented the old patch was not present at 10:00 AM and new patch was not placed. Personnel #13 later charted the patch was found and placed in the sharps container in the room, without a time designated. Personnel #16 documented as the witness, without a time. Personnel #13 documented the administration of the Fentanyl patch on 11/25/13 at 1:30 PM, without a location of placement. The "Medication Administration Record" for 11/26/13 reflected the Fentanyl patch was hand written in and documented as given at 3:00 PM by Personnel #14.

The "Medication Error Reporting" policy, effective 05/31/08, required, "Drugs administered in error and doses omitted shall be reported and reviewed in accordance with the policy...A medication error is defined as any deviation from established policies and/or procedures during the prescribing, transcribing, dispensing, administering, and monitoring of a drug...types of error...extra dose...in addition to a regularly scheduled dose...the person who discovers the error shall prepare a drug administration error report..."


The Quality Assurance meeting minutes for November 2013 through January 2014 were reviewed. There was no documentation of the patient's complaint of withdrawal symptoms on 11/26/13 or the missing Fentanyl patch from the 11/25/13 administration and subsequent dose of Fentanyl given on 11/26/13.


During an interview on 02/20/14 at 1:48 PM, Personnel #6 stated he remembered the incident with the Fentanyl Patch with Personnel #14. When asked about filing an incident report for the medication occurrence, Personnel #6 stated, "It didn't cross his mind." When asked about a possible drug diversion investigation, Personnel #6 stated, "I took it at face value...we have had no diversions in the year I have been here..."