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Based on interviews and documentation review the Hospital failed to ensure that medications were administered in accordance with the medication administration record and/or policy for 5 of 10 patients (Patient #1, Patient #2, Patient #3, Patient #4, and Patient #5).

Findings included:

Medication Administration Records for 10 patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) assigned to agency nurses on 10/3/10 (Agency Nurses #1. #2, and #3) were compared to medication dispense activity reports and medication charge reports. The following errors were identified:

Patient #1:
Agency Nurse #1 was interviewed on 11/10/10 at 11:55 A.M. Agency Nurse #1 reported speaking the the Clinical Leader after the medication error to determine what medications prescribed for Patient #1 could be administered. Agency Nurse #1 reported proceeding to administer medications to other assigned patients and did not administer Patient #1's morning medications (due at 8:00 A.M. and 9:00 A.M.).

The Clinical Leader was interviewed on 11/10/10 at 1:10 P.M. The Clinical leader reported thinking that Agency Nurse #1administered Patient #1's morning medications.

Review of the MAR, dated 10/3/10, indicated that medications due at 8:00 A.M., Phoslo and Renvela, and 9:00 A.M., Colace, Gemfibrozil, Novolin insulin (not in the medication dispensing system), Omeprazole, were not signed off as administered.

Review of the medication dispense and charge reports, dated 10/3/10, indicated the following:

Phoslo (ordered 3 times daily) was removed from the medication dispensing system twice on 10/3/10. Phoslo was not removed at at 8:00 A.M. and although due at 12:00 P.M. was not removed until approximately 1:22 P.M.

Renvela (ordered 3 times daily) was removed from the medication dispensing system 3 times on 10/3/10 however; the medication was due at 12:00 P.M. and was not removed from the medication dispensing system until approximately 1:23 P.M.

Colace (ordered twice daily) was not removed for the 9:00 A.M. dose.

Gemfibrozil (ordered twice daily) was not removed for the 9:00 A.M. dose.

Novolin Insulin was not dispensed through the medication dispensing system and therefor could not be verified.

Omeprazole (ordered daily) was not removed from the medication dispensing system.

Lidoderm patch, due to be removed at 9:00 A.M. was not signed as removed.

Although the multivitamin, ordered for 9:00 A.M. was signed as administered; the medication dispense activity and charge reports indicated that on 10/3/10 it was never removed from the dispensing system.

Patient #2:
Review of the MAR, dated 10/3/10, indicated that Patient #2 was administered the following medications due at 9:00 A.M. by Agency Nurse #1: Vasotec (antihypertensive medication ordered daily), Ferrous Sulfate (a mineral ordered twice daily 9:00 A.M. and 5:00 P.M.), and a multivitamin (ordered daily).

The Director of Nurses was interviewed on 11/5/10 intermittently throughout the survey. The Director said Patient #2's medications, due at 9:00 A.M., were located in the medication dispensing system.

Review of the medication dispense activity report and the medication charge report, dated 10/3/10, indicated that Vasotec and the multivitamin were not removed from the dispensing system. Ferrous Sulfate was removed at approximately 5:28 P.M. and administered as ordered.

Patient #3:
Review of the MAR, dated 10/3/10, indicated that all medications were signed as administered as ordered by Agency Nurse #1 including Baclofen at 9:00 A.M. and 1:00 P.M.

Review of the medication charge report, dated 10/3/10, indicated that Baclofen ordered for three times daily, had only been dispensed twice.

Review of the dispense activity report for Agency Nurse #1, dated 10/3/10, indicated that Baclofen was not removed from the medication dispensing system for the 9:00 A.M. dose.

Patient #4:
Review of the MAR, dated 10/3/10, indicated that all medications were signed as administered as ordered with the exception of Prevacid which was circled.

Review of the MAR and progress notes, dated 10/3/10, indicated there was no documentation as to why the medication was circled.

Review of the MAR, dated 10/3/10, indicated that Pletal 100 milligrams (mg) was signed as administered at 10:00 A.M. by Agency Nurse #1.

Review of the medication dispense activity and charge reports, dated 10/3/10, indicated that Pletal was dispensed in 50 mg tablets requiring 2 tablets to be removed to equal 100 mg. On 10/3/10 one 50 mg tablet was removed and administered at 10:00 A.M..

Patient #5:
Review of the MAR, dated 10/3/10, indicated that Patient #5 received medications at 9:00 A.M. as ordered.

Review of the medication dispensing activity report, dated 10/3/10, indicated that Patient #5's 9:00 A.M. and 1:00 P.M. medications were removed from the system between 12:50 P.M. and 12:55 P.M.

Review of the MAR and progress notes, dated 10/3/10, indicated that there was no documented reason as to why the 9:00 A.M. medications were delayed.

Based on interview and documentation review the Hospital failed to follow-up on education provided for medication errors to determine compliance.

Findings included:

Review of the Hospital's quality assurance program related to medication errors for the period of 6/10 through 9/10 indicated that medication errors were tracked on a monthly basis. Medication errors were tracked according to the person who committed the error and according to the type of error such as transcription or administration.

Review of the medication error log for the period of 6/10 through 9/10 indicated that the majority of errors were administration errors and the majority of errors were committed by staff employed by the Hospital (verses agency staff). Medication error rates tended to fluctuate rather than show steady improvement.

Review of medication error meeting minutes for the period of 8/10 through 9/10 indicated that medication errors were reviewed with staff and re-education was provided at each meeting.

The Director of Nursing was interviewed on 11/5/10 intermittently throughout the survey. The Director said nursing practices were observed whenever the Director was on the units and when deficient practice was observed it was addressed.

There was no documented evidence that follow-up actions such as formal observations of medication passes or audits of medication documentation accuracy were regularly conducted to ensure compliance with re-education and policy requirements.

Based on interview and documentation review the Hospital failed to identify all medication errors that occurred on 10/3/10.

Findings included:

The Hospital reported that on 10/3/10 a registered nurse who was working at the Hospital through a temporary staffing agency (Agency Nurse #1) , administered the wrong medications to the patient (Patient #1). A report was sent to the Department of Public Health at the request of Patient #1 and family members. An onsite survey was conducted. During the survey it was determined that Patient #1 had received Patient #5's medications. Patient #5 was located several rooms away from Patient #1, did not receive the same medications, and did not have a similar name.

The Director of Nurses was interviewed on 11/5/10 intermittently throughout the survey. The Director said the investigation did not include a review of all medications passed by Agency Nurse #1 on 10/3/10 to ensure there were no other errors and did not include an interview with Agency Nurse #1.

Please refer to A-0405 for information regarding medication errors identified during the onsite survey.