HospitalInspections.org

Based on interview and record review, the facility failed to ensure that medications were administered per facility policy and professional standards for one (1) of seven sampled patients (Patient #1). This failure had the potential to affect all patients admitted to the facility, current patient census 35 patients.


Findings:

Policy reviewed:

Review of facility policy on 06-07-22 at 2:25 p.m. with Staff ID #3, CNO, titled "Medication Management: Medication Administration," dated 09/01/21, stated "Purpose: ... establish the process for administering medications and it pertains to all areas of the hospital that administers medicines. Procedure: Compliance with medication orders: Medications shall be prepared and administered in accordance with the orders if the prescriber or practitioner responsible for the patient's care and accepted standards of practice."


Record Reviewed Patient ID #1

Admission date: 09-25-21 23:00

Record review on 06-07-22 at 11:00 a.m. along with Staff ID #3 of the clinical record of Patient #1 revealed she was a 89 year old female admitted to the facility on 09-25-21 for inpatient rehabilitation for "critical illness myopathy" following a 10 day inpatient hospital stay due to sepsis, acute myocardial infarction, heart failure and respiratory failure.

Further review of the clinical record revealed the following:

*Patient #1 had a history of atrial fibrillation, congestion, heart failure, chronic deep vein thrombosis, solitary kidney and numerous other conditions.
* Physician admission orders (dated 09-25-21) continued her hospital cardiac medications which included:
1) Amniodarone 200 mg by mouth every 12 hours.
2) Hydralazine 10 mg by mouth every 12 hours.
3) Isosorbide Dinitrate 10 mg by mouth twice daily.
4) Metoprolol 25 mg by mouth twice daily.
* Medications 1-4 above were scheduled to be given starting 9/26/21 at 09:00 a.m. and 09:00 p.m.

Review of the Medication Administration Record (MAR), dated 09-25-15 through 06-07-22, showed amniodarone, hydralazine, isosorbide and metoprolol were ordered and scheduled to be administered at 09:00 am and 09:00 pm on 9/26/21 and states "Not Given" with stated reason "Medication Parameter Not Met" by Staff RN ID# 9 on 9/26/21 at 08:38 am and LVN Staff ID # 10 at 08:24 p.m.

Review of all physician orders from 09-25-21 through 09-27-21 failed to reveal an order to hold, stop or discontinue any medications until the patient's transfer to higher level of care 09-27-21 at 10:15 a.m. for Patient #1 at which time all orders were discontinued.

Review of all nursing notes and communications from 09-25-21 through 09-27-21 failed to locate any nursing communications relaying communication with any provider regarding patient assessment, concerns about clinical changes or questions about medications.

Interviews:

Interview on 06-07-21 at 2:18 p.m. with Chief Nursing Officer (CNO) Staff ID #3 - she stated that medications were expected to be administered per physician order; if there was a concern that warranted holding the medication, the provider needed to be called and an order should be given to hold medications. CNO Staff ID #3 was unable to locate an order for the 09-26-21 day or night shift medications which were held. She went on to say there should have been an order and a note documenting that communication.

Interview on 06-07-21 at 2:37 p.m. with Pharmacy Director Staff ID # 7, she verified there were no "parameters" entered by the ordering physicians with the four cardiac medications (amniodarone, hydralazine, isosorbide dinitrate and metoprolol). She validated there were no standing ordersets or institutional standing orders which would govern administration of these medications differently than they were ordered.