HospitalInspections.org

Based on record review and interview, the hospital failed to ensure a Registered Nurse supervised and evaluated the nursing care of each patient by:

1. Failing to promptly notify a patient's physician of a significant change in condition for 1 of 3 patients reviewed with a significant change in condition out of a total sample of 20 (#1). Findings:

Patient #1: Patient #1 was admitted to the hospital on 11/11/2010 with diagnoses that included Demyelinating Polyneuropathy, Hypertension, and Generalized Weakness suspect exacerbation of Chronic Inflammatory Demyelating Polyneuropathy. Review of Patient #1's Graphic/I&O Record from the dates of 11/11/2010 through 11/14/2010 revealed the patient's pulse running from a low of 66 to a high of 99. Review of Patient #1's Graphic/I&O Record on the morning of 11/15/2010 at 8:00 a.m. revealed a pulse of 40. Review of Patient #1's Nurse Narrative Notes dated 11/15/2010 at 9:00 a.m. revealed "To gym (with) PTA (Physical Therapy Assistant) for activities. Good mood (and) motivation (with) positive effort noted. Further review of Nurse Narrative Notes for Patient #1 dated 11/15/2010 at 1150 (11:50 a.m.) revealed "HR (heart rate) = (equal) 38 to 44 (with) irregular rhythm. B/P = 147/84. Denies C/O (complaint of) CP (chest pain), SOB (shortness of breath), or palpitations. (Physician S7) notified (3 hours and 50 minutes after patient was assessed to have a pulse of 40/ 26 beats per minute less than any previously documented pulse) . . . Cont. (continue) to monitor HR (heart rate) (and) symptoms."

During a face to face interview on 11/17/2010 at 1:30 p.m., Registered Nurse S6 indicated she was the nurse that provided care to Patient #1 on the date of 11/15/2010 when the patient's pulse rate dropped to 40. S6 confirmed that she did not notify the patient's physician of the significant change in heart rate at 8:00 a.m. on 11/15/2010 and did not get medical clearance from a physician for Patient #1 to participate in physical exercise when his heart rate dropped to 40 on 11/15/2010 at 8:00 a.m. S6 indicated that she (S6) wanted to see how the patient (#1) responded to exercise before calling his doctor. S6 indicated the patient told her (S6) he (#1) had a history of low heart rate in the past. Registered Nurse S6 referred the surveyor to hospital memo titled, "Early Warning System".

Review of the hospital memo titled, "Early Warning System (no documented date/time/signature)" revealed in part, "Two or more of the following criteria out of limits should trigger a response: Systolic Blood Pressure <90mmHG (less than 90 millimeters mercury) >200mmHG (greater than 200 millimeters mercury), Respiratory Rate <9 (less than 9) >28 (greater than 28), Heart Rate <50 (less than 50) >120 (greater than 120), Oxygen Saturation <90 % (on room air or O2 (oxygen)), Urine output <50 ml (less than 50 milliliters) in 4 hours, Conscious Level: Acute change in LOC (level of consciousness). Once the patient's condition meets 2 or more criteria, the charge nurse will assess the patient, call the physician and report the patient's change (s) in condition. . . "

During a face to face interview on 11/19/2010 at 7:25 a.m., Physician S7 indicated nursing staff should inform the patient's physician if a patient's heart rate is low. S7 further indicated physician notification should be done promptly and should occur before the patient is sent to physical therapy for exercise. Physician S7 indicated she had not been aware of the hospital memo titled, "Early Warning System" indicating physician notification should occur when two or more criteria were present. Physician S7 indicated any single indicator, to include a heart rate less than 50, would warrant notification of the patient's attending physician.

During a face to face interview on 11/19/2010 at 8:10 a.m., Physical Therapist S8 indicated Patient #1 was allowed to ambulate 75 feet x 4 on the morning of 11/15/2010 when his heart rate was documented as 40. S8 indicated that he (S8) and Registered Nurse S6 determined that they (S6 and S8) would monitor Patient #1 during Physical Therapy to see how the patient (#8) responded before calling the patient's physician. S6 indicated the normal heart rate for Patient #1 during exercise, based on the patient's age of 86, would be 60 - 120. S6 confirmed that 40 was below the calculated normal heart rate for exercise in an 86 year old man.


2. Failing to perform ongoing nursing assessments for a patient with a significant change in condition for 1 of 3 patients reviewed with a significant change in condition out of a total sample of 20 (#8). Findings:

Patient #8: Patient #8 was admitted to the hospital on 8/04/2010 with diagnoses that included Peripheral Vascular Disease Status Post Right Below Knee Amputation, Hypertension, Non-insulin dependent Diabetes Mellitus, Debilitation, Deconditioning, and Cardiomyopathy. Review of Patient #8's lab results dated 8/05/2010 at 6:07 p.m. and reported to the patient's physician (S7) on 8/06/2010 at 1810 (6:10 p.m.) revealed in part: Hemoglobin 9.8 (normal 14.0 - 18.0) and Hematocrit 30.8 (normal 42.0 - 52.0). Further review revealed Patient #8's lab results dated 8/11/2010 at 5:08 p.m. and reported to the patient's physician (S7) on 8/11/2010 at 1730 (5:30 p.m.) revealed in part: Hemoglobin 6.2 (normal 14.0 - 18.0) and Hematocrit 19.4 (normal 42.0 - 50.0). Review of Patient #1's physician's orders dated 8/11/2010 at 1730 (5:30 p.m.) revealed in part, "Type (and) match- 2 units PRBC's (Packed Red Blood Cells) stat, Transfuse each over 3 hours." Review of Patient #8's Nurse Narrative Notes dated 8/11/2010 at 1730 (5:30 p.m.) revealed in part, "(Physician S7) noted of Hgb (hemoglobin) 6.2 (and) Hct (hematocrit) 19.4. New orders rec'd (received) (and) noted. . . Contacted (contracted blood bank service) re (regarding) transfusion procedures, awaiting return calls from (contracted blood bank service). Further review at 1925 (7:25 p.m.) on 8/11/2010 revealed in part, "(Contracted Blood Bank Service) to obtain T&M (type and match) for 2 units PRBCs in a.m. (morning) (physician ordered stat type and cross). (Physician S7) notified (and) order rec'd to obtain stool for occult blood. . ." Review of Patient #8's documented vital signs revealed a blood pressure of 90/59 with a heart rate of 100 on 8/11/2010 at 8:00 p.m. Further review revealed no documented evidence that Patient #8's vital signs were repeated until the morning of 8/12/2010 at 7:10 a.m. (11 hours and 10 minutes since the last recorded vital signs) when documentation revealed the patient's blood pressure was 71/52 with a heart rate of 87. Further review of Daily Nurse Notes dated 8/12/2010 at 5:00 a.m. revealed "lab drawn ... Type (and) match (11.5 hours after stat type and cross match had been ordered). Review of Patient #8's Nursing Notes dated 8/12/2010 at 7:10 a.m. revealed in part, "(Physician S7) notified of B/P (blood pressure) 71/52, HR (heart rate) 87, R (respirations) 18, T (Temperature) 101.1. orders rec'd to start IV (Intravenous/line) Give 200 ml (milliliters) NS (normal saline) IV (intravenous) bolus and then IV 100 ml (milliliters)/ hr (per hour) continuous. . . 0725 (7:25 a.m.) 18 g (gauge) IV initiated in L (left) FA (forearm) x 2 attempts per (Director of Nursing S2) NS 200 ml IV bolus initiated (without) diff. (difficulty) Infusing (without) difficulty. Site taped and intact. B/P (blood pressure) 98/50, HR (heart rate) = 80, R (respirations) = 18. . . 0750 (7:50 a.m.) transferred to (recipient acute care hospital). . ."

During a face to face interview on 11/18/2010 at 2:15 p.m., Director of Nursing S2 indicated she had been aware of the hospital's difficulty in obtaining a type and cross match for Patient #8 on the night of 8/11/2010. S2 indicated the nursing staff on duty had called her and informed her that the hospital's contracted Blood Bank service had informed them that they would not be able to come to MMO Rehabilitation and Wellness Hospital until the following morning to draw blood for a type and crossmatch for Patient #8. S2 indicated Physician S7 had also been aware. S2 indicated she (S2) had informed the staff on duty that they should monitor the patient (#8) through out the night until the contracted Blood Bank could arrive to draw blood for a type and cross match and the patient received the ordered transfusion. S2 indicated she was not sure if she said "monitor vital signs"; however that was what she meant and what she expected when she told her nursing staff to monitor Patient #8 during the night. S2 indicated she expected vital signs to be monitored at regular intervals through out the night due to the hospital's inability to get a "stat" type and crossmatch as ordered by Patient #8's physician which would delay the patient's blood transfusion. S2 indicated, as a result of this incident, the hospital had in-service education provided to the nursing staff (confirmed with record review) in regards to drawing type and cross matches as per the contracted blood blank's protocol; however, she (S2) had not identified the failure of nursing staff to assess Patient #8's vital signs as a problem. S2 indicated nursing staff should have monitored Patient #8's vital signs at regular intervals (no time frame specified).

During a face to face interview on 11/19/2010 at 7:25 a.m., Physician S7 indicated she was notified on 08/11/2010 when the hospital's contracted Blood Bank made it known that they (contracted blood bank) would not be able to draw blood for a type and cross match for Patient #8 until the following morning. S7 indicated she had informed nursing staff to monitor the patient (#8) closely during the night and she (S7) would transfer the patient (#8) out to an acute care hospital if the patient (#8) became symptomatic. S7 indicated she (S7) meant for staff to monitor vital signs and watch for bleeding. S7 indicated she (S7) had not been aware that no vital signs had been monitored on Patient #8 from the time of 8:00 p.m. on 8/11/2010 until next taken at 7:10 a.m. on 8/12/2010 (11 hours and 10 minutes later). S7 indicated nursing staff should have monitored the patient's vital signs every couple of hours until the patient received the blood transfusion as ordered.


3. Failing to assess a patient's apical heart rate prior to the administration of Metoprolol as indicated in the hospital's drug reference book (Nursing 2010 Drug Handbook) for 1 of 1 patients reviewed on the drug Metoprolol out of a total sample of 20 (#11). Findings:

Patient #11: Patient #11 was admitted to the hospital on 7/14/2010 with diagnoses that included Late Effect Hemiparesis, Glomerulonephritis, Hypertensive Chronic Kidney Disease, Anemia, Peptic Ulcer Disease, Seizure Disorder, and Hyperlipidemia. Review of Patient #11's physician's orders dated 7/14/2010 at 1900 (7:00 p.m.) revealed an order for Metoprolol 50 milligrams 3 tablets (150 milligrams) twice daily. Review of Patient #11's entire medical record revealed no documented evidence of an apical pulse being assessed prior to the administration of Metoprolol at 9:00 a.m. and 9:00 p.m. from the dates of 7/16/2010 through the day Metoprolol was discontinued on 8/02/2010. This finding was confirmed by the Director of Nursing S2.

During a face to face interview on 11/18/2010 at 1:05 p.m., Director of Nursing S2 indicated the hospital uses the Drug Reference Book titled, "Nursing 2010 Drug Handbook" as a reference for drug administration. S2 indicated she would expect nursing staff to follow the guidelines outlined in the reference book for administration of medications. S2 confirmed there was no documented evidence of monitoring Patient #11's apical pulse prior to the administration of Metoprolol as indicated in Nursing 2010 Drug Handbook.

Review of information regarding administration of Metoprolol located on page 387 of the Nursing 2010 Drug Handbook revealed in part, "Always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/minute, withhold drug and call prescriber immediately. Monitor blood pressure frequently; drug masks common signs and symptoms of shock."


4. Failing to ensure that the ordering practitioner was made aware of abnormal lab values in a timely manner for 3 of 20 sampled patients (#8, #10, #17). Findings:

Patient #10: Review of the medical record of Patient #10 revealed that the patient was admitted to the hospital on 7/07/10. Review of the admission orders revealed orders dated 7/07/10 at 3:15 p.m. for a Chemistry Panel to be obtained in a.m. on 7/08/10. Review of the Laboratory Report revealed that the Chemistry Panel was collected on 7/08/10 at 5:15 a.m. as ordered. Further review of the Laboratory Report revealed that the Chemistry Panel was printed and faxed to MMO Rehabilitation and Wellness Center on 7/08/10 at 7:07 p.m. The results of the Chemistry Panel revealed that the patient's Potassium level was high (5.9 with the normal reference range being 3.5 - 5.1). Review of the admission orders revealed orders dated 7/07/10 at 4:20 p.m. for 20 MEQ of Potassium Chloride ER to be administered by mouth twice daily. Review of the medical record revealed that 20 MEQ of Potassium Chloride ER was administered to Patient #10 on 7/08/10 at 9:00 p.m. which was after the laboratory report was faxed to the hospital indicating that Patient #10's Potassium level was high. There was no documentation to indicate that the registered nurse notified the physician/practitioner of the high Potassium level on 7/08/10 prior to administering the 20MEQ of Potassium Chloride to Patient #10. Review of the record revealed that the physician was notified of the high Potassium level on 7/09/10 and orders were received on 7/09/10 at 8:45 a.m. to discontinue the Potassium.

The DON (Director of Nursing) was interviewed on 11/18/10 at 1:15 p.m. The DON reviewed the medical record of Patient #10 and confirmed that there was no documentation to indicate that the ordering practitioner was notified of the patient's elevated Potassium level on 7/08/10. The DON reported that the registered nurse should have informed the ordering practitioner of the elevated Potassium on 7/08/10 after the fax was sent to the hospital from the contracted laboratory. The DON reported that she did not think that the registered nurse working on 7/08/10 at the time Patient #10's laboratory report was faxed to the hospital was aware of the fax coming over because faxes are received in the medical records office and not in the nursing station. The DON reported that the medical records office would have been locked at 7:07 p.m. on 7/08/10 which was the time the fax was sent to MMO from the contracted laboratory. The DON reported that she would have to implement a new system to ensure that the registered nurse working on the unit is aware of documents that are faxed from the laboratory to the hospital.

Patient #8: Review of Patient #8's medical record revealed a Chemistry Panel was drawn on 9/16/2010 at 5:15 a.m. as per physician's orders. Further review revealed the results of the panel were fax'd to the hospital on 9/16/2010 at 7:06 p.m. Review of these results revealed Patient #8's Potassium results were 5.8 milliequivalents per liter with a normal range of 3.5 - 5.1, BUN Level was 42 with a normal range of 5 - 25 milligrams per deciliter, and Creatinine Level was 1.79 milligrams per deciliter with a normal range of 0.57 - 1.25. Further review revealed Physician S7 was informed of the abnormal lab results on 9/17/2010 at 1505 (3:05 p.m.)/ 19 hours and 50 minutes after the lab results were faxed to the hospital. Physician #7 responded to the notification with an order for Kayexalate 30 Grams by mouth times one dose on 9/17/2010 at 1505 (3:05 p.m.). This finding was confirmed by Director of Nursing S2 on 11/19/2010 at 9:40 a.m.

Patient #17: Review of Patient #17's medical record revealed a Complete Blood Count (CBC) was drawn on 8/13/2010 at 4:50 a.m. as per physician's orders. Further review revealed the results of the CBC were fax'd to the hospital on 8/13/2010 at 5:08 p.m. Review of these results revealed Patient #17's Hemoglobin was 9.6 with a normal range of 12.0 - 16.0 grams per deciliter and #17's Hematocrit was 28.4 with a normal range of 37.0 - 47.0 percent. Further review revealed Physician S7 was informed of the abnormal lab results on 8/16/2010 at 11:00 a.m. (3 days after the results had been faxed to the hospital). Physician #7 responded to the notification with an order for Ferrous Sulfate 324 milligrams twice per day and and Iron Study on 8/16/2010 at 11:00 a.m. This finding was confirmed by Director of Nursing S2 on on 11/19/2010 at 9:40 a.m.

Review of a hospital policy titled "Midnight Chart Check" last revised 5/10 revealed in part, "Midnight Chart Checklist: Verify that results of all labs and x-rays ordered are on the chart. follow up with the facility to find out if results available. Verify whether MD (Medical Doctor) notified of abnormal results."




20638

Based on record review and interview the hospital failed to ensure physician's orders were timed for 4 of 20 sampled patients (#6, #7, #11, #17). Findings:

Review of Patient #6's physician's orders dated 6/12/2010 for Protonix and Simethicone revealed no documented time that the order was written. Further review of Patient #6's physician's orders dated 6/10/2010 for Amoxil and Nasonex revealed no documented time that the order was written.

Review of Patient #7's physician's orders dated 8/19/2010 for Diflucan, Lotrisome Cream, and Keflex revealed no documented time that the order was written.

Review of Patient #11's physician's orders dated 8/2/2010 for Labatelol revealed no documented time that the order was written.

Review of Patient #17's physician's orders dated 8/21/2010 for Lidoderm Patch and Lasix revealed no documented time that the order was written.

During a face to face interview on 11/19/2010 at 9:40 a.m., Director of Nursing S2 confirmed the above findings where physician's orders failed to have the time the order was written documented for Patients #6, #7, #11, and #17. S2 further indicated all entries in the medical record should be timed as indicated in hospital policy.

Review of the hospital policy titled, "Physician Orders, Effective 4/2010" presented by the hospital as their current policy revealed in part, "The physician order shall be dated and timed appropriately and shall be written in black ink."

Based on record review and interview the hospital failed to ensure a qualified Radiologist was on staff at the hospital with clinical privileges delineated by the medical staff to supervise and interpret radiological testing of patients in the hospital. Findings:

Review of physician credentialing files and a list of physicians on staff at the hospital revealed no documented evidence of a Radiologist on staff at the hospital.

This finding was confirmed by the hospital's Administrator S1 (who also served in the role of credentialing of physicians) on 11/17/2010 at 3:45 p.m.. S1 stated there was no Radiologist on staff at the hospital/ no radiologist credentialed at the hospital.

Based on observation and interview the hospital failed to ensure the safety of patients taking showers in the hospital as evidenced by having no "non-slip" flooring located in the hospital's two patient showers.
Findings:

Observations on 11/17/2010 at 11:30 a.m. revealed the two patient showers located in the hospital to have no "non-slip" flooring. This failure to have non-slip flooring in the patient showers could potentially result in a patient slipping and/or falling in the shower.

This finding was confirmed in a face to face interview with the hospital's administrator on 11/17/2010 at 11:40 a.m. who further indicated it would be in the best interest of patient safety for the hospital to have non-slip flooring applied in patient showers.

Based on record review and interview the hospital failed to ensure the hospital's Capillary Blood Glucose machine was evaluated for quality as per manufacturer's recommendations for 1 of 1 machine used in the hospital to test glucose levels. Findings:

Review of the hospital's "Daily Quality Control Record for Blood Glucose Testing" revealed the following:
7/24/2010: High Control Range milligrams/deciliter = 308 - 425, Test Result 433 (8 milligrams above acceptable range)
9/09/2010: Low Control Range milligrams/deciliter = 34 - 46, Test Result 47 (1 milligrams above acceptable range)
10/10/10: Low Control Required Range milligrams/deciliter = 34 - 46, Test Result 58 (12 milligrams above acceptable range)
10/21/2010: High Control Range milligrams/deciliter = 295 - 408, Test Result 413 (5 milligrams above acceptable range)
10/23/2010: High Control Range milligrams/deciliter = 295 - 408, Test Result 416 (8 milligrams above acceptable range)
Review of the entire log revealed no documented evidence that the quality control test were repeated immediately after receiving abnormal readings or that administration had been notified of testing that was outside of the acceptable range.

During a face to face interview on 11/17/2010 at 11:10 a.m., Director of Nursing S2 and Registered Nurse S6 confirmed the above findings. S2 and S6 further indicated that the nursing staff that recorded results that were out of range for quality control testing should have immediately repeated the test and if the test were still out of range they should have notified the Director of Nursing to investigate the quality performance of the machine and take action as needed.

Based on record review and interview the hospital failed to ensure the Infection Control Officer developed and enforced a system for preventing the risk of spreading infections through proper cleaning of beds between patients. Findings:

Observations on 11/17/2010 at 11:30 a.m. revealed Housekeeper S4 to be pushing a Housekeeping Cart holding plastic spray bottles. When asked to demonstrate how beds are cleaned between patients at the hospital, S4 held up a plastic spray bottle with no label. S4 indicated she was not sure of the name of the disinfecting product contained in the bottle. S4 indicated the process for cleaning beds was to spray the bed with the solution contained in the unlabeled spray bottle and then immediately wipe down. S4 left the area and returned with a bottle of "Room Sense 200 Disinfectant Cleaner/ AutoChlor" indicating it was the solution that was contained in the unlabeled spray bottle.

Review of Manufacturer's label regarding the use of "AutoChlor Room Sense 200 Disinfectant Cleaner" presented by the hospital as the current label revealed in part, "Allow surface to remain wet for 10 minutes."

During a face to face interview on 11/17/2010 at 11:40 a.m., Housekeeping Supervisor S5 indicated Housekeeper S4 should be using the hospital's disinfectant as recommended by the manufacturer. S5 indicated once the bed is thoroughly wet with the disinfectant spray it should sit for 10 minutes before being wiped clean. S5 further indicated the spray bottle containing the solution should be properly labeled with the contents of the bottle.

This finding was confirmed by Infection Control Officer S6 on 11/19/2010 at 9:30 a.m.

Based on record review and interview the hospital failed to ensure a Director of Respiratory Services was on staff at the hospital. Findings:

Review of physician credentialing files and a list of physicians on staff at the hospital revealed no documented evidence of a physician designated as Director of Respiratory Services.

This finding was confirmed by the hospital's Administrator S1 (who also served in the role of credentialing of physicians) on 11/19/2010 at 10:00 a.m. S1 stated no physician was serving in the role of Respiratory Director.

20638

Based on record review and interview, the hospital failed to ensure the effective implementation of quality indicators for all departments of the hospital to ensure that performance improvement activities focus on high-risk, high-volume, or problem prone areas. This was evidenced by the hospital's failure to identify a breakdown in the process of obtaining laboratory reports and/or data in a timely manner when the laboratory reports are faxed to the hospital after the close of normal business hours. Findings:

Review of the medical records of Patient's #8, #10, and #17 revealed a breakdown in the hospital's ability to process laboratory data in a timely manner. This review revealed delays in the processing of laboratory test as evidenced by delays in laboratory test being reviewed and/or evaluated by a qualified professional (registered nurse, laboratory technician, practitioner) in a timely manner to ensure that the ordering practitioner is aware of abnormal results so that informed decisions can be made regarding treatment interventions needed for positive patient outcomes based on abnormal lab values. (See findings cited at A0395 for details relating to the delays for each patient identified)

The DON (Director of Nursing) was interviewed on 11/18/10 at 1:15 p.m. The DON confirmed delays in the processing of laboratory test in that the results are not always reviewed in a timely manner. The DON reported that this delay would be more prevalent for laboratory results that are faxed over during the night shifts and the weekend shifts. The DON reported that laboratory reports are faxed to a fax machine located in the medical records office. The DON reported that this system works well during normal business hours on Monday thru Friday, but indicated that there are breakdowns during non-business hours. The DON reported that faxed copies of laboratory results are apparently sitting on the fax machine during off-hours and not being reviewed in a timely manner. The DON reported that the medical records office is not on the nursing unit and feels that is why the faxed results are not being reviewed timely. The DON reported that she would have to implement a new system to ensure that the registered nurse working on the unit is aware of documents that are faxed from the laboratory to the hospital.

The hospital's QAPI (Quality Assurance Performance Improvement) data was reviewed including the QAPI plan and the meeting minutes of the most recent two (2) QAPI meetings. This review revealed no evidence to indicate that the hospital's QAPI program included the identification of the breakdown in the process of obtaining laboratory reports and/or data in a timely manner when the laboratory reports are faxed to the hospital after the close of normal business hours and the implementation of quality indicators relating to these delays in the processing of laboratory test results.

The hospital's Administrator was interviewed on 11/19/10 at 10:45 a.m. The Administrator reported that he also functions as the hospital's QAPI Director. The Administrator confirmed that there is a breakdown in the processing of laboratory test results in that there are delays in the reviewing and reporting of laboratory test results. The Administrator reviewed the QAPI data and confirmed that the QAPI program failed to capture the identification of the breakdown in the process of obtaining laboratory reports when the laboratory reports are faxed to the hospital after the close of normal business hours and failed to ensure the implementation of quality indicators relating to these delays in the processing of laboratory test results.

Based on record review and interview the hospital failed to ensure medications were administered as per physicians orders for 4 of 20 sampled patients (#5, #7, #15, #18). Findings:

Patient #5:
Review of Patient #5's physician's orders dated 6/11/2010 at 1515 (3:15 p.m.) revealed an order for Actos 10 milligrams per PEG (Percutaneous Endoscopic Gastrostomy) daily. Review of Patient #5's Medication Treatment Administration Record revealed a circle around the 6/12/2010 9:00 a.m. dose of Actos with a handwritten note indicating "NA (not available)" beside the circled dosage. (17 hours and 45 minutes after the physician ordered Actos).

During a face to face interview on 11/18/2010 at 9:15 a.m., Director of Nursing S2 confirmed that Actos had not been available from the pharmacy for administration to Patient #5 as per the physician's orders for the 6/12/2010, 9:00 a.m. dose.

Patient #7:
Review of Patient #7's physician's orders dated 8/19/2010 with no documented time revealed an order for Keflex 250 milligrams by mouth three times per day for 7 days. Further review revealed the order had been taken off by nursing staff on 8/19/2010 at 0955 (9:55 a.m.). Review of Patient #7's Medication Treatment Administration Record revealed the first dose of Keflex was administered on 8/20/2010 at 6:00 a.m. (19 hours and 55 minutes after the order had been taken off).

During a face to face interview on 11/18/2010 at 9:15 a.m., Director of Nursing S2 indicated Patient #7 should have received the first dose of antibiotic (Keflex) on the evening that it was ordered (8/19/2010).

Patient #15:
Review of Patient #15's physician's orders dated 10/11/2010 at 1340 (1:40 p.m.) revealed an order for Effexor XR 150 milligrams one capsule by mouth daily. Further review of Patient #15's Medication Treatment Administration Record revealed a notation around the 10/12/2010 9:00 a.m. dosage of Effexor XR 150 milligram dosage indicating "not avail (available) from (pharmacy) Home Med (medication) given. Further review of the entire medical record revealed no documented evidence of a physician's order indicating Effexor XR from the patient's home medication could be administered and no documented evidence that the pharmacist and/or physician had identified the home medication as Effexor XR prior to administering the medication.

During a face to face interview on 11/18/2010 at 4:00 p.m., Director of Nursing S2 confirmed there was no order to administer Effexor XR from the patient's home medication for Patient #15 and no documented evidence that the Effexor XR brought to the hospital by the patient from home had ever been identified by a Pharmacist and/or Physician prior to the administration. S2 indicated the nurse should not have administered home medication without a physician's order and that hospital policy indicated medications administered from patient's home stock should be properly identified.

Patient #18:
Review of Patient #18's physician's orders dated 8/31/2010 at 1400 (2:00 p.m.) revealed an order for Novolin Regular Insulin sliding scale which included 2 units of insulin to be administered for a capillary blood glucose of 151 - 200. Further review of Patient #18's Medication Treatment Administration Record revealed the patient's capillary blood glucose level was 192 on 9/03/2010 at 2100 (9:00 p.m.). Review of the entire medical record revealed no documented evidence that Patient #18 was administered 2 units of insulin as required by physician's orders for sliding scale insulin in response to a 192 capillary blood glucose.

During a face to face interview on 11/19/2010 at 9:40 a.m., Director of Nursing S2 confirmed the above finding. S2 further indicated she could find no reason documented in Patient #18's medical record that would be an indication for holding the ordered sliding scale insulin. S2 indicated the patient should have received 2 units of regular insulin as ordered.

Review of the hospital policy titled, "Medications and Pharmaceutical Preparations" presented by the hospital as their current policy revealed in part, "The pharmacist and/or the attending physician shall identify medication brought from home."

Review of the hospital policy titled, "Reporting Medication Errors, Effective 5/2010" presented by the hospital as their current policy revealed in part, "Medication error reports shall be written for the following incidences: Medication errors involving wrong drug, dose, route of administration, time or administering the medication to the wrong patient. . . All omissions of scheduled medications without reasons for the omissions. All medication errors shall be reported promptly to the attending physician."