HospitalInspections.org

Based on observation, interview and record review, the facility failed to implement its policy on Protected Health Information (PHI - patient's health or treatment information) when a list including patient information was left unattended on a computer in the unit hallway.

This failure had the potential for non-staff individuals to read the patients' health information.

Findings:

An observation was conducted with the chief nursing officer (CNO) on 9/9/25 at 10:33 A.M. in the telemetry (patients with heart monitor) unit hallway. A facility patient list form which included patient names, age, primary problem, isolation precautions (measures to prevent spread of infection) was observed on top of a computer, unattended by a facility staff.

An interview was conducted with the CNO on 9/11/25 at 1:30 P.M. The CNO stated that the facility patient list observed on 9/9/25 belonged to a licensed nurse (LN). The CNO acknowledged that the LN should not have left the patient list unattended, to prevent facility guests and unlicensed personnel from gaining access to the patient's profile.

The facility's policy and procedure (P&P) titled, Safeguarding Protected Health Information, revised 1/30/2023. The P&P indicated, " ...Procedures ...Q. Patient information should never be left unattended ..."

Based on interview and record review, the facility failed to ensure medication was administered per physician's order and per hospital's policy and procedure when:

1. 9 of 30 patients (Patients 1, 2, 3, 4, 5, 7, 8, 12, and 15) were administered medication without documented evidence of the medication's indication.

2. 1 of 30 patients (Patient 7) was not administered a pain medication ordered for severe pain and instead was administered medication for breakthrough (fast-acting medication to treat a sudden, intense flare-up of pain that "breaks through" a person's regular, scheduled pain management treatment) pain.

These failures had the potential to affect patients' care and well-being.

Findings:

1a. Patient 1 was admitted to the facility on 7/15/25 with diagnoses which included pneumonia (inflammation of lungs), ETOH Abuse (excessive consumption of alcohol), ventilator management (use of mechanical ventilators to support or replace a patient's breathing), and critical care drip management (use of infusion pumps to deliver medications and/or fluids to unstable patients requiring continuous monitoring), per the history and physical dated 7/15/25.

A review of Patient 1's medication orders indicated, "Olanzapine (Zyprexa) tablet 5 mg (milligram) PO (by mouth)/Per Tube every 6 hours PRN (as needed) for agitation, first line; Diazepam (Valium) Injection 5 mg intravenous (IV - refers to administering a drug through a needle or tube inserted into a vein) every 6 hours PRN for agitation, second line; Quetiapine (Seroquel) tablet 75 mg PO/per tube every 6 hours PRN for agitation, third line."

A concurrent interview and record review was conducted on 9/10/25 at 10:20 A.M. with the Director of Quality/Risk Management (DQM). Per Patient 1's Medication Administration Record (MAR) dated July 2025, Patient 1 was administered Olanzapine 5 mg on 7/25/25 at 10:36 A.M. and 5:17 P.M.; Diazepam Injection 5 mg on 7/25/25 at 2:03 P.M.; and Quetiapine tablet 75 mg on 7/25/25 at 2:53 P.M. However, for each medication that was administered, there was no documented evidence that Patient 1 was exhibiting symptoms of agitation. The DQM acknowledged that the medications were administered without evidence of the ordered indication.


1b. Patient 2 was admitted to the facility on 8/27/25 with diagnoses which included cerebellar hemorrhage (bleeding in the brain) and agitation/delirium per the history and physical dated 8/27/25.

A review of Patient 2's medication orders indicated, "Olanzapine (Zyprexa) tablet 2.5 mg (milligram) oral every 12 hours PRN (as needed) for agitation; Lorazepam (Ativan) tablet 1 mg PO (by mouth) every 4 hours PRN for anxiety."

A concurrent interview and review of Patient 2's record was conducted on 9/10/25 at 10:50 A.M. with the Director of Quality/Risk Management (DQM). The DQM stated that Olanzapine 2.5 mg oral PRN for agitation was administered on 9/10/25 at 12:17 A.M. without documented evidence of agitation. In addition, the DQM stated that Lorazepam 1 mg oral tablet PRN for anxiety was administered on 9/9/25 at 5:49 P.M. without documented evidence of anxiety.


1c. Patient 3 was admitted to the facility on 9/5/25 with diagnoses which included traumatic subdural hematoma (collection of blood in the brain) and status post craniotomy (procedure of removing a section of the skull bone to access the brain) per the history and physical dated 9/5/25.

A review of Patient 3's medication orders indicated, Quetiapine (Seroquel) tablet 25 mg (milligram) Oral 3 times daily PRN (as needed) for agitation."

A concurrent interview and review of Patient 3's record was conducted on 9/10/25 at 11:09 A.M. with the Director of Quality/Risk Management (DQM). The DQM stated that Quetiapine 25 mg oral PRN for agitation was administered on 9/8/25 at 4 P.M., however there was no documented evidence of agitation.


1d. Patient 4 was admitted to the facility on 8/5/25 with diagnoses which included cerebral infarction (stroke - interruption of blood flow to the brain) per the history and physical dated 8/5/25.

A review of Patient 4's medication orders indicated, "Haloperidol (Haldol) tablet 2.5 mg (milligram) PO (by mouth)/Per tube every 6 hours PRN (as needed) for agitation, first line. Quetiapine (Seroquel) tablet 50 mg PO/per tube every 6 hours PRN for agitation, second line. Lorazepam (Ativan) tablet 0.5 mg per tube every 6 hours PRN for agitation, third line."

A concurrent interview and review of Patient 4's record was conducted on 9/10/25 at 1:28 P.M. with the Director of Quality/Risk Management (DQM). The DQM stated that the following "as needed" medications for agitation were administered without documented evidence of agitation: Quetiapine tablet 50 mg on 9/10/25 at 6:27 A.M.; Haloperidol tablet 2.5 mg on 9/10/25 at 3 A.M. and Lorazepam tablet 0.5 mg on 9/9/25 at 5:25 A.M.


1e. Patient 5 was admitted to the facility on 7/27/25 with diagnoses which included Acute Inflammatory Demyelinating Polyneuropathy (AIDP - an autoimmune disorder that affects the peripheral nervous system) per the history and physical dated 7/27/25.

A review of Patient 5's medication orders indicated, "Lorazepam (Ativan) tablet 0.25 mg (milligram) PO (by mouth)/per tube every 4 hours PRN (as needed) for anxiety."

A concurrent interview and review of Patient 5's record was conducted on 9/10/25 at 1:46 P.M. with the Director of Quality/Risk Management (DQM). The DQM stated that Lorazepam tablet 0.25 mg PRN for anxiety was administered on 9/2/25 at 11:15 P.M. without documented evidence of anxiety.



1f. Patient 7 was admitted to the facility on 8/19/25 with diagnoses which included pneumonia (infection of the lungs) per the history and physical dated 8/20/25.

A review of Patient 7's medication orders indicated, "Hydroxyzine (Atarax) tablet 25 mg (milligram) oral 3 times daily PRN (as needed) for anxiety."

A concurrent interview and review of Patient 7's record was conducted on 9/10/25 at 2:15 P.M. with the Director of Quality/Risk Management (DQM). The DQM stated that Hydroxyzine tablet 25 mg PRN for anxiety was administered on 8/27/25 at 11:34 A.M. without documented evidence of anxiety.



1g. Patient 8 was admitted to the facility on 8/15/25 with diagnoses which included pharyngeal and laryngeal obstruction (blockages in the throat - pharynx and voice box - larynx) secondary to squamous cell carcinoma (skin cancer) per the history and physical dated 8/15/25.

A review of Patient 8's medication orders indicated, "Quetiapine (Seroquel) tablet 25 mg (milligram) PO (by mouth) /per tube every 6 hours PRN (as needed) for agitation, first line. Alproxalam (Xanax) tablet 0.5 mg per tube every 6 hours PRN for agitation, second line."

A concurrent interview and review of Patient 8's record was conducted on 9/11/25 at 9:13 A.M. with the Director of Quality/Risk Management (DQM). The DQM stated that Quetiapine tablet 25 mg PRN for agitation was administered on 9/9/25 at 10:10 A.M. without documented evidence of agitation. In addition, Alprazolam tablet 0.5 mg PRN for agitation was administered on 9/8/25 at 2:41 P.M. without documented evidence of agitation, and that Patient 8 was assessed and documented as "Alert and Calm" on 9/8/25 at 2:42 P.M.


1h. Patient 12 was admitted to the facility on 7/19/25 with diagnoses which included surgical site infection with osteomyelitis (infection of the bone) per the history and physical dated 7/19/25.

A review of Patient 12's medication orders indicated, "Hydroxyzine (Atarax) tablet 50 mg (milligram) Oral Daily PRN (as needed) for anxiety, itching."

A concurrent interview and review of Patient 12's record was conducted on 9/11/25 at 10:49 A.M. with the Director of Quality/Risk Management (DQM). The DQM stated that Hydroxyzine tablet 50 mg Oral PRN for anxiety, itching was administered on 9/5/25 at 9:36 P.M. without documented evidence of anxiety or itching. In addition, per the Richmond Agitation Sedation Scale (RASS), Patient 12 was assessed and documented as "Alert and Calm" on 9/5/25 at 9:30 P.M.


1i. Patient 15 was admitted to the facility on 8/29/25 with diagnoses which included alcoholic pancreatitis (inflamed pancreas due to excessive alcohol consumption) per the history and physical dated 8/29/25.

A review of Patient 15's medication orders indicated, "Diazepam (Valium) tablet 2 mg (milligram), oral, every 12 hours PRN (as needed) for anxiety."

A concurrent interview and review of Patient 15's record was conducted on 9/11/25 at 11:24 A.M. with the Director of Quality/Risk Management (DQM). The DQM stated that Diazepam tablet 2 mg PRN for anxiety was administered on 9/8/25 at 8:28 A.M. without documented evidence of anxiety. In addition, per the Richmond Agitation Sedation Scale, Patient 15 was assessed and documented as "Alert and Calm" on 9/8/25 at 8:29 A.M.

An interview was conducted on 9/12/25 at 1:15 P.M. with the Chief Nursing Officer (CNO). The CNO stated that the "Six rights of medication" included "the right circumstance." The CNO acknowledged it was important to ensure that medication was administered to patients for the right indication (or circumstance), for patient safety.

A review of the hospital policy and procedure titled Medication Administration last revised 7/1/24 indicated, "Policy: ...14. Follow the '6' Rights of medication administration: ...I. The Right medication II. At the Right time III. In the Right dose IV. To the Right Patient V. By the Right route VI. In the right Circumstance ..."


2. Patient 7 was admitted to the facility on 8/19/25 with diagnoses which included pneumonia (infection of the lungs), per the history and physical dated 8/20/25.

A review of Patient 7's medication orders indicated "Oxycodone (Roxicodone) immediate release tablet 10 mg (milligrams) oral every 4 hours PRN (as needed) for moderate pain; Oxycodone (Roxicodone) immediate release tablet 15 mg oral every 4 hours PRN for severe pain; and Hydromorphone (Dilaudid) injection 2 mg Intravenous (IV - refers to administering a drug through a needle or tube inserted into a vein) every 4 hours PRN for breakthrough pain."

A concurrent interview and record review was conducted on 9/10/25 at 2:15 P.M. with the Director of Quality/Risk Management (DQM). The DQM referred to Patient 7's pain assessment record and Medication Administration Records (MAR) dated August and September 2025, and stated that Oxycodone immediate release 10 mg tablet (PRN) for moderate pain was administered on 8/29/25 at 6:54 P.M., and Oxycodone immediate release 15 mg tablet (PRN) for severe pain was last administered on 9/6/25 at 4:39 A.M. Further, the DQM stated that Patient 7 complained of moderate and severe pain 23 times, between 9/6/25 at 10:40 A.M. and 9/10/25 at 1:15 P.M. The DQM stated that Hydromorphone injection 2 mg IV PRN for breakthrough pain was administered 23 times, instead of the Oxycodone immediate release 10 mg for moderate pain and/or the Oxycodone immediate release 15 mg tablet that was ordered for severe pain.

An interview was conducted on 9/10/25 at 2:45 P.M. with Registered Nurse (RN) 1. RN 1 stated that Patient 7 complained of severe pain on 9/10/25 at 9:08 A.M. and 1:15 P.M. RN 1 stated Oxycodone immediate release tablet 15 mg PRN for severe pain were not administered on both occasions, and instead, Hydromorphone injection 2 mg IV PRN for breakthrough pain was administered. RN 1 stated that Patient 7 refused the Oxycodone tablet and only wanted the Hydromorphone IV. RN 1 stated that the physician was not notified, and that the pain medication order was not clarified prior to administering the Hydromorphone IV. RN 1 stated it was important to clarify the pain medications order to ensure physician orders were followed.

An interview was conducted on 9/10/25 at 3:50 P.M. with the Nurse Manager (NM). The NM stated that physicians orders were not followed, and further acknowledged that Patient 7's medication for severe pain and breakthrough pain should have been clarified with the physician, for patient safety.

A review of the hospital policy and procedure titled Medication Administration last revised 7/1/24 indicated, "Policy: ...14. Follow the '6' Rights of medication administration: ...I. The Right medication II. At the Right time III. In the Right dose IV. To the Right Patient V. By the Right route VI. In the right Circumstance ..."