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Based on review of clinical records, Medication Administration Policy and interview, it was determined the facility failed to assure medications were administered according to physician orders for 5 (#5, #6, #17, #20 and #21) of 17 (#5-#21) inpatients. Failure to follow physician orders for medication administration did not assure the safety or needs of the affected patients were met. The failed practice affected Patient #5, #6, #17, #20 and #21 and had the potential to affect the census of 17 patients on 06/26/12 and all patients who may be admitted to the facility. The findings were:

A. Clinical record review on 06/26/12 revealed the following:
1. Patient #5 was admitted on 06/18/12. A physician order was documented on 06/18/12 at 1420 for "Propranalol 20 mg (milligrams) PO (per os or by mouth) Q (every) 8 Hours". The Medication Administration Record (MAR) was reviewed and revealed:
Propranolol Hcl Tab, 25 mg PO Q 8 H, scheduled for 0600, 1400 and 2200 daily. The medication time was circled and blood pressure (B/P) documented on the MAR on the following dates and times: 06/18/12 at 2200 (BP 84/59); 06/19/12 at 0600 (B/P 108/61); 06/22/12 at 2200(BP103/57); 06/23/12 at 0600 (B/P 124/62); 06/24/12 at 0600 (B/P 124/76, HR 58). The Nursing Progress notes for Patient #5 were reviewed on 06/26/12 and revealed: On 06/18/12 at 2100 stated "med pass - meds well tolerated. Will continue to monitor." An entry on 06/18/12 at 2400 stated "Pt observed sleeping quietly. (Zero with line and triangle shape)(No) change in condition." On 06/19/12 at 0600, "AM med pass- meds well tolerated. Will cont (continue) to monitor." On 06/22/12 at 2200, "Pt (arrow up) in bed, wanting out of room...", 06/23/12 at 0600 "AM med pass- meds well tolerated." The review of the MAR and the Nursing Progress notes revealed there was no documentation a physician was notified the medication was not administered as ordered and no documentation the physician was notified of the blood pressures or heart rate listed in each instance.

2. Patient #6 was admitted 06/06/12. A physician order was documented on 06/06/12 for Metoprolol (Lopressor) 25 mg PO BID (two times per day). The MAR was reviewed and revealed the following dates and times circled: 06/07/12 at 2100, "held HR 50"; 06/09/12 at 2100, "held, pulse =56, B/P 133/60". A physician order was documented on 06/06/12 for Amiodarone (Pacerone) 100 mg PO daily. The MAR was reviewed and revealed the dates and times circled: 06/08/12 0900, "pulse 49", 06/12/12 at 0900, "pulse 52"; 06/22/12 at 0900, "Pulse 53". A physician order was documented on 06/06/12 for Furosemide (Lasix) 40 mg PO daily. The MAR was reviewed and revealed that on 06/22/12 at 0900 the medication time was circled and not initialed, "pulse 53 and B/P 121/55" was documented.
The Nursing Progress Notes were reviewed for 06/07/12, 06/08/12, 06/09/12, 06/12/12 and 06/22/12. There was no documentation a physician was notified the medication was not administered and no documentation the physician was notified of the blood pressure or heart rate listed in each instance.

3. Patient #17 was admitted on 06/05/12. A physician order was documented on 06/05/12 for "Baclofen (Lioresal) 5 mg PO TID (three times per day). The MAR was reviewed and revealed on 06/23/12 at 2100 the medication time was circled and written beside the time was "drowsy". Review of the Nursing Progress note for 06/23/12 at 2100 revealed, "Resting quietly - held Baclofen. Drowsy held. Will observe." There was no documentation the physician was notified the medication was not administered.

4. Patient #20 was admitted on 06/05/12. A physician order was documented on 06/05/12 for Metoprolol (Lopressor) 12.5 mg. The MAR was reviewed and revealed the following medication dates and times that were circled: 06/18/12 at 2100 (B/P 95/50); 06/23/12 at 2100 (B/P 90/50); 06/24/12 at 2100 (B/P 94/64).

a) A physician order was documented on 06/05/12 for Dronabinol (Marinol) 5 mg. The MAR was reviewed and revealed on 06/19/12 at 2100 "1" was documented and "1NA" was circled. The dosage was listed on the MAR as "2, 2.5 mg capsules=Dose". On 06/23/12 at 0900 the Dronabinol medication time of 0900 was circled and "Not given" written beside it.

b) A physician order for Zolpidem (Ambien) 5 mg was documented on 06/05/12. Review of the MAR revealed on 06/23/12 at 2100, the time was circled and beside it documented "90/60". On the MAR for 06/24/12 at 2100, for Ambien, the time was circled. Review of the Nursing Progress Notes for 06/18/12, 06/19/12, 06/23/12 and 06/24/12 revealed no documentation the physician was notified the medications were not administered.

5. Patient #21 was admitted on 06/12/12. A physician order was documented on 06/13/12 for "Neosporin oint(ointment) cover with 4 x 4 (four inch by four inch) at CT (chest tube) site qd (every day)." A physician order was documented on 06/14/12 at 1800 that stated "DC (discontinue) Neosporin + (plus) 4 x 4 Drsg (dressing) order for chest tube site. Maintain colostomy bag over chest tube site."

a) Review of MAR (Medication Administration Record) and "Skin /Wound Assessment" record revealed Pt. #21 received the treatment six days after the medication and treatment had been discontinued by the physician on 06/14/12. The medication and treatment "Neosporin ointment cover with 4 x 4 at CT site QD", on 06/15/12, 06/18/12 - 06/22/12. On 06/25/12, the MAR documentation revealed "Neosporin oint. cover (with) 4 x 4 at CT site QD. D/C 06/25/12".

b) The clinical record review findings were confirmed by the CNO on 06/26/12 at 1055.

c) In an interview on 06/26/12 at 0910 with the Chief Nursing Officer (CNO), Pharmacist #1, and LPN (Licensed Practical Nurse) #2, LPN #2 stated "if a medicine is circled, that means the medicine was not given." The Chief Nursing Officer (CNO) was asked by the Surveyor what should occur if a medication is not given or held. She stated it would be circled, and then referred to Pharmacist #1. Pharmacist #1 reviewed Medication Administration record and stated, "Circled means the medication was not given. The 'NA' looks like 'Not Available', but it's controlled and they may not know where to look. There should be an entry in the Nurses notes describing the deviation from the orders, physician notification and orders, if any regarding the medication." Pharmacist #1 and the CNO confirmed at the time of the interview that there was not a process in place to hold medications without a physician order. The facility Medication Documentation Policy and Procedure was requested and received from the CNO on 06/26/12 at 0915. Review of the policy revealed "Procedure 2. All medications must be ordered by the physician and administered by a registered nurse, licensed practical nurse or physician." "Procedure 3. The person who administers the dose accurately documents the dose on the MAR. Never initial doses you did not personally administer. Never pre-chart medications. Circle missed doses, refused doses or doses not swallowed. Explain in nursing narrative for each."

Based on observation, interview and review of policy and procedures, it was determined the facility failed to assure staff compliance with infection control measures for 3 (#5, #13 and #16) of 10 patients in isolation. The patients and staff would not be protected from exposure to potential infection without staff adherence to infection control policies and procedures in the facility. The failed practice affected Patient #5, #13 and #16 and had the potential to affect the patient census of 17 on 06/25/12. The findings were:

A. On 06/25/12, Patient #5 was identified by the Infection Control Nurse as requiring Contact Isolation. Observation on 06/25/12 at 0850 revealed the door to Patient #5's room did not have contact isolation sign or supplies available at the door of the room. Registered Nurse (RN) #1 stated she "thought" he was in isolation. In an interview at the time of observation, the Infection Control Nurse confirmed the patient was to be in "contact isolation" and stated Patient #5 had been "moved over the weekend and his isolation sign and supplies weren't moved with him."\

B. Observation on 06/25/12 at 0855 of Patient #13, revealed the door to the room had a sign and supplies on the door for contact isolation. The door to the room was open and two employees, CDM #1 (Certified Dietary Manager) Director and CDM #2 were standing in the room at the bedside in close proximity to the patient. CDM #1 and CDM#2 did not have on gloves or gown. When they exited the room, the Surveyor asked them if the patient in the room they had just exited had any type of isolation. They stated "we didn't touch him, so we just wash our hands." CDM#1 stated that today was her second day on the job at the facility. CDM #2, the Dietary Director, stated she had started three weeks ago. CDM #1 and #2 stated they had both had infection control orientation at the facility. At 0900 on 06/25/12, the CNO, Infection Control Nurse, and the administrator confirmed the findings and that the patient was in fact on contact precautions.

C. Observation on 06/25/12 at 1235 revealed CDM #1 entered Patient #16 room. She was in close proximity to the patient, standing to the left of the bed without a gown, gloves or any personal protection. The door to the room for Patient #16 had a sign and supplies for contact isolation precautions. Upon exit from Patient #16's room, CDM #1 stated to Surveyor, "I don't know what to do, no other staff was putting on protection when I started passing trays". The list of patients in isolation provided on 06/25/12 revealed the patient was in "Contact precautions for MRSA (Methicillin Resistant Staphylococus Aureus)Wound/C-diff (Clostridium Difficile)stool/VRE (Vancomycin Resistant Enteroccus) urine". In an interview with the Infection Control Nurse on 06/25/12 at 1310, she confirmed Patient #16 was on Contact Precautions and CDM #1 and CDM #2 had completed orientation that included infection control training. The Administrator presented a sign in sheet 06/26/12 at 1310 dated 06/05/12 with a copy of the contents presented at infection control orientation.

D. On 06/26/12, the "Infection Control" training documentation as provided by the Administrator was reviewed. Page two of the document, "Transmission Based Precautions" stated "Contact Precautions - Use standard precautions + gloves, gown, eye protection if warranted. Use disposable equipment or if you must reuse equipment, clean it thoroughly consider everything that has been in the room as contaminated."

E. The Administrator provided a copy of the facility policy # IC-06, "Isolation Precautions" on 06/26/12. The policy purpose "Isolation precautions are designed to minimize the transmission of infection in the hospital using current understanding of the way infections can be transmitted." Policy stated (item II.A.) "Isolation precautions should be taken with any patient known to have or suspected of having a communicable infection." Section III. B "Contact Precautions" stated "Contact Precautions are used for those diseases that are spread by direct or indirect contact. Item 4. "An isolation cabinet and Contact precautions sign must be placed on the patient's door."