HospitalInspections.org

Based on record review and interview,

A. Nursing Administration failed to monitor the nursing staff for not following the facility's policy on medication administration of controlled substances and routine medication. Also, Nursing Administration failed to conduct an investigation when nursing staff members 6 (8, 14, 15, 17, 18, and 19) of 6 have reported verbally and in writing their complaints against Nurse #5 concerning the medication administration of controlled substances to patients being cared for in the facility.
Refer to Tag: A 386



B. the facility failed to ensure that the RN evaluated and documented the patient's condition, failed to document provision of complete and accurate interventions, and failed to document the patient's response to the intervention that was provided in 1 of 20 patients whose medical records were reviewed.

Refer to Tag: A 395



C. a Registered Nurse failed to follow the facility's policies on medication administration of controlled substances and medication being administered to the patients in the facility citing 1(#5) of 2 (#8).

Refer to Tag: A 405

Based on record review and interview, Nursing Administration failed to monitor the nursing staff for not following the facility's policy on medication administration of controlled substances and routine medication.
Also, Nursing Administration failed to conduct an investigation when nursing staff members 6 (8, 14, 15, 17, 18, and 19) of 6 have reported verbally and in writing their complaints against Nurse #5 concerning the medication administration of controlled substances to patients being cared for in the facility.
An interview with Staff RN (Registered Nurse) #8 on 2/25/2015, at 1:30 PM, revealed the following:
Staff #8 was asked if there were any nurses that you were uncomfortable working with or were there any issues going on at the facility. Staff #8 stated, "I don't like working with Staff #5. He gives pain medication to my patients and doesn't tell you. I have told him, I will give my own medication to my patients. We do primary nursing care here and I will take care of my patients. He will just give pain medication and doesn't tell you and if you are not constantly checking your patient, too much pain medication will be given. My issues with him are communication: he does not communicate with you, disappears off the floor and doesn't let the nurses know that he has left the floor. Staff #8 was asked, have you reported this to anyone. Staff #8 stated, "I reported to my Charge nurse and I have told Assistant Director of Nursing, Director of Nursing, and Human Resource Director and sent an e-mail June 28, 2014 discussing all the complaints with Staff #5." This situation with Staff #5 has been going on for about a year now. Staff #8 was asked, has Administration made any attempts to correct the issues. Staff #8 stated, "No, not that I know of."
A record review of the e-mail sent to the Assistant Director of Nursing, Director of Nursing, and Human Resource Director on June 28, 2014 from Staff # 8 revealed the following:
"I am sending this email because I don't feel like my multiple verbal complaints have been taken seriously. Today I was giving my patient in room 122 evening meds and I expressed to her that she must have had a better day today because she has not requested anything else for pain since I gave her morning pain meds. Patient replied "No you are right I don't remember calling for anything for pain, but I could sure use some now". I went to the Pyxis to pull some Hydrocodone for her and saw that Staff #5 RN had pulled some for her at 1249 and had not informed me of this med transaction. I then went to my cart to further investigate any other meds that may have been pulled. I saw that Staff #5 RN had also pulled Hydrocodone at 0830 this AM without my knowledge. This was an even greater concern to me because at 0750 this AM I administered patient scheduled Oxycodone 30mg. I went to Staff #5 and I said to him, "Staff #5, I asked you this morning and many other mornings that if any of my patients call for pain meds to let me know and I would administer it unless I was off the unit. I told him that both times he pulled meds for this patient I have been available at the station or close at one of the other stations. I let him know that his lack of communication could have caused me to make a med error if I would have just pulled the pain med and gave it without noticing the last time med was pulled. I also informed him that if indeed my patient called for pain med none of the techs have come to me nor any of the other nurses that have been answering lights have come to me about this patient and that the pt. didn't remember calling for any pain meds either. Staff #5 repeatedly came up with the excuse that he should have told me and he just forgot. He said it wouldn't happen again and I informed him that he has said that too many times before and I don't feel like he takes what he is repeatedly doing serious. I told him that he also never follows up and does the pain medication effectiveness and that he needs to go in and do those because I was not going to do them. Staff #5 then came to me prior to leaving and asked me if he and I were still 'GOOD'. He then went on to hold his hand out to me and said lets shake on it. I told Staff #5 that this is no hand shaking matter and I felt like he was insulting my intelligence, so I asked him to leave me alone. I have previously said that I don't feel comfortable working with Staff #5 being my team leader and having access to my patient's narcotic medications and I know other nurses have reported the same or similar concerns. I am now requesting that I not be assigned to work with Staff #5 as my team leader. I feel my complaints and concerns regarding the way he handles pain meds without consulting with the primary nurse is not safe or acceptable, professional behavior. I have been a nurse for over 29 years and I am a patient advocate first. I only want to feel like I can trust that my patients are truly getting the care they deserve and this includes their pain meds when they need it and my 'Gut feeling is not sure if I can trust that Staff #5 is giving my patients the narcotics that he is pulling for them."


An interview with Staff RN (Registered Nurse) #14 on 2/25/2015 at 2:15 PM revealed the following:
Staff #14 was asked if there were any nurses you were uncomfortable working with or were there any issues going on at the facility. Staff #14 stated, "I don't like working with Staff #5 because he gives pain medication to my patients without communicating it to me. We do primary nursing care here and my concern is the care of my patients." Staff #14 was asked, have you reported this to anyone. Staff #14 stated, "No, it is just known in this facility that Staff #5 is known to give a lot of pain medication to the patients, because he has a Master Degree in pain management."

An interview with Staff LVN (Licensed Vocational Nurse) #15 on 2/25/2015 at 2:30 PM revealed the following:
Staff #15 was asked, were there any nurses you were uncomfortable working with or were there any issues going on at the facility. Staff #15 stated, "I'm not comfortable working with Staff #5. He gives pain medication to my patients and doesn't communicate to you that he has administered pain medication to your patient. We do primary nursing care here and I like to care for my own patients and that includes giving their medication. He disappears and you can't find him when you really need him. There was incident that occurred 10/28/2014. Staff #15 was asked have you reported this to anyone. Staff #15 stated, "I reported the complaint to my Charge Nurse and sent an e-mail to Assistant Director of Nursing and the Director of Nursing." Staff #15 was asked had Administration made any attempts to correct the issues. Staff #15 stated, "No."
A record review of the e-mail sent to the Assistant Director of Nursing and Director of Nursing on October 28, 2014 from Staff # 15 revealed the following:
"I would like to voice a concern about Norco medication that was administered to my patient in 130B on 10/28/14 @ 0939 & 1303. The Norco medication was administered by Staff #5 RN. I was the primary nurse for patient in 130B on 10/26 & 10/28 and I never administered more that Tylenol 650mg pre-therapy for L hip pain. Upon all of my rounding and AM assessment, patient 130B has never reported pain. I asked the patient about receiving medication and she denies receiving any pain medications other than AM Tylenol that I administered pre-therapy. Another reason this medication administration concerns me is that I was never notified of him administering these medications to my patient and that leaves room for error with medication administration. I notified charge nurse of the medication administration as she was the charge nurse during my shift.

This is not the first time this has happened with one of my patients that Staff #5 was team leading over and when reviewing my charts after this discovery, patient 130B is the only patient of mine who receives Norco, all of the rest receive Tramadol and he has not administered any Tramadol to any of my other patients who have pain complaints.

Please contact me with any concerns or questions if needed.
Thank you,
Staff #15, LVN"


An interview with Staff LVN (Licensed Vocational Nurse) #17 on 2/25/2015 at 3:00 PM revealed the following:
Staff #17 was asked, were there any nurses that you were uncomfortable working with or were there any issues going on at the facility. Staff #17 stated, "I had issues with Staff #5 passing pain medication to my patients and not communicating to me. He disappears and you can't find him when you really need him. Staff #17 was asked, have you reported this to anyone. Staff #17 stated, "Yes, I reported the Assistant Director of Nursing." Staff #17 was asked had Administration made any attempts to correct the issues. Staff #17 stated, "Yes, Staff #13 had a conference with Staff #5 and myself and we discussed how I did not feel comfortable with him passing my pain medication on my patients. He apologized and said he would not do it again, but after a time he would just go back to the same pattern. I am just disappointed in him."
An interview with Staff RN (Registered Nurse) #18 on 2/25/2015 at 3:15 PM revealed the following:
Staff #18 was asked, were there any nurses that you were uncomfortable working with or was there any issues going on at the facility. Staff #18 stated, "I'm not comfortable working with Staff #5. He gives pain medication, but doesn't give routine medication. He disappears and goes outside to smoke frequently." Staff #18 was asked have you reported this to anyone. Staff #14 stated, "No, it is just known in this facility that Staff #5 gives a lot of Norco and Hydrocodone. I just watch and make sure he is not giving my patients pain medication."

An interview with Staff RN (Registered Nurse/Charge Nurse) #19 on 2/26/2015 at 10:20 PM revealed the following:
Staff #19 was asked, were there any nurses that you were uncomfortable working with or were there any issues going on at the facility. Staff #19 stated, "I'm not comfortable working with Staff #5. He just does not fit in with the team. He is just an odd man. Staff #5 is known to give a lot of pain medication instead of trying other comfort measures before giving pain medication. This is a Rehabilitation Hospital. He goes outside and smokes too much. He disappears from the floor and you can't find him. Staff #19 was asked, have you ever talked to him about giving other nurses medication. Staff #19 stated, "I have had numerous conversations with him to not give pain medications to patients that are not assigned to him. He will say okay, but goes back to the same pattern. We had problems over the weekend between Staff #5 and Staff #8. They do not like each other. I heard Staff #5 say I'm sick of her and I hate her." Staff #19 was asked, have you reported this to anyone. Staff #19 stated, "Yes, I have reported this to the Assistant Director of Nurses."

A review of records and six (6) interviews revealed no evidence that Nursing Administration conducted any investigations of the verbal or written complaints against Staff #5.

An interview with the Assistant Director of Nursing (#13) on 2/25/2014, at approximately 3:00 PM, confirmed she only received a verbal complaint that Staff #5 was acting strange over the weekend and left the building and did not clock out. The complaint was reported to the Charge Nurse over the weekend. Staff #13 stated, "I checked the time clock and Staff #5 had clock out. The only other issue was Staff #17 had reported Staff #5 for giving pain medication to his patient and not communicating with him. Staff #13 was asked had there been anything written up about this incident. Staff #13 stated, "No."
An interview with the Assistant Director of Nursing and the Director of Nursing on 2/25/2014, at 4:00 PM, confirmed they had not received any written complaints about Staff #5.
An interview with the Human Resource Director on 2/25/2014, at 4:00 PM, confirmed she had received one e-mail in June 2014 about Staff #5.
An interview with the Pharmacist on 2/25/2015, at 12:00 PM, and again on 2/26/2015, at 11:15, revealed Staff #5 was the highest user of controlled substance in the facility. The pharmacist had made Nursing Administration aware that Staff #5 always pulls 2 Hydrocodone when administering medication. A review of records provided by the Pharmacist revealed Staff #5 failed to scan the patient identification bracelet, scan the medication package, and pulls medication and doesn't document the medication until an hour later. The Pharmacist was asked had this report been given to the Director of Nursing. Pharmacist stated, "Yes."
A review of the facility policy titled, "Medication Diversion Prevention" revealed the following:
"The policy and procedures described herein establish the minimum requirements for a hospital. Pharmacy directors and CEO's will be responsible for demonstrating compliance with these requirements. However, both state and federal law govern the purchasing, storage, administration, safeguarding, and recordkeeping, including timelines, with respect to controlled substances. Each pharmacy director should review the relevant state law and determine if the policy needs to be modified to reflect more stringent laws of the state that govern controlled substances. All such modifications must be approved by the hospital ' s Medical Executive Committee, retaining supporting documentation in the pharmacy.

7. Looking for high use and following up
Identification of staff and processes that lead to diversion is an ongoing concern, requiring constant surveillance. The Chief Nursing Officer (CNO) or designee should, at least monthly, look for common signs of diversion through observation of medication administration, review of sign out logs and high user reports, and patterns of staff behavior. Any flags identified will trigger a formal audit as described below. Communication between the DOP and CNO should facilitate early detection of diversion.

Each day's reports of discrepancies, whether generated by an ADM or collected manually from a logbook, will be reviewed by the CNO or designee. This review will include an effort to identify any trends in unit, staff involved, shift, specific medications and methods of resolution. Any such findings would trigger further investigation and all warranted disciplinary actions necessary to fully implement this policy.

A formal audit will be completed quarterly. The CNO should be provided with a list of staff with high utilization of CS from an automatic dispensing machine (ADM) report. For manual systems, the CNO or designee will review one randomly selected pay periods CS dispensing logs. A report of the review will include the names of each nurse included in the review, notations of any identified flags (examples listed below), and action plans developed in conjunction with the DOP to address any observations.

The appearance of nurses who administer a significantly higher number of CS than the other nurses should be considered a " flag " but does not constitute any evidence of impropriety. It would be prudent to then look at the manual or electronic records for patients serviced by that nurse from the chart or from Medics to review the pattern of administration. Examples of further "flags" that might support or refute the hypothesis of diversion are:

a. For a specific patient, a higher use of PRN CS use only on the shifts of selected nurses.

b. The removal of medications for more than the immediate need of the patient, but shown on the medication administration record (MAR) as being administered later than removal.

c. Constant removal of the maximum number of PRN medications.

d. A failure of dispensing records, whether manual or from the dispensing machine, to agree to the patient ' s MAR, as to medications administered.

e. Removal of medications by override in ADMs that are not supported by physician orders.

f. Failure of the MAR to agree to the records of CS removed on the nursing unit.

g. In a manual recording system, the appearance of entries out of chronological order (i.e. the time added or removed is prior to the time on the last record), fictitious patient names used to sign out CS, incorrect patient identification information recorded on the sign- out log, and illegible handwriting or marks on the log.

Should one or more of these further flags exist, the CNO and DOP should begin an investigation following the Policy 412-Internal Investigation for Alleged Fraud or Criminal Activity.

Anytime a patient expresses concern over whether or not a medication is correct, looks different than they have received before, or has any question related to any medication about to be administered, the nurse should immediately stop and confirm accuracy of the medication, dose, patient's orders, and answer any patient questions or concerns.
Additionally, anytime a patient or family expresses concern regarding omission of medications an investigation of the omission should be initiated."

A record review of the two (2) e-mails sent to the Assistant Director and the Director of Nursing, Staff interviews, Pharmacist interview, and Patient #17 interview revealed no evidence that Nursing Administration was enforcing the facility's policies for "Medication Diversion Prevention", "Medication Administration Record", and "Medication Administration Policy." Also, the interview with Staff #5 confirmed he was not following the facility's policies on "Medication Administration Record" and "Medication Administration Policy."

Based on document review and interview, the facility failed to ensure the RN evaluated and documented the patient's condition, failed to document provision of complete and accurate interventions and failed to document the patient's response to the intervention that were provided in 1 of 20 patients whose medical records were reviewed.

On 2/25/2015, at 1:00 p.m., in the Chief Nursing Officer's office, the electronic medical record (EMR) for the Rehabilitation Hospital, patient (Pt/pt.) #1, was reviewed and revealed the following: Pt #1 was a 56 year old female, who had transferred from a Long Term Acute Care (LTAC) facility. Review of Pt #1's MR from the LTAC revealed, Pt #1 developed necrosis of her fingers and great toe of her right foot prior to admission to the Rehab facility. She was admitted to the Rehabilitation facility on 12/2/2014.

A further review of the Rehab Hospital's EMR for pt. #1 revealed RN #5, who completed pt. #1's admission assessment, was identified as the team lead. On 12/2/2014, at 1523 hours, the team lead RN failed to document vital signs (V/S, blood pressure, pulse, respiration and temperature) upon admission. Pt #1's cardiovascular assessment was documented as follows: nail bed color dark and capillary refill greater than 2 seconds, radial pulse both left and right were 2 plus and normal, the bilateral pedal pulses were 2 plus and normal as well. Team lead RN #5 gave pt. #1 her first dose of hydrocodone for pain management at 1806 hours, without evidence of assessing her vital signs or any assessment of the location, cause or nature of her pain.

The next V/S for pt. #1 was documented at 1900 hours on 12/2/2014, by the nurse tech. Pt #1's B/P was 135/83, respiratory rate was 18, temperature was 100.1 and pulse rate was 108. The MR indicated the blood pressure and temperature were high. At 2100 hours, the V/S were recorded, minus the temperature, as unchanged. No further RN documentation, assessment or intervention was found.

The first assessment with V/S appear in the MR on 12/3/2014, at 0700, by Licensed Vocational Nurse (LVN) #6, who documented the following: radial pulse bilaterally 2 plus and normal, respirations unlabored regular pattern, B/P 107/73, respiratory rate 18, temperature 98.2, and pulse 110. She also documented "Continues to have necrotic areas to pads of left hand 3rd and 4th digit, right foot necrotic area to pad of 1st and 2nd digit, left foot 1st digit necrotic area resolving with faint red/purple discoloration".

On 12/3/2014, the Physical Therapist's documentation indicated at 11:00 a.m., pt. #2 participated in Physical Therapy and had an oxygen saturation of 93 percent on room air. At 12:07 p.m., RN #5 documented he administered pt. #1's pain medication for a pain scale of 8 of 10 in pain intensity. No V/S or RN assessment was documented.

The MR documentation revealed pt. #1 complained of pain with a pain scale intensity of 7 of 10 at 4:00 p.m. No RN assessment or intervention was documented. Pt #1 requested she be allowed to make a phone call and the nurse assisted her then left the room.

No further documentation occurs until 3 hours later on 12/3/2014, at 1900 hours (7:00 p.m.). The RN documented the following: "B/P 90/60, Pt #1 complained of pain in her abdomen with a pain scale of 10/10 in intensity." The RN failed to document in the nurses notes that hydrocodone was given for pain without effect, and pt. #1, later was given Diluaded with some relief. This was discovered during an audit of the medication removal record from the electronic narcotic storage unit.

Further review revealed, the RN documented bilateral pedal and radial pulses were "thready" and 1 plus, but failed to document a pulse rate. The RN documentation indicated a rebreather mask had been placed on pt. #1, however the RN failed to document pt. #1's respiratory rate or the oxygen flow rate. The RN documentation reflected her skin was gray, ashen, clammy and pale. She was cold with dusky mucous membranes. The RN documented the heart rhythm was regular but no rate was recorded. Nursing documentation ends with no further intervention or assessment.

Review of the physician's discharge summary revealed the following: Pt #1 was admitted (12/2/2014) in stable condition and "somewhere between 4:00 and 6:00 in the evening of (12/3/2014) began experiencing abdominal pain". "She (pt. #1) contacted her daughter, who arrived and asked the staff to evaluate her. They notified me around 7:00 stating that her oxygen saturation was down but because of the ischemic digits were unable to get an accurate reading". "At the time the pt's saturation came up with a face mask to 97 percent. We did an EKG (electrocardiogram) which revealed sinus tachycardia with a rate of 114". There was no clear evidence of ischemia. Due to her severe abdominal pain, discoloration and drop in blood pressure and tachycardia it was felt in the best interest to transfer back to (Acute Hospital), so we called 911 and sent her to the Emergency Room".

On 2/26/2015, at 10:00 a.m., in the CNO's office, an interview with the CNO revealed, she was in her office the evening pt. #1's daughter arrived and left her office to speak with the daughter who had requested help for her mother. She confirmed there was very little documentation from the nursing staff; the evening of pt. #1's change of condition, and ultimate transfer to acute care services occurred. She confirmed the RN should document full vital signs. The CNO also confirmed the nurse failed to document when the physician was notified and when and how the pt. #1 left the facility.

At no time from the date of admission 12/2/2014, through 12/3/2014, did the Registered Nursing staff document a complete assessment on pt#1 that included completed V/S. The only complete set of V/Ss was documented by a Licenses Vocational Nurse.

Based on record review and interview, a Registered Nurse failed to follow the facility's policies on medication administration of controlled substances and medication being administered to the patients in the facility citing 1(#5) of 2 (#8).
A review of the March, April, September, December 2014, and January 2015 medication administration for controlled substances revealed the following:
The medication administration log was for the dates of March 17, 2014, through April 10, 2014.
A total of twelve (12) doses of Narco (Acetaminophen-Hydrocodone) were documented given to the patients by Staff #5 prior to the controlled substance ever being dispensed from the Pyxis (Pyxis is an automated dispensing system supporting decentralized medication management. Barcode scanning is to help ensure accurate medication dispensing, features to prevent loading of the wrong medication and active alerts to provide an added safety precaution for high risk medications.) Further review of the log revealed Staff #5 pulled the Narco (Acetaminophen-Hydrocodone) from the Pyxis, but did not document the administration of the medication. There was no evidence to know if the patient received the Narco (Acetaminophen-Hydrocodone).
The medication administration log was for the dates of September 1-25, 2014.
A total of fifteen (15) doses of Acetaminophen-Hydrocodone were documented given to the patient by Staff #5 prior to the controlled substance ever being dispensed from the Pyxis. Further review of the log revealed Staff #5 documented a controlled substance (Acetaminophen-Hydrocodone) given to the patient, but the medication was not documented as pulled from the Pyxis where the controlled substances were kept. Also, the record indicated that on 2 different occasions the patients' armband was not scanned nor was the medication scanned per the facility policy. On one occasion the armband indicated one (1) Acetaminophen-Hydrocodone pulled, but the Pyxis showed 2 Acetaminophen-Hydrocodone were pulled by Staff #5. On 7 different occasions the log indicated a greater than 30 minute time limit from the time the medication was pulled from the Pyxis until the time the medication was administered to the patient. The log showed an hour from the time the medication was pulled, to the time the medication was administered. Staff #5 failed to follow the facility's policy.
The medication administration log was for the dates of December 14, 2014 through January 14, 2015.
A total of forty-two (42) doses of Acetaminophen-Hydrocodone were documented given to the patient by Staff #5 prior to the controlled substance ever being dispensed from the Pyxis. Further review of the log revealed Staff #5 on 3 different occasions documented controlled substances (Hydromorphone, Librium, and Acetaminophen-Hydrocodone ) were given to the patient, but the medication was not documented pulled from the Pyxis where the controlled substances were kept. Also, the record indicated that on 9 different occasions the patients' armbands were not scanned and 4 different times the medication was not scanned per the facility policy.
On 7 different occasions the log indicated a greater than 30 minute time gap from the time the medication was pulled from the Pyxis until the time the medication was administered to the patient. The log showed an hour from the time the medication was pulled, to the time the medication was administered. Staff #5 failed to follow the facility's policy.
A review of the medication log dated 12/28/2014, revealed Nurse #5 administered a total of 36 controlled medications to 8 different patients during a 12 hour shift. That calculates to 4.5 controlled medications per patient. Further review of the log revealed Acetaminophen-Hydrocodone 2 tablets were pulled from the Pyxis at 10:09 AM and administered at 10:11 AM to Patient #18. Nurse #5 also pulled an Oxycodone 1 tablet at 10:16 AM from the Pyxis and administered the medication at 11:01 AM. This administration of an additional medication had the likelihood to not allow enough time to evaluate Patient #18 pain level.
A phone interview was conducted with Staff #11 on 3/24/2015 at approximately 9:00 AM. Staff #11 was asked if any of the nursing staff made her feel uncomfortable. Staff #11 stated, "Nurse #5 makes me feel uncomfortable with how he gives pain medication to my patients and doesn't communicate with me to let me know what he has given. I recall one incident where my patient (#17) reported to me that Nurse #5 came in his room with a cup full of pills. Patient #17 reported to me that Nurse #5 said it was pain medication, but that the patient had not ask for any pain medication. When I tried to give him his routine medication he refused all of them and refused his medication for the rest of the night." Staff #11 stated, "I reported the incident to my charge nurse (Staff #12) and she sent an e-mail to the Director of Nurses about Patient #17's complaint."
A phone interview was conducted with Patient #17 on 3/24/2015, at approximately 11:00 AM.. Patient #17 was asked if he had had any problems with the nursing staff during his stay at the facility. Patient #17 stated, "Well one time a gray headed nurse older man (Nurse #5) had brought me medication in a cup with about 5 tablets in it. I had never had medication brought to me like that and he said it was my pain medication. I told him I didn't ask for any pain medication. I tried to report that incident to the Director of Nurses and someone in Administration, but no one would listen to me so I just gave up and let it go. I won't go back to that place again."
A review of Patient #17's medication record revealed the patient was admitted to the facility on 9/16/2014 and discharged on 10/2/2014. The record showed patient #17 received pain medication.
The pain medication schedule for patient #17 was as follows:
9/17/2014- 5:02 AM
9/18/2014- 7:34 and 18:44(6:44 PM)
9/19/2014- 16:07 (4:07 PM)
9/20/2014- None
9/21/2014- 8:41 AM
9/22/2014- 8:55 AM and 10:12 AM
9/23/2014-15:02 (3:02 PM)
9/24/2014- 14:13 (2:13 PM)
9/25/2014- 12:17 PM
9/26/2014- 00:49 AM (12:49 AM)
9/27/2014- None
*9/28/2014- 7:23 AM, 11:48 AM and 17:28 (5:28 PM)
9/29/2014- None
9/30/2014- None
10/1/2014- None
10/2/2014- None
A further review of the medication revealed the patient usually only had one dose of pain medication in in 24 hour period or if 2 doses were given the medication was approximately 12 hours apart. There was never a day during the admission stay where the patient received pain medication approximately every 4 hours except for the day Nurse #5 was giving medication on 9/28/2014. Patient #17 received 3 doses of pain medication and that was the day Patient #17 complained to the nurse that he had not ask for any pain medication. A review of the patient record on 9/28/2014 revealed no pain assessment completed by Nurse #5 after the patient had received 3 doses of pain medication that day.
A review of the facility policy titled, "Medication Administration Policy" revealed the following:
"PURPOSE:
To administer medications to the patients in a safe and timely manner. The nursing staff at the
Hospital will adhere to the following:

1. All medications will be given in an appropriate, safe and timely manner in compliance with physician's orders.

4. Takes medication to the patient following the standard measures as to: Ensure the eight rights of medication administration are being met before any medication administration-Right time, right route, right amount, right medication, right patient, right documentation, right effect, and right education. To further ensure proper patient identification, two patient identifiers should be utilized prior to medication administration. This may be accomplished by verbal communication with a competent patient or the patient's representative. When a patient cannot provide a verbal confirmation, a confirmation of the patient's identity using two patient specific identifiers on the armband is appropriate.

10. Verifies that the medication is being administered at the proper time, in the prescribed dose, and by the correct route.

11. Advises the patient or if appropriate, the patient's family about any potential clinically significant adverse reaction or other concerns about administering a new medication.

12. Documents new medication education to family and follow up note 30 minute-60 minutes after medication administration of any side effects or concerns.

13. If the seal on a drug is broken, or vial cracked, etc., do not give the medication. Pharmacy departmental personnel are to be notified, the original medication returned and the medication replenished.
*No medication should be opened prior to administration.

14. Documents in the EMR on the medication administration record (MAR) that the medication has been given. The acceptable method is scanning the patient ID bracelet and scanning the medications administered to the patient.

15. Notifies pharmacy personnel of any missing medications. The pharmacist obtains the medication from the pharmacy. The pharmacist gives the medication directly to the nurse or places it in the Pyxis.

16. Administers PRN medications, when necessary as ordered:
a. Prepares the medication at the appropriate areas.
b. Takes the medication to the patient observing the safety standards described in Number 4 of this Procedure.
c. Documents medication administration appropriately in the EMR. The acceptable method is scanning the patient ID bracelet and scanning the medications administered to the patient.

17. Administers controlled substance medications when necessary as ordered:
a. Prepares the medication at the medication area, observing the safety standards described in Number 4 of the Procedure.
b. Takes the medication to the patient observing safety standards described in Number 4 of this Procedure.
c. If an amount is to be given that requires wasting part of the unit dose, request another licensed person to witness the disposal of that amount of controlled substance at the Pyxis.
d. Charts the medication appropriately in the EMR utilizing the scanning method and documents utilizing the medication effectiveness form.

19. Documents administration of medication:
a. The nurse administers a medication after which he or she: (1) Documents in the EMR on the MAR according to the medication administration policy. The acceptable method is to scan the patient ID bracelet and each medication administered to the patient. The nurse will sign electronically in the EMR that each med was given. This is for routine, prn, and stat/one time doses. Medication effectiveness documentation will be completed when appropriate."

A review of the facility policy titled, "Medication Administration Record" revealed the following:
"POLICY:
To assure safe, accurate, current and standardized documentation of all medications administered and to reduce repetition and the need for multiple medication profiles.
1. The Medication Administration Record (MAR) will be used for all patients receiving medications, including those areas where medications are self-administered.

B. General Guidelines
1. All medications administered are recorded, by selecting the medication administration task in the toolbar, then scanning the patient's armband, then scanning each medication package. Proper administration and selecting the "sign" or check box in the toolbar will constitute the nurses signature and record date and time.

D. Documentation of the MAR
1. When administering a scheduled medication, the RN or LVN scans the patient armband, verifying the patient's identity. Then the RN or LVN scans each package of medication to be administered, and completes all fields on the medication administration page to ensure accurate and complete documentation. By selecting the "sign" or "check mark" the entry is completed including electronic signature, date, and time of administration.

2. If a scheduled medication is omitted, the RN/LVN selects the "Not given" box, indicating the reason, and records an explanation in the "comments" field, using a "Nurses Progress Note" for any additional information.

3. The RN/LVN logged into the system will be recorded as the individual giving the medication; this will include the person's name, title, date, and time.

4. PRN medications will be documented in the same manner as routine medications. An entry is made in the nurse's notes or on the medication administration page indicating why the medication was given and the patient response to the medication.

5. When a patient armband will not scan, a new armband must be created and placed.

6. Medications that will not scan need to be reported to the pharmacy for correction."
An interview with Staff #5 on 2/26/2015, at 1:50 PM, confirmed he was not following the facility policy for the documentation and administration of routine or controlled substance medication.
An interview with the Human Resource Director on 2/26/2015, at 2:00 PM, confirmed she was present during the interview with Nurse #5 who stated he was not following the facility policy for the documentation and administration of routine or controlled substance medication.
An interview with the Pharmacist on 2/26/2014, at 3:00 PM, confirmed all medications were individually packaged with a bar code to be scanned when administered to the patient, even the controlled substances.
An interview with the Staff #13 on 2/26/2015, at approximately 3:30 PM confirmed the correct way to administer medication was to be present in front of the patient and scan the patient's armband and then scan the medication.