HospitalInspections.org

Based on record reviews and interviews the hospital failed to ensure an RN supervised and evaluated the nursing care for the patient upon admission and on an ongoing basis by failing to ensure the patient received: 1) the antibiotics (Rocephin and Zithromax) as ordered by the physician on the day of admission for 1 of 3 focused records reviewed out of a total of 10 of 22 sampled patients, (#4); 2) an Intravenous Site (IV) as ordered by the physician on the day of admission for 1 of 3 focused records reviewed out of a total of 10 of 22 sampled patients, (#4); and 3) Intravenous fluids as ordered by the physician on admission into the hospital and on an ongoing basis for 1 of 3 focused records reviewed out of a total of 10 of 22 sampled patients, (#4). Findings:

Patient #4:

The medical record of Patient #4 was reviewed. #4 was admitted to the 6th unit on 12/21/09 at 12:00 pm with the primary diagnosis of Pneumonia. S14, MD wrote an order on 12/21/09 at 10:33 am for: IV: 1/2 normal saline infusing at 100 cc/hr, Rocephin 1 gram intravenous piggy back (IVPB) daily and Zithromax 250 mg IVPB daily. There was no documented evidence in the patient ' s medical record when the IV site was started by nursing staff on 12/21/09. There was documentation #4 had a left, forearm, 20 gauge IV site noted with a saline lock on 12/21/09 at 2000 (8:00 pm) -8 hours after she was admitted into the hospital. There was no documentation that #4 was administered ? NS for the first, 20 hours of her admission into the hospital (12/21/09 at 12:00 pm through 12/22/09 at 8:00 am) as ordered by the physician. #4 was administered Normal Saline (NS) IVF (intravenous fluids) for 12 hours through the left, forearm IV site (12/22/09 at 8:00 am to 8:00 pm). There was no documented evidence she was administered the intravenous fluids, (1/2 NS at 100 cc/hr), as ordered by S14, MD on admit for 34 hours after she was admitted into the hospital.

Further review revealed the antibiotics (Rocephin and Zithromax) was administered to #4 on 12/22/09 at 9:00 am-(about 33 hours after her admission into the hospital) and Zithromax at 10:00 am -(about 34 hours after she was admitted into the hospital).

An interview was conducted with S9, Pharmacy Director on 2/4/10 at 11:30 am. He indicated medications are dispensed for administration to the patient within 2 hours of their admission into the hospital. He verified Patient #4 did not receive her antibiotics (Rocephin and Zithromax) as ordered by the physician on 12/21/09 for 33 hours after she was admitted into the hospital. He confirmed pharmacy did not package and dispense the antibiotics for administration until 12/22/09 at 7:36 am (31 hours and 36 minutes). He reported the antibiotics were not dispensed as per policy within 2 hours of admission into the hospital. He continued the patient did not receive the antibiotics as ordered by the physician on 12/21/09.

An interview was conducted with S11, RN on 2/3/10 from 9:20 am to 9:30 am. She reviewed #4's medical record. S11 indicated she had performed the patient ' s initial admission assessment on 12/21/09 from 12:00 pm to 12:37 pm. She indicated she did not start the patient's IV site during her initial assessment of the patient. S11, RN reported #4 had an IV site documented to her left, forearm at 2000 (8:00 pm) with a saline lock, which meant there was no fluids flowing through the IV site. She verified S14, MD ' s admission orders read as follows: IV site with ? NS infusing at 100 cc/hr, Rocephin and Zithromax IVPB daily during her admission to the hospital. S11 confirmed there was no documented evidence in #4's medical record that an IV site was started for 8 hours after admitted into the hospital. She verified #4 had no IV fluids infusing for 20 hours after she was admitted into the hospital. S11, reported #4 received NS fluids on 12/22/09 for 12 hours, but the physician had ordered ? NS. S11, RN confirmed #4 was administered ? NS fluids for the last 13 hours of her hospital stay. S11 indicated the patient ' s length of stay in the hospital was about 46 hours in which she did not receive her ? NS fluids as ordered by the physician. She confirmed there was no documented evidence #4 received her antibiotics, (Rocephin and Zithromax) as ordered daily on 12/21/09. She continued all medications are administered to the patient 2 hours after they are admitted into the hospital.

An interview was held with S23, RN on 2/3/10 from 9:40 am to 10:00 am. She reviewed the patient ' s medical record. S23, confirmed she provided #4's nursing care during the day shift on 12/22/09 (7:00 am to 7:00 pm). She verified the patient had a left forearm IV site, intact with a 20 gauge catheter with NS (normal saline) infusing at 100 cc/hr with 900 cc to be infused was documented during her initial assessment performed at 8:00 am- at the beginning of her shift. S23, RN verified the patient did not have an IV site for 8 hours after she was admitted into the hospital. S23 confirmed the patient did not receive the ? NS fluids as ordered by the physician for 32 hours during her hospital stay. S23, RN reported the patient received NS fluids for 12 hours during her day shift, 12/22/09 in which the physician ordered ? NS fluids to be administered to the patient. She indicated that the patient did not receive her antibiotics (Rocephin and Zithromax) as ordered by the admitting physician, S14, MD on 12/21/09. S23 reported knowledge that the patient had missed the IVF and antibiotics that morning after S14, MD had addressed the missed IVF and antibiotics with the night nurse, S12, RN prior to her shift starting. S23, RN recalled getting report from S12 RN -night nurse that the patient did not receive the antibiotics (Rocephin and Zithromax) on 12/21/09 as ordered by the physician.

An interview was held with S12, RN on 2/4/10 from 8:30 am to 8:45 am. He reviewed #4's medical record. He indicated he had provided her with nursing care during the night, 12/21/09 from 7:00 pm to 7:00 am. He reported he did not have time to review the physician ' s admission orders written, 12/21/09 during his shift that night. He confirmed #4 had an IV site to the left forearm with a 20 gauge catheter during his assessment at 8:00 pm. He indicated he did not start the patient ' s IV site. He reported no knowledge of who had started the patient ' s IV site that he had documented at 8:00 am. He reviewed #4's medical record and indicated #4 was not administered the antibiotics (Rocephin or Zithromax) as ordered by S14, MD on admission (12/21/09). He reported he was unaware that the patient had missed the IV antibiotics (Rocephin and Zithromax) on 12/21/09 until the next morning, (12/22/09) when S14, MD had questioned, why the patient had not received the antibiotic medications as ordered from the day before. He confirmed this was a medication error in which he had not filed an electronic occurrence report, nor had he reported the medication error to Monty Person, S9, Pharmacy Director. He indicated the patient was not administered the antibiotics as ordered by the attending physician, S14, MD on 12/21/09 for 33 hours after admitted into the hospital. He reported all medications are administered to the patient within 2 hours of admission into the hospital. He indicated the patient's antibiotics did not follow policy to be administered within 2 hours of hospitalization.

In an interview with S7, ACNO on 2/4/10 from 8:45 am through 8:55 am. She indicated the patient ' s antibiotic (Rocephin and Zithromax) medications were missed on 12/21/09 and 12/23/09. S7 reported all nursing staff that provided the patient's care during her hospitalization all denied starting #4's IV site on 12/21/09. She verified Patient #4 was without an IV site for 8 hours. S7, ACNO confirmed #4 had no intravenous fluids for 20 hours after being admitted into the hospital. (12/21/09 at 12:00 pm through 12/22/09 at 8:00 am) . S7 indicated #4 was administered NS through the left forearm IV site (12/22/09 at 8:00 am to 8:00 pm) for 12 hours during her admission, but the physician ordered 1/2 Normal Saline. S7, ACNO indicated the physician's order for 1/2 Normal Saline fluid was not followed. S7, ACNO verified there was no documented evidence #4 was administered the intravenous fluids, (1/2 NS at 100 cc/hr), as ordered by S14, MD on admit for 34 hours after she was admitted into the hospital.

Review of the medical record for Patient #4 revealed she was discharged from the Telemetry Unit (6th floor) on 12/23/09 at 10:40 am. Further review revealed there was no documented evidence #4 received her scheduled antibiotics (Rocephin and Zithromax) at 9:00 am and 10:00 am on 12/23/09. Patient #4's IV site was documented as discontinued at 9:00 am.

A telephone interview was conducted with S14, MD on 2/4/10 from 12:20 pm through 12:30 pm. S14 recalled Patient #4 was not administered her antibiotic medication on 12/21/09 as ordered IVPB or the IVF to treat her Pneumonia. S14, MD denied knowledge that the patient did not receive her scheduled IV antibiotics on 12/23/09 (Rocephin and Zithromax) at 9:00 am before her IV site was removed at 9:00 am and was discharged to home at 10:40 am. S14 denied knowledge #4 did not have an IV site for 8 hours and no IVF for 20 hours after she was admitted into the hospital. S14 reported no knowledge that the patient received normal saline fluids for 12 hours- when she had ordered, ? NS. S14, MD indicated she was not aware that the patient did not receive the IVF as ordered ? NS for 32 hours of her 46 hour hospital stay. S14 stated that she expects nursing staff to implement all of patients ' care orders to be followed including medication administration (antibiotics - Rocephin and Zithromax) and IV sites with IVF infusing (1/2 NS infused at 100 cc/hr). S14, MD replied, I did not expect the staff to administer her antibiotics before she was discharged to home because I gave her a prescription for oral antibiotics to start taking after she got home and recalled the patient was anxious to go home. S14 indicated the patient should had received her IV and antibiotic medications within 2 hours of her admission into the hospital on 12/21/09 and she did not receive these medications for 32 hours after she was admitted.

Based on record reviews and interviews, the hospital failed to ensure the patients were administered antibiotics and/or oxygen therapy as ordered by the prescribing physicians as evidenced by failing to: 1) administer antibiotics (Rocephin and Zitheromax) for 33 hours after the patient was admitted into the hospital for 1 of 3 focused records reviewed out of a total of 10 of 22 sampled patients, (Patient #4) and 2) administer oxygen 2 liters per nasal cannula for 1 of 3 focused records reviewed out of a total of 10 of 22 sampled patients, (Patient #3). Findings:

Patient #4:
The medical record of Patient #4 was reviewed. #4 was admitted to the 6th unit on 12/21/09 at 12:00 pm. There was a physician's order written for Rocephin 1 gram intravenous piggy back (IVPB) daily and Zithromax 250 mg IVPB daily. The Medication Administration revealed pharmacy recorded the antibiotics (Rocephin and Zithromax) on 12/22/09 at 7:36 am - 31 hours and 36 minutes after the patient was admitted into the hospital. Further review revealed #4 was administered the Rocephin at 9:00 am about 33 hours after her admission into the hospital and and Zithromax at 10:00 am - about 3 4 hours after she was admitted into the hospital.

An interview was conducted with S9, Pharmacy Director on 2/4/10 at 11:30 am. He indicated medications are dispensed for administration to the patient within 2 hours of their admission into the hospital. He verified Patient #4 did not receive her antibiotics (Rocephin and Zithromax) as ordered by the physician on 12/21/09 for 33 hours after she was admitted into the hospital. He confirmed pharmacy did not package and dispense the antibiotics for administration until 12/22/09 at 7:36 am (31 hours and 36 minutes). He reported the antibiotics were not dispensed as per policy within 2 hours of admission into the hospital. He continued the patient did not receive the antibiotics as ordered by the physician on 12/21/09.

Patient #3:
There was an observation conducted on Patient #3 on 2/3/10 at 10:55 am. #3 was observed wearing a nasal cannula with Oxygen at 5 liters per minute. The surveyor was accompanied by S7, RN ACNO during this observation. Another observation was conducted with S7, RN ACNO and S26, RN at 11:40 am. S7 and S26 confirmed #3's oxygen settings were at 5 liters.

Review of the medical record for patient #3 on 02/03/10 at 11:00 am revealed there was an order for Oxygen 2 liters per minute via nasal cannula written on 2/2/10 at 10:10 pm by the attending physician. S7, RN ACNO and S26, RN reviewed and verified that the attending physician's orders for oxygen were 2 liters per minute via nasal cannula.

An interview was held with on 02/03/10 at 11:40 am with S7, RN ACNO and S26, RN. They both confirmed the patient's oxygen administration was 5 liters instead of 2 liters as ordered by the attending physician. They both indicated the attending physician's orders for oxygen to be administered via nasal cannula at 2 liters per minute were not being followed.

Based on record reviews, observations and interviews, the pharmacy failed to ensure the emergency drugs, biologicals and supplies were in accordance with the applicable standards of practice and were consistent with the applicable Federal and State laws by failing to have emergency medications and/or supplies (IV Catheter Kits) available in the emergency crash carts were not expired as evidenced by: 1) having 20 expired medications in 5 of the 18 Emergency Carts and 4 expired IV Catheter Kits in 3 of the 18 Emergency Carts available during an emergency situation and 2) failing to ensure these 6 of 18 Emergency Carts were periodically inspected to ensure there were no expired medications or supplies (IV Catheter Kits) available during an emergency situation. Findings:

Cart #1:

An observation was made of the Emergency Cart #1 located in the Emergency Department on 2/4/10 at 2:50 pm with S9, Pharmacy Director. Cart #1 had an orange sticker noted on the outside of drawer #1 with the following label, Drug Expired: 2/ 2010, Metroprolol, Last Checked: 2/1/10. There was 1 medication, Metroprolol expired on 2/1/10 in drawer #1 of the cart. S9, Pharmacy Director verified the cart was last checked on 2/1/10 and the Metroprolol was documented on the orange tag on the outside of drawer #1 as expired 2/2010.

Record review of Emergency (Crash) Cart #1's Log revealed this cart was last checked on 2/1/10 with no documented location the cart was in the hospital containing an expired medication, Metroprolol on 3/1/10.

In an interview with S9, Pharmacy Director during the observation of Cart #1 at 2:50 pm, he verified there was 1 expired medication in Cart #3. He reviewed the cart's log and verified it was last checked on 2/1/10. He indicated this cart was last checked on 2/1/10 and it contained the expired medication, Metroprolol after the routine cart inspection was performed by staff. He reported the emergency cart check failed to ensure that the expired Metrorpolol was removed during the carts monthly inspection performed on the same day that the medication expired (2/1/10).

Cart #7:

An observation was made of the Emergency Cart #7 located in MICU on 2/4/10 at 2:35 pm with S9, Pharmacy Director. There were 5 medications, [(3) Metroprolol expired 2/1/10 and (2) Atropine Sulfate Syringes expired 12/ 2009] and (2) IV Catheter Start Kits with the expiration date of 12/2009. S9, Pharmacy Director verified there were 5 expired medications and 2 expired IV Catheter Kits in Cart #7.

Record review of Emergency (Crash) Cart #7's Log revealed this cart was last checked on 12/14/09 with no documented location the cart was located in the hospital.

In an interview with S9, Pharmacy Director during the observation of Cart #9 at 2:35 pm, he verified there were 5 expired medications and 2 expired IV Catheters in Cart #7. He reviewed the cart's log and verified it was last checked on 12/14/09. He indicated this cart was not routinely checked, monthly as per policy.

Cart #9:

An observation was made of the Emergency Cart #9 located in Pharmacy on 2/4/10 at 1:50 pm with S9, Pharmacy Director. There were 3 medications, [(2) Metroprolol expired 2/1/10 and (1) Sodium bicarbonate expired 1/2010] and an IV Catheter Start Kit with the expiration date of 12/2009. S9, Pharmacy Director verified there were 3 expired medications and 1 expired IV Catheter Start Kit in Cart #9.

Record review of Emergency (Crash) Cart #9's Log revealed this cart was last checked on 9/4/09 in the Cath Lab.

In an interview with S9, Pharmacy Director during the observation of Cart #9 at 1:50 pm, he verified there were 3 expired medications and 1 expired IV Catheter Start Kit in Cart #9. He reported this cart had come from the Cath Lab (5 minutes ago). S9 denied knowledge of what Cart # had replaced Cart #9 five minutes ago. He was unable to provide a record system that kept track of the 18 Carts locations in the hospital.

Cart #15:

An observation was made of the Emergency Cart #15 located in ICU on 2/4/10 at 2:15 pm with S9, Pharmacy Director. The cart had an orange label noted on drawer #1 labeled, Last check on 2/2/10. There was 1 expired IV Catheter Start Kit observed in drawer #3 of the cart with the expiration date of 12/2009. S9, Pharmacy Director verified the cart was last inspected on 2/2/10 and there was an expired IV Catheter Kit left in Cart #15.

Record review of Emergency (Crash) Cart #15's Log revealed this cart was last checked on 1/8/10 with no documented location the cart was located in the hospital with no documented no medication named first to expire on 3/1/10. Review of Cart #15's Log revealed there was no documented evidence the cart was last inspected on 2/2/10.

In an interview with S9, Pharmacy Director during the observation of Cart #15 at 2:15 pm, he verified there was 1 expired IV Catheter Kit Cart #15. He reviewed the cart's log and verified it was last checked on 1/8/10. He reported the cart check failed to ensure that the expired IV Catheter Kit (12/09) was removed during the carts monthly inspections performed on 1/8/10 and 2/2/10.

Cart #16:

An observation was made of the Emergency Cart #16 located in PACU on 2/4/10 at 1:20pm with S8, Surgery Director. There were noted 9 medications, [(2) Calcium Cloride, (2) Flumazenil, (1) Verapamil HCL, and (1) Epinephrine with the expiration date of 1/2010 and (3) Metorolols with an expiration date of 2/1/10. S8, Surgery Director confirmed during this observation the 6 medications had expired on 1/2010 and the 3 medications had expired on 2/1/10. At 1:45 pm, S8 Surgery Director presented S9, Pharmacy Director the 9 medications from the PACU, Emergency, Cart #16. S9, Pharmacy Director verified there were 9 medications expired with 6 medications that expired on 1/2010 and 3 medications expired on 2/1/10.

Record review of Emergency (Crash) Cart #16's Log revealed this cart was last checked on 9/4/09 with no documented location the cart was located in the hospital.

S8, Surgery Director was interviewed during the PACU Emergency Cart observation at 1:25 pm and confirmed there were 9 medications expired in Cart #16. He indicated Pharmacy ensures Cart #16 is inspected monthly for expired medications. In an interview with S9, Pharmacy Director on 2/4/10 at 1:45 pm, he verified there were 9 medications expired the Emergency Crash Cart #16 located in PACU with 6 medications expired on 1/2010 and 3 medications expired on 2/1/10. S9 reviewed the Emergency Crash Cart #16's Log and verified this cart was last checked on 9/4/09. S9, Pharmacy Director indicated the Crash Carts are to be inspected monthly for expired medicaitons. He reported the Carts are not routinely inspected every month or prn (as needed) to ensure there are no expired medications available patient usuage during an emergency situation.

Cart #18:

An observation was made of the Emergency Cart #18 located in ICU on 2/4/10 at 2:10 pm with S9, Pharmacy Director. The cart had an orange label noted on the outside of drawer #1 labeled, Drug Expired: 2/10, Metroprolol, Last Check: 2/1/10. There 3 expired Metroprolol noted in drawer #1 with the expiration date of 2/1/10. S9, Pharmacy Director verified the cart was last inspected by him on 2/1/10 and he did not remove the 3 expired Metroprolol vials from Cart #18.

Record review of Emergency (Crash) Cart #18's Log revealed this cart was last checked on 12/16/09 with no documented location the cart was located in the hospital with no documented no medication named first to expire on 1/10. Review of Cart #18's Log revealed there was no documented evidence the cart was last inspected on 2/1/10 by S9, Pharmacy Director.

In an interview with S9, Pharmacy Director during the observation of Cart #15 at 2:10pm, he verified there were 3 expired metrorpolol vials in Cart #18. He reviewed the cart's log and verified it was last checked on 12/16/09. He indicated he had inspected the cart on 2/1/10 but failed to remove the 3 expired medications during the carts monthly inspection.

Review of the policy titled, "Emergency Drugs: Monitoring and Inspection" Policy number: 712-03-06, Policy initiated date 7/1/09, with no revision or retired date documented, page 1 of 1, read, To provide guidelines for the monitoring and inspection of all emergency drugs stocked in the hospital. Emergency drug containers shall be checked by the pharacy at least monthly and after each use to remove outdated drugs and ensure completeness of content. This inspection shall assure that all items required for immediate availability are actually present and are in usuable condition. A record of the inspections shall include: the inspection date, location of the emergency drugs, and the signature of the inspector.

Review of the policy titled, "Crash Cart Use" Policy initiated date: 7/1/09 with no policy number, revision date or retired date documented, page 2 of 5 read, To define the process for checking and restocking Emergency "Crash" carts between and after use. Pharmacy will restock all medications and supplies. Pharmacy will check for and replace any expired supplies/medications.

Based on record reviews and interview the hospital failed to 1) ensure pharmacy packaged and dispensed the antibiotics (Rocephin and Zithromax) for administration to the patient were in a timely manner (within 2 hours of admit) by failing to have the antibiotics (Rocephin and Zithromax) available for administration to the patient for 31 hours and 36 minutes for 1 of 10 focused medical records reviewed for antibiotic intravenous administrations out of a total of 22 sampled patients, (#4) and 2) ensure the pharmacy reviewed medication orders completeness for 2 of 22 sampled patients (#1, #10) by failing to get clarification on medication orders without a dose indicated by the ordering physician. Findings:

1) Patient #4

Patient #4's medical record was reviewed. #4 was admitted to the 6th unit on 12/21/09 at 12:00 pm. There was a physician's order written for Rocephin 1 gram intravenous piggy back (IVPB) daily and Zithromax 250 mg IVPB daily. The Medication Administration revealed pharmacy recorded the antibiotics (Rocephin and Zithromax) on 12/22/09 at 7:36 am - 31 hours and 36 minutes after the patient was admitted into the hospital. Further review revealed #4 was administered the Rocephin at 9:00 am about 33 hours after her admission into the hospital and and Zithromax at 10:00 am - about 3 4 hours after she was admitted into the hospital.

An interview was conducted with S9, Pharmacy Director on 2/4/10 at 11:30 am. He indicated medications are dispensed for administration to the patient within 2 hours of their admission into the hospital. He verified Patient #4 did not receive her antibiotics (Rocephin and Zithromax) as ordered by the physician on 12/21/09 for 33 hours after she was admitted into the hospital. He confirmed pharmacy did not package and dispense the antibiotics for administration until 12/22/09 at 7:36 am (31 hours and 36 minutes). He reported the antibiotics were not dispensed as per policy within 2 hours of admission into the hospital. He continued the patient did not receive the antibiotics as ordered by the physician on 12/21/09.

2)

Patient #1

Review of the medical record for patient #1 on 02/03/10 at 11:00 a.m. revealed an order for Lotensin 10 (no measurement of dose included) one po (by mouth) daily - start now.

In an interview on 02/03/10 with S6RN, Rehab Director he indicated that the order for Lotensin required clarification of the amount of medication ordered the physician ordered.

In an interview on 02/04/10 at 9:05 a.m. with S9RpH, Pharmacy Director he confirmed the order for #1's Lotensin needed clarification and that the pharmacist should not dispense medication based on this order without clarification.

Patient #10

Review of the medical record of patient #10 on 02/03/10 at 12:30 p.m. revealed an order dated/timed 11/21/09 (no time documented) that read "30 Restoril po (by mouth) HS (hour of sleep) PRN (as needed) sleep."

In an interview on 02/04/10 at 9:05 a.m. with S9, RpH, Pharmacy Director, he indicated the medication required clarification as to the dose ordered by the physician.

Review of a hospital policy titled "Medication Orders", policy number PS.10.5-04 MM.01.01.01, date of last revision 03/09, presented as current policy, reads in part: "Purpose: To define and educate those staff members who are involved with obtaining, reviewing, and processing medication orders on the requirements and guidelines associated with the various aspects of a medication order. Policy: Medication orders will be written and processed in accordance with the provisions of this policy....Procedure. I. Required elements of a Med Order: Order for drugs shall be written on a Physician's Order Form.......Each drug order shall include: a. Patient Name b. Date of order c. Drug name, strength (and dosage form if necessary).

Based on record review and interview the hospital failed to ensure the pharmacy immediately reported a medication administration error to the attending physician for 1 of 22 sampled patients by not filling out an incident report and having no documented evidence of notification of the physician that the medication was not administered for three hours when the order was to start "now." (#1) Findings:

Review of the medical record for patient #1 on 02/03/10 at 11:00 a.m. revealed an order for Lotensin 10 (no measurement of dose included) one po (by mouth) daily - start now.

In an interview on 02/03/10 at 11:21 a.m. with S5RN she indicated she had "just administered" the medication to #1. S5RN further indicated that a "now" medication should be administered to a patient within 1-2 hours.

In an interview on 02/03/10 with S6RN, Rehab Director he indicated a "now" dose should be administered to the patient within one hour. He further indicated that the order for Lotensin required clarification of the amount of medication ordered the physician ordered.

In an interview on 02/04/10 at 9:05 a.m. with S9RpH, Pharmacy Director he confirmed the order for #1's Lotensin needed clarification, that the pharmacist should not dispense medication based on this order without clarification and that it took pharmacy over 3 hours to provide the nurse the medication. S9RpH, Pharmacy Director further indicated that "now" medications should be administered within one hour.

In the same interview S9RpH, Pharmacy Director confirmed there was no notification of the the physician responsible for the care of the patient of the late medication administration and no incident/medication variance form was filled out.

Review of a hospital policy titled "Medication Orders", policy number PS.10.5-04 MM.01.01.01, date of last revision 03/09, presented as current policy, reads in part: "Purpose: To define and educate those staff members who are involved with obtaining, reviewing, and processing medication orders on the requirements and guidelines associated with the various aspects of a medication order. Policy: Medication orders will be written and processed in accordance with the provisions of this policy....Procedure. I. Required elements of a Med Order: Order for drugs shall be written on a Physician's Order Form.......Each drug order shall include: a. Patient Name b. Date of order c. Drug name, strength (and dosage form if necessary)

Based on record review and interview the hospital failed to ensure the History and Physical (H&P) was on the patients medical record prior to surgery for 1 of 22 sampled patients (#8) by having the time on the dictated H&P indicating the report was not typed until after the patient was in surgery. Findings:

Review of the medical record on 02/03/10 at 12:50 p.m. for patient #8 revealed the H&P was typed on 01/11/10 at 9:01 a.m. Review of the Cath Lab procedure report revealed the procedure started 01/11/10 at 7:30 a.m.

In an interview on 02/04/10 at 9:30 a.m. with S21Director of Outpatient Services he confirmed that the H&P could not have been on the chart prior to the procedure as it was not yet typed.

Based on record reviews, observations and interviews, the hospital failed to:
1) ensure the nurse immediately reported a medication administration error to the attending physician for 1 of 22 sampled patients by not administering a "now" dose for over 3 hours and failing to notify the physician. (#1);
2) ensure the nurse administered the patient's oxygen therapy at 2 liters as ordered by the prescribing physician as evidenced by the patient receiving oxygen therapy at 5 liters per nasal cannula for 1 of 3 focused records reviewed out of a total of 10 of 22 sampled patients, (#3) and
3) ensure the nurse administered the patient's antibiotics as ordered by the prescribing physician in a timely manner by failing to administer the antibiotics (Rocephin and Zithromax) as ordered by the prescribing physician on 12/21/09 for 1 of 3 focused records reviewed out of a total of 10 of 22 sampled patients, (#4). Findings:

1) Patient #1:
Review of the medical record for patient #1 on 02/03/10 at 11:00 a.m. revealed an order for Lotensin 10 (no measurement of dose included) one po (by mouth) daily - start now.

In an interview on 02/03/10 at 11:21 a.m. with S5RN she indicated she had "just administered" the medication to #1. S5RN further indicated that a "now" medication should be administered to a patient within 1-2 hours.

In an interview on 02/03/10 with S6RN, Rehab Director he indicated a "now" dose should be administered to the patient within one hour. He further indicated that the order for Lotensin required clarification of the amount of medication ordered the physician ordered.

In an interview on 02/04/10 at 9:05 a.m. with S9RpH, Pharmacy Director he confirmed the order for #1's Lotensin needed clarification, that the pharmacist should not dispense medication based on this order without clarification and that it took pharmacy over 3 hours to provide the nurse the medication. S9RpH, Pharmacy Director further indicated that "now" medications should be administered within one hour.

In the same interview S9RpH, Pharmacy Director confirmed there was no notification of the the physician responsible for the care of the patient of the late medication administration and no incident/medication variance form was filled out.

2) Patient #3:
An observation was performed on Patient #3 on 2/3/10 at 10:55 am. #3 was observed wearing a nasal cannula with Oxygen at 5 liters per minute. The surveyor was accompanied by S7, RN ACNO during this observation. Another observation was conducted with S7, RN ACNO and S26, RN at 11:40 am. S7 and S26 confirmed #3's oxygen settings were at 5 liters.

Review of the medical record for patient #3 on 02/03/10 at 11:00 am revealed there was an order for Oxygen 2 liters per minute via nasal cannula written on 2/2/10 at 10:10 pm by the attending physician. S7, RN ACNO and S26, RN reviewed and verified that the attending physician's orders for oxygen were 2 liters per minute via nasal cannula.

An interview was held with on 02/03/10 at 11:40 am with S7, RN ACNO and S26, RN. They both confirmed the patient's oxygen administration was 5 liters instead of 2 liters as ordered by the attending physician. They both indicated the attending physician's orders for oxygen to be administered via nasal cannula at 2 liters per minute were not being followed.

3) Patient #4:
The medical record of Patient #4 was reviewed. #4 was admitted to the 6th unit on 12/21/09 at 12:00 pm. There was a physician's order written for Rocephin 1 gram intravenous piggy back (IVPB) daily and Zithromax 250 mg IVPB daily. The Medication Administration revealed pharmacy recorded the antibiotics (Rocephin and Zithromax) on 12/22/09 at 7:36 am - 31 hours and 36 minutes after the patient was admitted into the hospital. Further review revealed #4 was administered the Rocephin at 9:00 am about 33 hours after her admission into the hospital and and Zithromax at 10:00 am - about 3 4 hours after she was admitted into the hospital.

An interview was conducted with S9, Pharmacy Director on 2/4/10 at 11:30 am. He indicated medications are dispensed for administration to the patient within 2 hours of their admission into the hospital. He verified Patient #4 did not receive her antibiotics (Rocephin and Zithromax) as ordered by the physician on 12/21/09 for 33 hours after she was admitted into the hospital. He confirmed pharmacy did not package and dispense the antibiotics for administration until 12/22/09 at 7:36 am (31 hours and 36 minutes). He reported the antibiotics were not dispensed as per policy within 2 hours of admission into the hospital. He continued the patient did not receive the antibiotics as ordered by the physician on 12/21/09.

Review of a hospital policy titled "Medication Orders", policy number PS.10.5-04 MM.01.01.01, date of last revision 03/09, presented as current policy, reads in part: "Purpose: To define and educate those staff members who are involved with obtaining, reviewing, and processing medication orders on the requirements and guidelines associated with the various aspects of a medication order. Policy: Medication orders will be written and processed in accordance with the provisions of this policy....Procedure. I. Required elements of a Med Order: Order for drugs shall be written on a Physician's Order Form.......Each drug order shall include: a. Patient Name b. Date of order c. Drug name, strength (and dosage form if necessary)