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Citation Text for Tag 0144, Regulation FA28

Based on interview and record review the hospital failed to provide a safe environment for one of one patient
(Patient #2) who's medical health declined after transfer to the hospital's rehabilitation unit. There, the patient received multiple sedating medications including opioids, and required hospital emergent medical interventions twice within six hours.

Findings included:

During an interview on 10/18/22 at 10:36 AM, Personnel #10 stated patient #2 had been "doing fine until she was transferred over to the rehabilitation unit and there was an issue with the stacking of medication by the nurse." Personnel #10 stated "they needed to address their PRN order sets and education to nursing regarding the stacking of medications."

Record review of patient #2 Rapid Response Sheets dated 10/14/22 at 0345 and 10/14/22 at 0917 reflected the patient needed rapid emergency medical intervention for "acute decrease in LOC" (level of consciousness). The patient required increased administration of oxygen, three doses of Narcan and one dose of Romazicon, during the first Rapid Response. The patient received an additional dose of Narcan during the second Code Rapid Response.

Record review of patient #2's medication order dated 10/13/22 reflected the patient was to receive Lyrica 25mg at 2200. The MAR reflected that Personnel #13 administered Lyrica 25mg at 2105.

Record review of patient #2's medication order dated 10/13/22 reflected the patient was to receive Melatonin 10mg at bedtime. The MAR reflected that Personnel #13 administered Melatonin 10mg on 10/13/22 at 2105.

Record review of patient #2's medication order dated 10/13/22 reflected the patient was to receive Atarax 25mg at bedtime prn, Klonopin 0.5mg twice a day as needed, Restoril 15mg as needed, Norco 5mg/325mg every four hours as needed for pain, Morphine 15mg three times a day as needed for severe pain, and Tylenol 650mg every 4 hours as needed for pain. The MAR reflected that Personnel #13 administered Atarax 25mg on 10/13/22 at 2107, Klonopin 0.5mg at 2107, Restoril 15mg at 2107, Norco 5mg/325mg at 2107, Morphine 15mg at 2315, Restoril 15mg at 2315, and Tylenol 650mg at 2315.

During an interview on 10/18/22 at 3:55 PM, Personnel #6 confirmed Personnel #13 administered to patient #2 Lyrica 50mg and Melatonin 10mg on 10/13/22 at 2105, Klonopin 0.5mg, Norco 5mg/325mg, Atarax 25mg, and Restoril 15mg on 10/13/22 at 2107, Morphine 15 mg, Tylenol 650 mg and Restoril 15 mg at 2315 resulting in a Code Rapid Response.

During an interview on 10/18/22 at 3:26 PM, Personnel Physician# 10 confirmed patient #2 "received multiple sedating medications resulting in two Code Rapid Responses."

The CDC (Centers for Disease Control) website stated that Narcan (Naloxone) was a "life-saving medication" that could "reverse an overdose from opioids."

Citation Text for Tag 0398, Regulation FA28

Based on record review and interview, the hospital failed to ensure that all licensed nurses who provided services in the hospital adhered to the policies and procedures of the hospital. One of one patient (Patient #1) did not receive medications according to the hospital protocol and subsequently experienced a decline in their health and required emergency medical interventions by the hospital Code Rapid Response Team.

Findings included:

Record review of Hospital titled Medication Administration and dated 07/25/22 reflected that "all medications should be administered within one hour of scheduled time" (page 2).

Record review of patient #1's medication order dated 09/18/22 reflected the patient was to receive Flexeril 5mg and Trazadone 100mg by mouth at 2100. The MAR (Medication Administration Record) reflected Personnel #13 administered Flexeril 10mg and Trazadone 100mg by mouth to patient #1 on 09/18/22 at 1915

Record review of patient #1's medication order dated 09/18/22 reflected the patient was to receive Ultram 50mg and Neurontin 200mg by mouth at 2200. The MAR reflected that Personnel #13 administered both medications on 09/18/22 at 1915.

Record review of patient #1's medication order dated 09/19/22 reflected the patient was to receive Ultram 50mg and Neurontin 200mg by mouth at 0600. The MAR reflected that Personnel #13 administered both medications on 09/18/22 at 0342.

During an interview on 10/18/22 at 12:39 PM, Personnel #3 confirmed Personnel #13 administered to patient #1, Flexeril 10mg on 09/18/22 at 1915, one hour and 45 minutes prior to scheduled time, Trazadone 100mg at 1915, one hour and 45 minutes prior to scheduled time, Ultram 50mg and Neurontin 200mg at 1915, two hours and 45 minutes prior to scheduled time.

During an interview on 10/18/22 at 3:26 PM, Personnel Physician# 10 confirmed patient #1 was overmedicated leading to a Code Rapid Response.