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Based on a review of medical records, facility policies and procedures, and staff interviews, it was determined that nursing staff failed to ensure that one patient (P) (P#1) of three patients (P#1, P#2, and P#3) reviewed received a medication as ordered by the physician. Specifically, the nursing staff failed to administer the medication, Zenpep (a digestive enzyme supplement used to replace enzymes when the body does not have enough of its own) to P#1 as per physician orders.


Findings include:


A review of medical records revealed that P#1 arrived at the facility's emergency department (ED) on 11/3/25 at 3:42 p.m. with a diagnosis of gastrointestinal bleeding (blood loss from the digestive tract due to injury or disease).


A review of the Medication Administration Record (MAR) revealed the following active orders for Zenpep:
" An order dated 11/5/25 at 11:40 a.m. for Zenpep 40,000 units, two capsules with meals and one capsule with snacks, up to eight times per day.
" An order dated 11/5/25 at 12:27 p.m. for Zenpep with similar dosing instructions on a PRN basis.
" An order dated 11/5/25 at 1:10 p.m. for Zenpep to be administered two times daily with meals.


Documentation revealed that Zenpep was administered on 11/5/25 at 2:51 p.m. The documentation failed to reveal additional doses for 11/5/25.


Documentation revealed Zenpep was administered on 11/7/25 at 10:45 a.m. The documentation failed to reveal additional doses for 11/7/25.


A review of the facility's policy titled "Medication Management," policy #18762131, last revised 10/2025, revealed that medications were to be administered as ordered. For medication administration to be considered "timely," medications must be administered within a 2-hour window (1 hour before the scheduled time and up to 1 hour after).


A review of the facility's policy titled "Assessment and Reassessment," policy #17240230, last revised 2/2025, revealed that all patient care providers were involved in the provision of patient care, including the assessment of patient needs; planning care, treatment, or services; providing care, treatment, or services; and coordinating care treatment or services at the facility.


A telephone interview was conducted in the facility's conference room on 12/23/25 at 9:20 a.m. with Gastroenterologist (GST) AA, who stated that the medication (Zen-pep) was important, but it would not affect P#1's overall level of care, and the goal was to administer the medication two to three capsules (60,000 to 80,000 units) with meals depending on the strength of the medication. GST AA stated that if a dose was missed, it could cause increased diarrhea.


An interview was conducted in the facility's conference room on 12/23/25 at 10:00 a.m. with Charge Nurse (CN) CC, who stated that he had requested that GST AA add a PRN (as required) dose of the medication for P#1, so the medication could be taken at any time when P#1 was eating instead of the scheduled dose, which may be challenging due to the different timings in meal time and medication administration time.

Based on review of medical records, facility policies, and staff interviews, the facility's staff failed to ensure complete and accurate documentation of blood transfusion administration. Specifically, the facility failed to document the end time of a blood transfusion for one patient (P) (P#1) of three patients reviewed (P#1, P#2, and P#3).


Findings include:


A review of medical record revealed that P#1 arrived at the facility's emergency department (ED) on 11/3/25 at 3:42 p.m. with a diagnosis of gastrointestinal bleeding (blood loss from the digestive tract due to injury or disease).


A review of the physician orders revealed that one unit of packed red blood cells (RBCs- concentrated form of red blood cells used to treat significant blood loss or severe anemia) was ordered for P#1 on 11/6/25 at 4:17 a.m.
A continued review of P#1's medical record revealed the blood transfusion was initiated on 11/6/25 at 7:46 a.m. Documentation failed to reveal when the blood transfusion was completed. Additionally, there was no documentation to demonstrate that post-transfusion monitoring and completion requirements were met.


A review of the facility's policy titled "Patient Rights," policy #13838417, last approved 7/2023, revealed that all patients were to be treated in a manner that preserved their dignity, autonomy, self-esteem, civil rights, and involvement in their own care. Patients had the right to receive considerate and respectful care, including consideration of cultural, spiritual, psychosocial, and personal values, beliefs, and preferences.


A review of the facility's policy titled "Blood and Blood Components Administration/Auto Transfusion," policy #12690842, last approved 7/2023, revealed that RN, LPN, Physician, or APP should remove the blood bag and tubing when blood administration is completed. The blood administration tubing and blood filter could be used for the infusion of up to two units of blood, but no longer than four hours from the time of initial use.
The RN, LPN, Physician, or APP should obtain post-transfusion vital signs and complete the transfusion in the Epic blood administration flow sheet.
The RN, LPN, Physician, or APP should document the amount of blood product infused in the Epic blood administration flow sheet.
The RN, LPN, Physician, or APP should document the patient's tolerance and significant findings in the medical record.


An interview was conducted in the facility's conference room on 12/23/25 at 11:15 a.m. with Registered Nurse (RN) EE, who stated that she could not recall if P#1 had a blood transfusion, and why the stop time was not documented.


An interview was conducted in the facility's conference room on 12/23/25 at 11:25 a.m. with Patient Safety Manager (PSM) JJ, who stated that the stop-time of the blood transfusion should have been documented in the electronic medical record (EMR).