HospitalInspections.org

Based on record reviews and interviews the hospital failed to meet the Condition of Participation for Governing Body as evidence by:

1. Failing to ensure contracted pharmacy services were provided in a manner which enabled the hospital to remain in compliance with the Condition of Participation of Pharmacy Services. This was evident by the contracted pharmacist not providing required supervision over the pharmacy services to ensure the hospital had implemented a system to monitor for medication errors. This failure resulted in the hospital having 203 medication errors between the dates of 1/22/2011and 1/23/2011. (Deficiency cited at A0266)

2. Failing to ensure that the contracted pharmacy provide timely delivery of medications 24 hours a day, 7 days a week to allow for administration of medications in accordance with the orders of the physician. The medications were being shipped from the contracted pharmacy via UPS Ground requiring up to 43 hours to arrive at the hospital after being ordered, delaying administration to the patients. This failure resulted in 126 medication errors for 11 of 11 patients sampled. (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) ( Deficiency cited at A0501)

Based on record review and interview the Hospital failed to meet the Condition of Participation for Pharmacy as evidenced by:

1. Failing to ensure the contracted pharmacist was responsible for the overall administration, supervision, and coordination of pharmacy services provided to the hospital. This was evident by the contracted pharmacist not providing required supervision over the pharmacy services to ensure the hospital had implemented a system to monitor for medication errors. This failure resulted in the hospital having 203 medication errors between the dates of 1/22/2011and 1/23/2011 and failing to ensure that variance reports were completed when medication were missed. (see findings at A0492)

2. Failing to ensure that medications were delivered in a manner that meets the needs of the patient and the orders of the physician responsible for the care of the patient for 11 of 11 sampled patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) as evidenced by medications being shipped via UPS Ground requiring up to 43 hours to arrive at the hospital after being ordered, delaying administration to the patient. Review of these 11 medical records revealed 126 medication errors.(see findings at A0501)

26458


Based on record reviews and interviews the hospital failed to ensure a pharmacist was responsible for the overall administration, supervising, and coordinating all activities of pharmacy services provided to the hospital as evidenced by the Contracted pharmacy "a" not ensuring timeliness of medication deliveries and first dose medications, not overseeing medication errors, and variance reports. Findings:

Review of the Pharmacy and Therapeutics meeting dated 12/20/2010,revealed S1, S2, S15, S16 (via telephone conference) and, S22 MD were present for the meeting. Review of the new or changed business policies/procedures revealed a discussion about the selection of meds/IV antibiotics, administration of meds/in need of a preprinted MARS, the amount of time spent by staff to first dose at Pharmacy "c", if timeliness of med deliveries/courier service. The medication error review revealed A. October- six medication errors were reported, five transcription related, two of the five noted order and did not place it on the MAR, and one mislabeled blister pack. B. November- eight medication errors she reported, one availability issue and not available as first dose, for packaging/dispensing errors, two wrong medications pulled from ER kit at when card of medications was available in the med cart and given both by PRN nurse, and one transcription era that was a near miss. C. Plan of action taken- fax pharmacy issues they were involved in and called and documented on investigation form of occurrence reports, and education and counseling sessions with nursing staff.

A telephone interview was held with S16 Contracted Pharmacist on 1/24/2011 at 3:25 PM. He indicated he works as an outside consultant for Contracted Pharmacy "a". He reported that there was no collaboration between pharmacy and nursing to ensure the drug to drug interactions for patients. S16 indicated S2 DON sent him medication errors to review in January 2011 but did not send the information to Contracted Pharmacy "a" . He indicated this data does not help him since he did not have access to patient demographics or to their database. S16 added that medication errors and omissions or not getting to the pharmacy. He further indicated the only pharmacy issues he deals with at the hospital during his visits or to ensure narcotics are correct, the correct ship date, that the narcotics are signed out, and that the medicine room is locked. S16 Contracted Pharmacist indicated he was never given authority by the hospital nor was he delegated with the policies and procedures of what was required of him as a contracted pharmacist with Contracted Pharmacy " a " .

A telephone interview was conducted with S7, Owner of Contracted Pharmacy "a" and S13 Pharmacy Manager of Contracted Pharmacy "a" on 1/24/2011 at 1:15 PM. He indicated that S16 was a consulting pharmacist contracted through his company. He added that S16 should be reviewing medications to ensure that the hospital is in compliance with the regulations. S13 indicated to her knowledge the hospital had a zero percent medication error rate and that the pharmacy had not been contacted or notified of any medication errors since the hospital opened in March 2010. S13 indicated that if the hospital does not hear back from a pharmacist related to 1st dosing of medications after 30 to 45 minutes, the nurse should assume that there are no drug to drug interactions and proceed with the administration of the first dose medications. She added there is not a policy or procedure that addresses this issue.

Review of a document from (contracted pharmacy " a " ) marked " exhibit " a " , titled " Procedure - Facility Procedures; 3/15/2010 reads in part: " 2. New Patient...Prescriptions received for new residents and/or new prescription order at the facility will be delivered the same day the pharmacy receives the prescription order ... "

26458


Based on record review and interview the hospital's contracted pharmacy failed to ensure that medications were dispensed in a manner that meets the needs of the patient and the orders of the physician responsible for the care of the patient for 11 of 11 sampled patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) as evidenced by medications being shipped via UPS Ground requiring up to 43 hours to arrive at the hospital after being ordered, delaying administration to the patient. Review of these 11 medical records revealed 126 medication errors. Findings:

Patient #1 - Review of the medical record for Patient #1 revealed she was admitted to the hospital on 1/13/2011 at 10:30 PM with diagnosis that included Schizoaffective Disorder, Chronic/Deferred and post operative cholecystectomy. Admission Physician Orders on 1/13/2011 revealed medication orders for Azopt (ophthalmic) 1 drop three times a day, Nexium 40 milligrams(mgs) PO Daily, Micatin powder 1 application under breast twice a day, Timolol (ophthalmic solution) 1 drop to left eye twice daily. Additional Physician Orders were written on 1/14/2011 at 4:30 PM for Flush Protocol for Peripherally Inserted Central Catheter (PICC) line (every 12 hours).

Review of the Medication Administration Record (MAR) revealed she did not receive the following 13 medications as ordered by the practitioner: on 1/13/2011 Timolol (ophthalmic solution) at 9:00 PM, on 1/14/2011 Azopt (ophthalmic) drops at 3:00 PM, Nexium 40 mgs at 9:00 AM, Micatin powder 1 application under breast at 9:00 AM, and Timolol (ophthalmic solution) at 9:00 AM and 9:00 PM, on 01/15/2011 Azopt (ophthalmic) drops at 3:00 PM, on 1/16/2011- 1/20/2011 Protocol Flush for Peripherally Inserted Central Catheter (PICC) line (every 12 hours) at 9:00 AM and 9:00 PM on 1/16/2011. On 1/17/2011, 1/18/2011 at 9:00 PM, 1/19/2011, and on 1/20/11 for the 9:00 AM scheduled flushes.

Review of documentation faxed to DHH/HSS FO3 on 01/20/11 at 9:53 a.m. from contracted pharmacy "a" revealed that the package containing the Timolol, Azopt and Nexium for Patient #1 was processed at the pharmacy on 01/14/11 and shipped to Seaside Health System via UPS Ground on 01/14/11. Further review of the UPS label revealed the medications for Patient #1 were received on 01/15/11 at 11:45 a.m. at Seaside Health System. This resulted in a 37 hour and 15 minute delay in physician ordered
medications for patient #1 to be available for administration.

Patient #2 - Review of the medical record for Patient #2 revealed she was admitted to the hospital on 1/13/2011 at 4:10 PM with diagnoses that included Schizophrenia and Congestive Heart Failure.

Admission Physician Orders on 1/13/2011 revealed medication orders for Trazodone 150 mg at bedtime, Depakote ER 750 mg at bedtime, Ativan 1 mg at bedtime, Seroquel 300 mg at bedtime, Glucotrol XL 2.5 mg daily at 5:00 PM, and Cogentin 1 mg three times a day.

Review of the Medication Administration Record (MAR) revealed she did not receive the following 7 medications as ordered by the practitioner: on 01/13/2011 Glucotrol XL 2.5 mg daily at 5:00 PM, Trazodone 150 mg at bedtime, Depakote ER 750 mg at bedtime, Ativan 1 mg at bedtime, Seroquel 300 mg at bedtime, and Cogentin 1 mg at 9:00 PM. On 1/14/2011 Cogentin 1 mg at 9:00 AM and 3:00 PM.

Review of documentation faxed to DHH/HSS FO3 on 01/20/11 at 9:53 a.m. from contracted pharmacy "a" revealed that the package containing the Glucotrol, Trazodone, Depakote, Ativan and Seroquel for Patient #2 was processed at the pharmacy on 01/14/11 and shipped to Seaside Health System via UPS Ground on 01/14/11. Further review of the UPS label revealed those medications for Patient #2 were received on 01/15/11 at 11:45 a.m. at Seaside Health System. Further review revealed the Cogentin was on the shipment dated 01/17/11 (Monday) that arrived at Seaside Health Systems on 01/18/11 at 10:32 a.m. This resulted in a 43 hour and 35 minute delay in physician ordered medications for patient #2 to be available for administration.

Patient #3 - Review of the medical record for Patient #3 revealed she was admitted to the hospital on 1/18/2011 at 3:20 PM with diagnoses that included Schizophrenia, Urinary Tract Infection, and Hypertension. Admission Physician Orders on 1/18/2011 for Benztropine 1 mg twice a day, Seroquel 600 mg at bedtime, Fanapt 8 mg daily, and Potassium Chloride ER oral 20 mEq twice a day. Further review of the physician order on 1/18/2011 at 9:25 PM revealed an order that read, "OK to start medication in AM 1/19/2011." Review of physician orders 1/19/2011 at 8:30 AM revealed additional orders for Albuterol 2.5 mg 13 ml nebs every 8 hours, Benztropine 1 mg daily, Lasix 20 mg every day, Omeprazole 20 mg every morning and thiamine 10 mg daily.

Review of the Medication Administration Record (MAR) revealed she did not receive the following 21 medications as ordered by the practitioner: On 1/19/2011 Seroquel 600 mg at 9:00 PM, Fanapt 8 mg at 9:00 AM, Potassium Chloride ER oral 20 mEq at 9:00 PM, Albuterol 2.5 mg 13 ml nebs at 2:00 PM and 10:00 PM, Benztropine 1 mg at 9:00 AM, Lasix 20 mg at 9:00 AM, Omeprazole 20 mg at 9:00 AM, Thiamine 10 mg at 9:00 AM, Albuterol 2.5 mg 13 ml nebs at 2:00 PM and 10:00 PM. On 1/20/2011 Fanapt 8 mg at 9:00 AM, Potassium Chloride ER oral 20 mEq at 9:00 PM, Albuterol 2.5 mg/3 ml nebs at 6:00 AM, Benztropine 1 mg at 9:00 AM, Lasix 20 mg at 9:00 AM, Omeprazole 20 mg at 9:00 AM, Thiamine 10 mg at 9:00 AM, Lasix 20 mg at 9:00 AM.

Patient #4 - Review of the medical record for Patient #4 revealed he was admitted to the hospital on 1/11/2011 at 3:50 PM with a diagnoses of Schizophrenia and an assessment of malnutrition. Admission Physician Orders on 1/11/2011 revealed a medication order for Multivitamin Daily.

Review of the Medication Administration Record (MAR) revealed he did not receive the following 3 medications as ordered by the practitioner: for 1/14/2011, 1/15/2011, and 1/20/2011 Multivitamin at 9:00 AM.

Patient #5 - Review of the medical record for Patient #5 revealed she was admitted to the hospital on 1/17/2011 at 3:50 PM with diagnoses of Major Depression, recurrent, severe without psychosis. Admission Physician Orders on 1/17/2011 revealed a medication order for Multivitamin Daily and on 1/18/2011 an order for Remeron 15 mg at bedtime.

Review of the Medication Administration Record (MAR) revealed she did not receive the following 2 medications as ordered by the practitioner: On 1/19/2011 Remeron 15 mg at 9:00 PM, and on 1/20/2011 Multivitamin at 9:00 AM.

An interview was held with S2 Director of Nurses on 1/24/11 at 1:00 PM. After review of the medical records for Patient ' s #1, #2, #3, #4, and #5, she confirmed all of the missed doses of medications for these patients and could offer no explanation why the medications had not been administered as ordered. She further indicated that no variance reports had been completed by the nurses. She reported there was no documentation in the medical record that the attending physician had been notified of the missed doses of medications. S2 added that no QA related to missed medications had been started before 1/22/11.

Patient #6 - Review of the Medical Record for Patient #6 on 01/20/11 at 10:30 a.m. revealed the following:

The patient was admitted to Seaside Health System on 01/12/11 at 1950 (7:50 p.m.). Review of the Medication Administration Record (MAR) revealed she did not receive the following 23 medications as ordered by the practitioner. The following medications were ordered by the physician and not administered to the patient: Evoxac 30 mg (milligrams) peg (percutaneous endogastric tube) tid (3 times daily) at 2100 (9:00 p.m.) on 01/12/11 and 9:00 a.m. on 01/13/11. (note on MAR reads: ordered pharmacy), Advair Diskus 1 puff bid (twice a day) at 2100 (9:00 p.m.) on 01/12/11, 9:00 a.m. and 2100 (9:00 p.m.) on 01/13/11, and 9:00 a.m. on 01/14/11. (note on MAR reads: ordered pharmacy), Betapace 80 mg peg bid at 2100 (9:00 a.m.) on 01/12/11. (note on MAR reads: ordered pharmacy), Astalin 137 mcg (micrograms) 1 spray each nostril bid at 2100 (9:00 p.m.) on 01/12/11, 9:00 a.m. and 2100 (9:00 p.m.) on 01/13/11, 9:00 a.m. on 01/14/11, and 9:00 a.m. on 01/16/11. (note on MAR reads: ordered pharmacy), Pepcid 20 mg peg bid at 2100 (9:00 p.m.) on 01/12/11, 9:00 a.m. and 2100 (9:00 p.m.) on 01/13/11. (note on MAR reads: ordered pharmacy), Synthroid 50 mcg peg daily at 6:30 a.m. on 01/17/11, Docusate Sodium 15 ml (milliliters) peg daily at 9:00 a.m. on 01/19/11, Seroquel 25 mg peg 12:00 noon on 01/18/11, Gabiscon 30 ml peg bid at 9:00 a.m. and 2100 (9:00 p.m.) on 01/17/11, 9:00 a.m. and 2100 (9:00 p.m.) on 01/18/11. On 01/19/11 at 1500 (3:00 p.m.) a dose that was not ordered was administered.

In an interview on 01/21/11 at 12:45 p.m. with S2DON she confirmed the 23 medication errors on Patient #6. S2DON further stated that there were no medication variance reports filled out and there was no notification of the physician or the pharmacy for any of the 23 medication errors.

Review of documentation faxed to DHH/HSS FO3 on 01/20/11 at 9:53 a.m. from contracted pharmacy "a" revealed that the package containing the Evoxac, Advair Diskus, Betapace, Astalin, Pepcid Synthroid, Docusate and Seroquel for Patient #6 was processed at the pharmacy on 01/13/11 and shipped to Seaside Health System via UPS Ground on 01/13/11. Further review of the UPS label revealed the medications for Patient #6 were received on 01/14/11 at 11:12 a.m. at Seaside Health System. This resulted in a 39 hour and 22 minute delay in physician ordered medications for patient #6 to be available for administration.

Patient #7 - Review of the Medical Record for Patient #7 on 01/20/11 at 9:00 a.m. revealed the following:

The patient was admitted to Seaside Health System on 01/12/11 at 1950 (7:50 p.m.). The following medications were ordered by the physician and not administered to the patient:
Spiriva 10 mcg inhalation daily for 9:00 a.m. on 01/12/11, and 9:00 a.m. for 01/13/11, Advair Diskus 250/50 one puff twice daily for 2100 (9:00 p.m.) for 01/12/11 and 9:00 a.m. and 2100 (9:00 p.m.) for 01/13/11 (note reads: ordered pharmacy).

In an interview on 01/24/11 at 9:40 a.m. with S2DON she confirmed the 5 medication errors on Patient #7. S2DON further stated that there were no medication variance reports filled out and there was no notification of the physician or the pharmacy for any of the 5 medication errors.

Review of documentation faxed to DHH/HSS FO3 on 01/20/11 at 9:53 a.m. from contracted pharmacy "a" revealed that the package containing the Spiriva and Advair Diskus for Patient #7 was processed at the pharmacy on 01/13/11 and shipped to Seaside Health System via UPS Ground on 01/13/11. Further review of the UPS label revealed the medications for Patient #6 were received on 01/14/11 at 11:12 a.m. at Seaside Health System. This resulted in a 39 hour and 22 minute delay in physician ordered medications for patient #7 to be available for administration.

Patient #8 - Review of the Medical Record for Patient #8 on 01/20/11 at 9:30 a.m. revealed the following:

The patient was admitted to Seaside Health System on 01/10/11 at 1630 (4:30 p.m.). The following medications were ordered by the physician and not administered to the patient: Clonazepam 0.5 mg po tid for 1730 (5:30 p.m.) on 01/10/11 and 1730 (5:30 p.m.) on 01/19/11, Cogentin 1 mg po bid for 9:00 a.m. on 01/12/11 and 9:00 a.m. on 01/15/11, Zyprexa 20 mg po at bedtime for 2100 (9:00 p.m.) on 01/15/11, Haldol 20 mg po bid for 2100 (9:00 p.m.) for 01/15/11, Amaryl 2 mg po before breakfast for 6:30 a.m. on 01/17/11.

In an interview on 01/24/11 at 9:40 a.m. with S2DON she confirmed the 7 medication errors on Patient #8. S2DON further stated that there were no medication variance reports filled out and there was no notification of the physician or the pharmacy for any of the 7 medication errors.

Review of documentation faxed to DHH/HSS FO3 on 01/20/11 at 9:53 a.m. from contracted pharmacy "a" revealed that the package containing the Clonazepam, Cogentin, Zyprexa, Haldol, and Amaryl for Patient #8 was processed at the pharmacy on 01/10/11 and shipped to Seaside Health System via UPS Ground on 01/10/11. Further review of the UPS label revealed the medications for Patient #8 were received on 01/11/11 at 11:20 a.m. at Seaside Health System. This resulted in a 18 hour and 50 minute delay in physician ordered medications for patient #8 to be available for administration.

Patient #9 - Review of the Medical Record for Patient #9 on 01/20/11 at 11:00 a.m. revealed the following:

The patient was admitted to Seaside Health System on 01/18/11 at 10:00 a.m. The following
medications were ordered by the physician and not administered to the patient: Nasonex nasal spray each nostril at bedtime for 2100 (9:00 p.m.) on 01/18/11. (note on MAR reads: "on order"), Combivent Inhaler 2 puffs 4 times a day for 1300 (1:00 p.m.), 1700 (5:00 p.m.), and 2100 (9:00 p.m.) on 01/18/11. (note on MAR reads: " on order " ), Clindamycin 450 mg po tid for 1500 (3:00 p.m.) and 2100 (9:00 p.m.) on 01/18/11. (note on MAR reads: "on order"), Sahris 10 mg sublingual bid for 2100 (9:00 p.m.) on 01/18/11. (note on MAR reads: "on order").

In an interview on 01/24/11 at 9:40 a.m. with S2DON she confirmed the 7 medication errors on Patient #9. S2DON further stated that there were no medication variance reports filled out and there was no notification of the physician or the pharmacy for any of the 7 medication errors.

Patient #10 - Review of the Medical Record for Patient #10 on 01/20/11 at 10:00 a.m. revealed the following:

The patient was admitted to Seaside Health System on 01/10/11 at 2345 (11:45 p.m.). The following medications were ordered by the physician and not administered to the patient: Clorazil 300 mg po qhs (bedtime) for 2100 (9:00 a.m.) on 01/10/11, and for 2100 (9:00 a.m.) on 01/10/11, Lithium 450 mg po bid for 9:00 a.m. on 01/15/11, 2100 (9:00 p.m.) on 01/19/11, and 9:00 a.m. on 01/20/11, Clorazil 350 mg po qhs for 2100 (9:00 p.m.) for 01/19/11, Depakote ER (extended release) 750 mg po for 2100 (9:00 p.m.) for 01/19/11.

In an interview on 01/24/11 at 10:40 a.m. with S2DON she confirmed the 7 medication errors on Patient #10. S2DON further stated that there were no medication variance reports filled out and there was no notification of the physician or the pharmacy for any of the 7 medication errors.

Patient #11 - Review of the Medical Record for Patient #11 on 01/20/11 at 12:30 p.m. revealed the following:

The patient was admitted to Seaside Health System on 01/10/11 at 1830 (6:30 p.m.) The following medications were ordered by the physician and not administered to the patient: Clonidine 0.3 mg po for 2100 (9:00 p.m.) on 01/10/11, and 1500 (3:00 p.m.) on 01/16/11, Combivir 150-300 mg orally bid for 2100 (9:00 p.m.) on 01/10/11, Benadryl 50 mg po qhs for 2100 (9:00 p.m.) on 01/10/11, Docusate Calcium 240 mg po bid for 2100 (9:00 p.m.) on 01/10/11, Gabapentin 300 mg po tid for 2100 (9:00 p.m.) on 01/10/11, Haldol 5 mg po qhs for 2100 (9:00 p.m.) on 01/10/11, Kaletra 200/50 po bid for 2100 (9:00 p.m.) on 01/10/11, Lorazepam 1 mg po tid for 2100 (9:00 p.m.) on 01/10/11, Lyrica 50 mg po tid for 2100 (9:00 p.m.) on 01/10/11, Naproxen Sodium 220 mg 2 tabs bid for 2100 (9:00 p.m.) on 01/10/11, Seroquel 50 mg po bid for 2100 (9:00 p.m.) on 01/10/11, Tamulosin HCl 0.4 mg po bid for 2100 (9:00 p.m.) on 01/10/11, Nystatin Cream to catheter bid for 2100 (9:00 p.m.) on 01/10/11, 9:00 a.m. and 2100 (9:00 p.m.) for 01/11/11, and for 9:00 a.m. for 01/13/10, Zosyn 2.25 gm IVPB (intravenous piggyback) every 8 hours for 7 days (ordered 01/11/11 at 8:15 a.m.) for 2 doses prior to order to D/C on 01/11/11 at 1700 (5:00 p.m.). Same order re-written 01/12/11 at 8:00 a.m. Dose missed for 6:00 a.m. on 01/17/11. Dose missed for 1400 (2:00 p.m.) on 01/18/11, Celexa 20 mg po q AM ordered 01/11/11 at 1530 (3:30 p.m.) for 9:00 am on 01/12/11, Spiriva 1 puff qhs for 2100 (9:00 p.m.) on 01/11/11, Lyrica 50 mg po tid for 9:00 a.m. on 01/12/11, 1500 (3:00 p.m.) on 01/16/11 and 1500 (3:00 p.m.) and 2100 (9:00 p.m.) on 01/17/11 and for 9:00 a.m. for 01/18/11, Lorazepam 1 mg po tid for 1500 (3:00 p.m.) on 01/16/11, Didanosine ER 400 mg qAM for 9:00 a.m. on 01/16/11, and Simvastatin 20 mg po daily for 9:00 a.m. on 01/16/11.

In an interview on 01/21/11 at 12:15 p.m. with S2DON she confirmed the 31 medication errors on Patient #11. S2DON further stated that there were no medication variance reports filled out and there was no notification of the physician or the pharmacy for any of the 31 medication errors.

Review of the content list of a package shipped via UPS ground on 01/11/11 at 7:47 p.m. C.O.D. from contracted pharmacy "a" revealed it contained the Zosyn, Lorazepam, Seroquel, Tamsulosin, Simvastatin, Clonidine, Haldol, Spiriva, and Nystatin medications ordered for patient #11. The package is date/time stamped as received at Seaside Health Systems with a signature and $1598.91 "collected" . This time was 25 hours and 17 minutes after the physician ordered the medications for patient #11.

Review of a contracted pharmacy "a" document titled "Procedure - Facility Procedures" dated 03/15/2010, labeled " Internal Document Confidential, read in part: "...2. New Patient:..Prescriptions received for new residents and/or new prescription order at the facility will be delivered the same day the pharmacy receives the prescription order ..."

Based on record review and interviews the hospital failed to have a process for identification and reduction of medication errors as evidenced by having no documented evidence of medication variances that were being monitored by the hospital which resulted in 203 medication errors that occurred since admission and identified by the Director of Nurses during an audit of medications on 1/22/2011 and 1/23/2011 for patients currently in the hospital. Findings:

Review of the hospital Policies and Procedures titled Medication Errors/Occurrence Report revealed in part " ... A medication error is defined as any deviation from establish policies and/or procedures during the prescribing, transcribing, dispensing, administering, and monitoring at the drug. Medication errors will be reported to the ordering physician. Medication errors will be reported to the pharmacist. Medication errors will be investigated, analyzed, and trended through risk management in collaboration with pharmacy; and reported through facility appropriate committees (i.e. Quality Council, Medical Staff, Pharmacy and Therapeutics, etc) ... "

Review of the hospital Policies and Procedures titled Medication Administration Record revealed in part " ... Purpose is to reduce medication administration errors. 3. Orders on medications are transmitted to the pharmacy for the purposes of providing ordered medications and maintaining records of medications ordered for each patient. 4. Certain medications will be maintained on the unit as " stock meds " 6. Medication may be administered 30 minutes before or 30 minutes after the established time. 8. Each medication is documented on the MAR after it is taken by the patient. 9. If the patient refuses to take a prescribed medication or it is not available to take a medication when ordered, the nurse must document the medication as if it was given, circled the notation, and document the reason the medication was not given ... "

Review of the Pharmacy and Therapeutics Meeting from 12/20/2010 revealed no documentation related to medication variance reports by Nursing or that were identified by Pharmacy for the 21 medications errors identified by the hospital from October 2010 to December 16, 2010.

Review of the Policy and Procedure from Contracted pharmacy "a" dated 3/15/2010 revealed in part "... 8. Therapeutics Committee/Performance Improvement Committee: A Contracted pharmacy "a" representative will be available to participate in the Pharmacy and Therapeutic Committee and when necessary the Performance Improvement Committee. The meeting will be approximately one hour during business hours no more than once a month..."

Review of the QA/PI Meeting Minutes from 1/06/2011 revealed no documentation of indicators related to medication administration errors, no medication variance reports, combined with not having documentation that the attending physicians had been notified of omissions of medication or that medication errors had been documented and were identified in QA/PI.

An interview was held with S1 Administrator, S2 Director of Nurses, and S15 Clinical Director of Psych and QA/PI on 1/21/ 2011 at 12:15 PM. She reported no medication variance reports or documentation that the attending physicians had been notified of omissions of medication or of medication errors had been documented. She added that three medication errors had been identified though Quality Assurance (QA) in November and December of 2010. She indicated that no QA/PI that had been conducted related to the contracted pharmacy and the missed doses of medications. She further indicated that no one in administration had been checking the medical records behind nurses to analyze and ensure that the 24 hour chart checks were accurate relating to medication administration, availability, and accuracy.

An interview was held on 1/24/201 at 10:00 a.m. with S1 DON. She indicated that she had personally checked all medications and MARS over the weekend of the patients in the hospital. She reported the total number of individual medication doses missed were 203. She added there were a total of 3635 opportunities for medication administration. This is a medication error rate of 6%. S1 DON indicated this is the first QA that had been performed at the hospital related to missed doses of medications. She further indicated that no variance reports had been completed or sent to the pharmacy for these missed medications.

26458


Based on record review (policy and procedures), and interview, the Registered Nurse 1) failed to ensure that medications were administered to patients as ordered by the physician responsible for the care of the patient as evidenced by 203 medication errors on current patients not being identified for 11 of 11 sampled patients with focused medication administration review. (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11), and 2) failed to ensure the hospital's policies and procedures were followed by nursing staff relative to completion of the Medication Administration Record (MAR), by not accurately documenting on the Medication Administration Record (MAR) for patient #1. Documentation on the MAR for patient #1 for the date of 01/19/11 at 2100 revealed the patient had received Lithium and Depakote when the patient actually refused to take the medication. Findings:

Patient #1 - Review of the medical record for Patient #1 revealed she was admitted to the hospital on 1/13/2011 at 10:30 PM with diagnosis that included Schizoaffective Disorder, Chronic/Deferred and post operative cholocystectomy. Admission Physician Orders on 1/13/2011 revealed medication orders for Azopt (ophthalmic) 1 drop three times a day, Nexium 40 milligrams(mgs) PO Daily, Micatin powder 1 application under breast twice a day, Timolol (ophthalmic solution) 1 drop to left eye twice daily. Additional Physician Orders were written on 1/14/2011 at 4:30 PM for Flush Protocol for Peripherally Inserted Central Catheter (PICC) line (every 12 hours).

Review of the Medication Administration Record (MAR) revealed she did not receive the following 13 medications as ordered by the practitioner: on 1/13/2011 Timolol (ophthalmic solution) at 9:00 PM, on 1/14/2011 Azopt (ophthalmic) drops at 3:00 PM, Nexium 40 mgs at 9:00 AM, Micatin powder 1 application under breast at 9:00 AM, and Timolol (ophthalmic solution) at 9:00 AM and 9:00 PM, on 01/15/2011 Azopt (ophthalmic) drops at 3:00 PM, on 1/16/2011- 1/20/2011 Protocol Flush for Peripherally Inserted Central Catheter (PICC) line (every 12 hours) at 9:00 AM and 9:00 PM on 1/16/2011. On 1/17/2011, 1/18/2011at 9:00 PM, 1/19/2011, and on 1/20/11 for the 9:00 AM scheduled flushes.

Review of documentation faxed to DHH/HSS FO3 on 01/20/11 at 9:53 a.m. from contracted pharmacy "a" revealed that the package containing the Timolol, Azopt and Nexium for Patient #1 was processed at the pharmacy on 01/14/11 and shipped to Seaside Health System via UPS Ground on 01/14/11. Further review of the UPS label revealed the medications for Patient #1 were received on 01/15/11 at 11:45 a.m. at Seaside Health System. This resulted in a 37 hour and 15 minute delay in physician ordered medications for patient #1 to be available for administration.

Patient #2 - Review of the medical record for Patient #2 revealed she was admitted to the hospital on 1/13/2011 at 4:10 PM with diagnoses that included Schizophrenia and Congestive Heart Failure.

Admission Physician Orders on 1/13/2011 revealed medication orders for Trazodone 150 mg at bedtime, Depakote ER 750 mg at bedtime, Ativan 1 mg at bedtime, Seroquel 300 mg at bedtime, Glucotrol XL 2.5 mg daily at 5:00 PM, and Cogentin1 mg three times a day.

Review of the Medication Administration Record (MAR) revealed she did not receive the following 7 medications as ordered by the practitioner: on 01/13/2011 Glucotrol XL 2.5 mg daily at 5:00 PM, Trazodone 150 mg at bedtime, Depakote ER 750 mg at bedtime, Ativan 1 mg at bedtime, Seroquel 300 mg at bedtime, and Cogentin1 mg at 9:00 PM. On 1/14/2011 Cogentin 1 mg at 9:00 AM and 3:00 PM.

Review of documentation faxed to DHH/HSS FO3 on 01/20/11 at 9:53 a.m. from contracted pharmacy "a" revealed that the package containing the Glucotrol, Trazadone, Depakote, Ativan and Seroquel for Patient #2 was processed at the pharmacy on 01/14/11 and shipped to Seaside Health System via UPS Ground on 01/14/11. Further review of the UPS label revealed those medications for Patient #2 were received on 01/15/11 at 11:45 a.m. at Seaside Health System. Further review revealed the Cogentin was on the shipment dated 01/17/11 (Monday) that arrived at Seaside Health Systems on 01/18/11 at 10:32 a.m. This resulted in a 43 hour and 35 minute delay in physician ordered medications for patient #2 to be available for administration.

Patient #3 - Review of the medical record for Patient #3 revealed she was admitted to the hospital on 1/18/2011 at 3:20 PM with diagnoses that included Schizophrenia, Urinary Tract Infection, and Hypertension. Admission Physician Orders on 1/18/2011 for Benztropine 1 mg twice a day, Seroquel 600 mg at bedtime, Fanapt 8 mg daily, and Potassium Chloride ER oral 20 mEq twice a day. Further review of the physician order on 1/18/2011 at 9:25 PM revealed an order that read, " OK to start medication in AM 1/19/2011. " Review of physician orders 1/19/2011 at 8:30 AM revealed additional orders for Albuterol 2.5 mg/3 ml nebs every 8 hours, Benztropine 1 mg daily, Lasix 20 mg every day, Omeprazole 20 mg every morning and thiamine 10 mg daily.

Review of the Medication Administration Record (MAR) revealed she did not receive the following 21 medications as ordered by the practitioner: On 1/19/2011 Seroquel 600 mg at 9:00 PM, Fanapt 8 mg at 9:00 AM, Potassium Chloride ER oral 20 mEq at 9:00 PM, Albuterol 2.5 mg 13 ml nebs at 2:00 PM and 10:00 PM, Benztropine 1 mg at 9:00 AM, Lasix 20 mg at 9:00 AM, Omeprazole 20 mg at 9:00 AM, Thiamine 10 mg at 9:00 AM, Albuterol 2.5 mg 13 ml nebs at 2:00PM and 10:00PM. On 1/20/2011Fanapt 8 mg at 9:00 AM, Potassium Chloride ER oral 20 mEq at 9:00 PM, Albuterol 2.5 mg/3 ml nebs
at 6:00 AM, Benztropine 1 mg at 9:00 AM, Lasix 20 mg at 9:00 AM, Omeprazole 20 mg at 9:00 AM, Thiamine 10 mg at 9:00 AM, Lasix 20 mg at 9:00 AM.

Patient #4 - Review of the medical record for Patient #4 revealed he was admitted to the hospital on 1/11/2011 at 3:50 PM with a diagnoses of Schizophrenia and an assessment of malnutrition. Admission Physician Orders on 1/11/2011 revealed a medication order for Multivitamin Daily.

Review of the Medication Administration Record (MAR) revealed he did not receive the following 3 stock medications as ordered by the practitioner: for 1/14/2011, 1/15/2011, and 1/20/2011Multivitamin at 9:00 AM.

An interview was held with S2 DON on 1/24/2011 at 10:20 AM. She indicated there was no excuse for nurses not administer the stock Multivitamin.

Patient #5 - Review of the medical record for Patient #5 revealed she was admitted to the hospital on 1/17/2011 at 3:50 PM with diagnoses of Major Depression, recurrent, severe without psychosis. Admission Physician Orders on 1/17/2011 revealed a medication order for Multivitamin Daily and on 1/18/2011 an order for Remeron 15 mg at bedtime.

Review of the Medication Administration Record (MAR) revealed she did not receive the following 2 medications as ordered by the practitioner: On 1/19/2011 Remeron 15 mg at9:00 PM, and on 1/20/2011a Multivitamin at 9:00 AM.

An interview was held with S2 Director of Nurses on 1/24/11 at 1:00 PM. After review of the medical records for Patient's #1, #2, #3, #4, and #5, she confirmed all of the missed doses of medications for these patients and could offer no explanation why the medications had not been administered as ordered. She further indicated that no variance reports had been completed by the nurses. She reported there was no documentation in the medical record that the attending physician had been notified of the missed doses of medications. S2 added that no QA related to missed medications had been started before 1/22/11.

Patient #6 - Review of the Medical Record for Patient #6 on 01/20/11 at 10:30 a.m. revealed the following:

The patient was admitted to Seaside Health System on 01/12/11 at 1950 (7:50 p.m.). Review of the Medication Administration Record (MAR) revealed she did not receive the following 2 medications as ordered by the practitioner. The following medications were ordered by the physician and not administered to the patient: Evoxac 30 mg (milligrams) peg (percutaneous endogastric tube) tid (3 times daily) at 2100 (9:00 p.m.) on 01/12/11 and 9:00 a.m. on 01/13/11. (note on MAR reads: ordered pharmacy), Advair Diskus 1 puff bid (twice a day) at 2100 (9:00 p.m.) on 01/12/11, 9:00 a.m. and 2100 (9:00 p.m.) on 01/13/11, and 9:00 a.m. on 01/14/11. (note on MAR reads: ordered pharmacy), Betapace 80 mg peg bid at 2100 (9:00 a.m.) on 01/12/11. (note on MAR reads: ordered pharmacy), Astalin 137 mcg (micrograms) 1 spray each nostril bid at 2100 (9:00 p.m.) on 01/12/11, 9:00 a.m. and 2100 (9:00 p.m.) on 01/13/11, 9:00 a.m. on 01/14/11, and 9:00 a.m. on 01/16/11. (note on MAR reads: ordered pharmacy), Pepcid 20 mg peg bid at 2100 (9:00 p.m.) on 01/12/11, 9:00 a.m. and 2100 (9:00 p.m.) on 01/13/11. (note on MAR reads: ordered pharmacy), Synthroid 50 mcg peg daily at 6:30 a.m. on 01/17/11, Docusate Sodium 15 ml (milliliters) peg daily at 9:00 a.m. on 01/19/11, Seroquel 25 mg peg 12:00 noon on 01/18/11, Gabiscon 30 ml peg bid at 9:00 a.m. and 2100 (9:00 p.m.) on 01/17/11, 9:00 a.m. and 2100 (9:00 p.m.) on 01/18/11. On 01/19/11 at 1500 (3:00 p.m.) a dose that was not ordered was administered.

In an interview on 01/21/11 at 12:45 p.m. with S2DON she confirmed the 23 medication errors on Patient #6. S2DON further stated that there were no medication variance reports filled out and there was no notification of the physician or the pharmacy for any of the 23 medication errors.

Review of documentation faxed to DHH/HSS FO3 on 01/20/11 at 9:53 a.m. from contracted pharmacy " a " revealed that the package containing the Evoxac, Advair Diskus, Betapace, Astalin, Pepcid Synthroid, Docusate and Seroquel for Patient #6 was processed at the pharmacy on 01/13/11 and shipped to Seaside Health System via UPS Ground on 01/13/11. Further review of the UPS label revealed the medications for Patient #6 were received on 01/14/11 at 11:12 a.m. at Seaside Health System. This resulted in a 39 hour and 22 minute delay in physician ordered medications for patient #6 to be available for administration.

Patient #7 - Review of the Medical Record for Patient #7 on 01/20/11 at 9:00 a.m. revealed the following:

The patient was admitted to Seaside Health System on 01/12/11 at 1950 (7:50 p.m.). The following medications were ordered by the physician and not administered to the patient:
Spiriva 10 mcg inhalation daily for 9:00 a.m. on 01/12/11, and 9:00 a.m. for 01/13/11, Advair Diskus 250/50 one puff twice daily for 2100 (9:00 p.m.) for 01/12/11 and 9:00 a.m. and 2100 (9:00 p.m.) for 01/13/11 (note reads: ordered pharmacy).

In an interview on 01/24/11 at 9:40 a.m. with S2DON she confirmed the 5 medication errors on Patient #7. S2DON further stated that there were no medication variance reports filled out and there was no notification of the physician or the pharmacy for any of the 5 medication errors.

Review of documentation faxed to DHH/HSS FO3 on 01/20/11 at 9:53 a.m. from contracted pharmacy " a " revealed that the package containing the Spiriva and Advair Diskus for Patient #7 was processed at the pharmacy on 01/13/11 and shipped to Seaside Health System via UPS Ground on 01/13/11. Further review of the UPS label revealed the medications for Patient #6 were received on 01/14/11 at 11:12 a.m. at Seaside Health System. This resulted in a 39 hour and 22 minute delay in physician ordered medications for patient #7 to be available for administration.

Patient #8 - Review of the Medical Record for Patient #8 on 01/20/11 at 9:30 a.m. revealed the following:

The patient was admitted to Seaside Health System on 01/10/11 at 1630 (4:30 p.m.). The following medications were ordered by the physician and not administered to the patient: Clonazepam 0.5 mg po tid for 1730 (5:30 p.m.) on 01/10/11 and 1730 (5:30 p.m.) on 01/19/11, Cogentin 1 mg po bid for 9:00 a.m. on 01/12/11and 9:00 a.m. on 01/15/11, Zyprexa 20 mg po at bedtime for 2100 (9:00 p.m.) on 01/15/11, Haldol 20 mg po bid for 2100 (9:00 p.m.) for 01/15/11, Amaryl 2 mg po before breakfast for 6:30 a.m. on 01/17/11.

In an interview on 01/24/11 at 9:40 a.m. with S2DON she confirmed the 7 medication errors on Patient #8. S2DON further stated that there were no medication variance reports filled out and there was no notification of the physician or the pharmacy for any of the 7 medication errors.

Review of documentation faxed to DHH/HSS FO3 on 01/20/11 at 9:53 a.m. from contracted pharmacy "a" revealed that the package containing the Clonazepam, Cogentin, Zyprexa, Haldol, and Amaryl for Patient #8 was processed at the pharmacy on 01/10/11 and shipped to Seaside Health System via UPS Ground on 01/10/11. Further review of the UPS label revealed the medications for Patient #8 were received on 01/11/11 at 11:20 a.m. at Seaside Health System. This resulted in a 18 hour and 50 minute delay in physician ordered medications for patient #8 to be available for administration.

Patient #9 - Review of the Medical Record for Patient #9 on 01/20/11 at 11:00 a.m. revealed the following:

The patient was admitted to Seaside Health System on 01/18/11 at 10:00 a.m. The following
medications were ordered by the physician and not administered to the patient: Nasonex nasal spray each nostril at bedtime for 2100 (9:00 p.m.) on 01/18/11. (note on MAR reads: " on order " ), Combivent Inhaler 2 puffs 4 times a day for 1300 (1:00 p.m.), 1700 (5:00 p.m.), and 2100 (9:00 p.m.) on 01/18/11. (note on MAR reads: " on order " ), Clindamycin 450 mg po tid for 1500 (3:00 p.m.) and 2100 (9:00 p.m.) on 01/18/11. (note on MAR reads: " on order " ), Sahris 10 mg sublingual bid for 2100 (9:00 p.m.) on 01/18/11. (note on MAR reads: " on order " ).

In an interview on 01/24/11 at 9:40 a.m. with S2DON she confirmed the 7 medication errors on Patient #9. S2DON further stated that there were no medication variance reports filled out and there was no notification of the physician or the pharmacy for any of the 7 medication errors.

Patient #10 - Review of the Medical Record for Patient #10 on 01/20/11 at 10:00 a.m. revealed the following:

The patient was admitted to Seaside Health System on 01/10/11 at 2345 (11:45 p.m.). The following medications were ordered by the physician and not administered to the patient: Clorazil 300 mg po qhs (bedtime) for 2100 (9:00 a.m.) on 01/10/11, and for 2100 (9:00 a.m.) on 01/10/11, Lithium 450 mg po bid for 9:00 a.m. on 01/15/11, 2100 (9:00 p.m.) on 01/19/11, and 9:00 a.m. on 01/20/11, Clorazil 350 mg po qhs for 2100 (9:00 p.m.) for 01/19/11, Depakote ER (extended release) 750 mg po for 2100 (9:00 p.m.) for 01/19/11.

In an interview on 01/24/11 at 10:40 a.m. with S2DON she confirmed the 7 medication errors on Patient #10. S2DON further stated that there were no medication variance reports filled out and there was no notification of the physician or the pharmacy for any of the 7 medication errors.

Patient #11 - Review of the Medical Record for Patient #11 on 01/20/11 at 12:30 p.m. revealed the following:

The patient was admitted to Seaside Health System on 01/10/11 at 1830 (6:30 p.m.) The following medications were ordered by the physician and not administered to the patient: Clonidine 0.3 mg po for 2100 (9:00 p.m.) on 01/10/11, and 1500 (3:00 p.m.) on 01/16/11, Combivir 150-300 mg orally bid for 2100 (9:00 p.m.) on 01/10/11, Benadryl 50 mg po qhs for 2100 (9:00 p.m.) on 01/10/11, Docusate Calcium 240 mg po bid for 2100 (9:00 p.m.) on 01/10/11, Gabapentin 300 mg po tid for 2100 (9:00 p.m.) on 01/10/11, Haldol 5 mg po qhs for 2100 (9:00 p.m.) on 01/10/11, Kaletra 200/50 po bid for 2100 (9:00 p.m.) on 01/10/11, Lorazepam 1 mg po tid for 2100 (9:00 p.m.) on 01/10/11, Lyrica 50 mg po tid for 2100 (9:00 p.m.) on 01/10/11, Naproxen Sodium 220 mg 2 tabs bid for 2100 (9:00 p.m.) on 01/10/11, Seroquel 50 mg po bid for 2100 (9:00 p.m.) on 01/10/11, Tamulosin HCl 0.4 mg po bid for 2100 (9:00 p.m.) on 01/10/11, Nystatin Cream to catheter bid for 2100 (9:00 p.m.) on 01/10/11, 9:00 a.m. and 2100 (9:00 p.m.) for 01/11/11, and for 9:00 a.m. for 01/13/10, Zosyn 2.25 gm IVPB (intravenous piggyback) every 8 hours for 7 days (ordered 01/11/11 at 8:15 a.m.) for 2 doses prior to order to D/C on 01/11/11 at 1700 (5:00 p.m.). Same order re-written 01/12/11 at 8:00 a.m. Dose missed for 6:00 a.m. on 01/17/11. Dose missed for 1400 (2:00 p.m.) on 01/18/11, Celexa 20 mg po q AM ordered 01/11/11 at 1530 (3:30 p.m.) for 9:00 am on 01/12/11, Spiriva 1 puff qhs for 2100 (9:00 p.m.) on 01/11/11, Lyrica 50 mg po tid for 9:00 a.m. on 01/12/11, 1500 (3:00 p.m.) on 01/16/11 and 1500 (3:00 p.m.) and 2100 (9:00 p.m.) on 01/17/11 and for 9:00 a.m. for 01/18/11, Lorazepam 1 mg po tid for 1500 (3:00 p.m.) on 01/16/11, Didanosine ER 400 mg qAM for 9:00 a.m. on 01/16/11, and Simvastatin 20 mg po daily for 9:00 a.m. on 01/16/11.

In an interview on 01/21/11 at 12:15 p.m. with S2DON she confirmed the 31 medication errors on Patient #11. S2DON further stated that there were no medication variance reports filled out and there was no notification of the physician or the pharmacy for any of the 31 medication errors.

Review of the content list of a package shipped via UPS ground on 01/11/11 at 7:47 p.m. C.O.D. from contracted pharmacy " a " revealed it contained the Zosyn, Lorazepam, Seroquel, Tamsulosin, Simvastatin, Clonidine, Haldol, Spiriva, and Nystatin medications ordered for patient #11. The package is date/time stamped as received at Seaside Health Systems with a signature and $1598.91 " collected " . This time was 25 hours and 17 minutes after the physician ordered the medications for patient #11.

Review of a Seaside Health System Policy titled "Medication Management", effective date 03/10, review date 10/10, reads in part: "Policy. Medication errors will be documented, investigated, analyzed and reported in accordance with Seaside Health System guidelines. Purpose. To assure a safe patient care environment. To document potential isolated or trended issues involving medications. To document communication between pharmacy, nursing and medical staffs. To guide practice consistent with State regulations. Definition. A medication error is defined as any deviation from established policies and/or procedures during the prescribing, transcribing, dispensing, administering, and monitoring of a drug. Procedure. All medication errors of action or omission, including labeling, will be documented on an Occurrence Report. By the end of the shift of incident, the Occurrence Report will be forwarded to the appropriate supervisor and/or Chief Clinical Officer (CCO) for review of completeness and for assessment/categorization of severity of error. Within 24 hours of incident the Occurrence Report will be forwarded to the Risk Management Department. Medication errors will be reported to the ordering physician. Medication errors will be reported to the pharmacist. Medication errors will be investigated, analyzed, and trended through Risk Management in collaboration with Pharmacy; processed through Quality Improvement activities; and reported through facility appropriate committees (i.e. Quality Council, Medical Staff, Pharmacy and Therapeutics, etc.) ...the Chief Clinical Officer in collaboration with pharmacy will ensure completion of an Occurrence Report for all medication errors."
2) The Medication Administration Record for (MAR) patient #10 was copied on 01/20/11 at 10:00 a.m. Review of the MAR revealed the 2100 (9:00 p.m.) dose of Lithium Carbonate 450 mg and the dose of Depakote ER (extended release) were not administered to patient #10.
In an interview with S2DON on 01/24/11 at 11:00 a.m. the MAR was reviewed to confirm missed medication doses. The MAR for the Lithium and Depakote for 01/19/11 at 2100 (9:00 p.m.) was now documented as administered.
In an interview on 01/24/11 at 2:50 p.m. with S14LPN she stated that when she returned for her night shift beginning on 01/20/11 that she noticed the Lithium and Depakote were not initialed as administered for 01/19/11 at 2100 (9:00 p.m.) and she " thought I did not sign the MAR so I signed it thinking it was an oversight. " S14LPN further stated, after being shown the two copies of the MAR, " Now I realize that he refused the Depakote and Lithium on 01/19/11. " S14LPN stated that she had notified the RN Charge Nurse that patient #10 had refused the medications on 01/19/11. S14LPN further confirmed that the MAR on the medical record of patient #10 is incorrect. S14LPN confirmed that no medication variance report has been filled out and the physician has not been notified of the medication refusal by patient #10.
Review of a Seaside Health System Policy titled "Medication Management" ,effective date 03/10, review date 10/10, reads in part: " Policy. Medication errors will be documented, investigated, analyzed and reported in accordance with Seaside Health System guidelines. Purpose...Definition. A medication error is defined as any deviation from established policies and/or procedures during the prescribing, transcribing, dispensing, administering, and monitoring of a drug. Procedure. All medication errors of action or omission, including labeling, will be documented on an Occurrence Report...Medication errors will be reported to the ordering physician. Medication errors will be reported to the pharmacist..."