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Based on medical record review, document review and interview, in three (3) of 20 medical records reviewed, it was determined the nursing staff failed to follow physicians' orders for administration of narcotic medications. (Patient #s 1, 2 and 3).

Findings include:

Review of medical record for Patient #1 identified the following: The patient was admitted to the facility on 7/20/19 with a complaint of pain and fevers for four (4) days. The patient had a previous medical history of Sacral Cancer and the admitting diagnosis was Urinary Tract Infection. The patient had been receiving Morphine via an Intrathecal Pump (ITP) at home for pain management. An intravenous Hydromorphone Patient-Controlled Analgesia (PCA) was initiated on 7/21/19 for additional pain management. On 7/22/19 at 5:56 PM, the patient's PCA order was Hydromorphone, 1 mg/ml in 100 ml of Normal Saline (NS) at 0.1 mg /hour continuously and a demand dose of 0.4mg every 15 minutes. On 7/23/19 at 8:33 AM, the patient's order was changed to Hydromorphone 0.2 mg/ml in 50 ml of Normal Saline at 0 (zero) rate and a demand dose of 0.2 mg every 10 minutes.

On 7/23/19 at 8:23 PM, a nurse identified that the patient's Hydromorphone infusion of 1mg/ml in 100 ml Normal Saline was still infusing instead of the 0.2 mg/ml in 50 ml Normal Saline Solution of Hydromorphone which was ordered at 8:33 AM on 7/23/19. The PCA pump had been programmed to administer 0.2 mg of Hydromorphone so the patient received the correct dosage but not the prescribed concentration of the medication. The patient had received 2.2 ml of the 1mg/ml in 100 ml of Normal Saline concentration of Hydromorphone.

Review of medical record for Patient #2 identified the following: This 70-year-old patient was admitted to the facility on 2/7/2020 for the management of dysphagia (difficulty swallowing) and chest pain due to radiation therapy. The patient's preexisting medical condition included metastatic prostate cancer. The patient's PCA order on 2/10/2020 at 1:00 PM was for Fentanyl 10 mcg/hour in 100 ml Normal Saline at zero (0) rate and a demand rate of 25 mcg every 10 minutes with a lockout interval of 10 minutes. The patient had also started to wear a Fentanyl patch on 2/10/2020 at 1:10 PM which administered Fentanyl 25 mcg/hour for 72 hours. The PCA order was changed at 10:00 PM on 2/10/20 to Fentanyl at Zero (0) rate and demand dose of 25 mcg every 10 minutes with a lockout interval of 10 minutes.

There was no indication that the PCA order was not picked up until 5:03 AM on 2/11/2020, a seven (7) hour delay for discontinuation of the continuous dosing.

Review of medical record for Patient #3 identified the following: This 75-year-old patient was admitted on 1/20/2020 for management of syncope and Myeloid Leukemia. On 2/5/2020 at 10:29 AM, the physician ordered Hydromorphone 0.2 mg/ml in 50 ml of Normal Saline with a continuous rate of 0.2 mg/hour with a demand dose of 0 via a PCA pump. Review of the medication administration record revealed that on 2/7/2020 at 2:03 PM, the patient began to receive 0.02 mg/hour until 2/8/20 at 7:16 AM when the error was identified. This error contributed to the patient's need for three (3) Clinician Activated Boluses on 2/7/2020 at 9:25 PM and on 2/8/2020 at 1:54 AM and 1:54 AM.