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Based on record reviews, interviews, and observation, the facility failed to identify problems of medication errors both with the electronic medication system and staff performance, which resulted in inaccurate tracking of medication errors. The facility's consulting pharmacy failed to have a system in place to readily identify loss or diversion of all controlled substances in a time frame between the actual loss and the time of discovery.
Findings:

On 10/27/10 at 3:11 p.m. in an interview with S2DON, she stated there was only one documented medication error for the 2nd quarter (April, May, and June). She added there were no errors documented by the contracted Pharmacist (S3) for this quarter. S2DON also stated she had not identified any problems with the medication administration monitoring because the pharmacist had not provided her with any medication discrepancies. She stated, according to the QI committee, checking the MARs for discrepancies had improved since they now require the night nurse to conduct a 24 hour chart check each night. She confirmed that the mistakes on the MARs had improved this quarter since the previous quarter.

1) Failing to have a policy implemented for the medication-related device, (the Omnicell System):

Review of the "Pharmacy Services Agreement", dated July 1, 2007 read in part the Pharmacy would render all services in accordance with PHARMACY'S Policies and Procedures Manual. Further review of the " Pharmacy Services " revealed the agreement automatically renewed annually.

Review of the hospital's curent Policy and Procedure Manuals revealed there was no documented evidence the manuals contained a policy related to the medication-related device, the Omnicell System. These policies found in the manuals were presented during the survey process from 10/20/10 through 10/27/10. Further review of the manuals
revealed there was no documentation regarding the dispensing of controlled medications from the Omnicell System (Medication Dispensing System). There was no Pharmacy Policy and Procedure Manual presented during the survey proces from 10/20/10 to 10/27/10. There was no Pharmacy Policy related to the Omnicel system presented during the survey. There was no Pharmacy Policy to address the dispensing of controlled medications from the Omnicell System presented during the survey from 10/20/10 through 10/27/10.

In an interview on 10/27/10 at 2:30 p.m., S3Pharmacy Director indicated the Omnicell system had been used by the hospital staff for about 3 years, (in 2007). He reported Pharmacy did not have a Policy and Procedure Manual. He indicated there was no policy developed and implemented regarding the dispensing of controlled medications from the Omnicell System used by the hospital staff since 2007.

2) Failing to develop, implement, review or revise a policy for narcotic medication discrepancies in the Omnicell System:

During an observation of the Omnicell System on 10/20/10 from 1:20 p.m. through 3:00 p.m. with S3Pharmacy Director, there were 18 narcotic medication discrepancies noted in the Omnicell at this time. Further observation revealed the Omnicell kept a medication count of all narcotic medications in the system. The 18 narcotic medication discrepancies identified by the surveyor did not match the medication count in the Omnicell. The 18 narcotic medications had discrepancies with the Omnicell ' s medication counts were short or over tablets of medication. The 18 narcotic medication count discrepancies were as follows:
Patient #1:
Percocet medication count was over 2 tablets on 10/17/10;

Patient #2:
Lortab medication count was over 25 tablets on 10/13/10,
Lortab medication count was over 10 tablets on 10/18/10,
Lortab medication count was short 24 tablets on 10/13/10,
Lortab medication count was short 10 tablets on 10/14/10;

Patient #14:
Lortab medication count was short 1 tablet on 10/13/10,
Tramadol (Ultram) medication count was 10 tablets over on 10/13/10,
Clorazepate (Tranxene) medication count was 1 tablet over on 10/14/10;

Patient #15:
Lortab medication count was over 10 tablets on 10/14/10;

Patient #16:
Zolpidem (Ambien) medication count was short 10 tablets on 10/15/10,
Zolpidem (Ambien) medication count was over 10 tablets on 10/15/10;

Patient #17:
Zolpidem (Ambien) medication count was over 1 tablet on 10/15/10.
Lortab medication count was short 10 tablets on 10/18/10,
Lortab medication count was short 10 tablets on 10/19/10,
Lortab medication count was over 10 tablets on 10/19/10.

During the same observation of the Omnicel System on 10/20/10 from 1:20 p.m. through 3:00 p.m. with S3 Pharmacy Director, he confirmed there were 18 narcotic medication discrepancies in the Omnicell system. He confirmed the above findings for Patient #1, #2, #14, #15, #16, #17.

In interview on 10/27/10 at 2:30 p.m., S3Pharmacy Director confirmed the following medication errors:
Patient #1 had 1 medication error for Percocet on 10/17/10.
Patient #14 had 2 medication errors for Tranxene on 10/14/10 and 10/15/10.
Patient #17 had 1 medication error for Ambien on 10/15/10.

In another interview on 10/27/10 at 2:30 p.m., S3, Pharmacy Director indicated there was no " Narcotic Discrepancy" policy developed, revised, or reviewed by pharmacy to resolve the 18 narcotic medication discrepancies identified by the surveyor on 10/20/10.

Further review of the hospital ' s current Policy and Procedure Manuals revealed there was no policy to address the narcotic medication discrepancies in the Omnicell System presented during the survey from 10/20/10 through 10/27/10.

25059

Based on record reviews and interviews, the hospital failed to ensure verbal/telephone orders were infrequently used as evidenced by having verbal/telephone orders written for 9 of 10 focused patient records reviewed for verbal/telephone orders out of a total of 21 patient records reviewed, (#1, #2, #5, #6, #9, #10, #11, #15, #17).
Findings:

Patient #1:
Review of the medical record for #1 revealed there were two (2) RBVO (read-back verbal order) written on the " Admit Orders " for 10/12/10 at 5:00 p.m. (1700). There were three (3) " Physicians Orders " with RBVO for 10/12/10 at 5:00 p.m., 10/14/10 at 2:17 p.m. (1417), 10/21/10 at 3:40 p.m. (1540). There were eight (8) " Physicians Orders " written as phone /telephone orders on 10/16/10 at 6:55 a.m. (0655), 10/16/10 at 2:40 p.m. (1440), 10/16/10 at 2:50 p.m. (1450), 10/16/10 at 3:00 p.m. (1500), 10/20/10 at 11:20 a.m. (1120), 10/18/10 at 3:30 p.m. (1530), 10/12/10 at 5:00 p.m., 10/13/10 at 5:20 p.m. (1720). All of the above verbal/telephone orders did not have the date/time the physician authenticated the order.

In an interview on 10/27/10 at 3:55 p.m., S2DON confirmed the above verbal orders and phone/telephone orders written for Patient #1. S2 indicated these orders did not have the date/time that the prescribing physician authenticated them. S2 stated that the admitting physician is called every time a new patient is admitted into the hospital. She indicated the nurses write the physician ' s admission orders " Admit Orders " for the patients at this time.

Patient #2:

Review of the medical record for #2 revealed there were two (2) RBVO written on the " Admit Orders " for 10/13/10 at 1:30 p.m. (1330). There were two (2) other RBVO written on the " Physician ' s Orders " for 10/13/10 at 1:30 p.m., " Sliding Regular Insulin " orders for 10/13/10 at 1:30 p.m. (1330), " Physicians Orders " for 10/13/10 at 8:00 p.m. (2000) and 10/14/10 at 12:45 p.m. (1245). There was one (1) " Physicians Orders " PO (phone order) written on 10/14/10 with no time documented that the nurse spoke to the physician. Further review of the verbal/phone orders revealed the prescribing physician signed these orders, but did not authenticate the orders with the date/time.

In an interview on 10/27/10 at 3:45 p.m., S2DON indicated Patient #2 ' s verbal orders on 10/13/10 and 10/14/10 did not have the date/time that the prescribing physician authenticated the verbal orders.

Patient #15:

Review of the medical record for #15 revealed there were two (2) " Admit Orders) " , written RBVO for 10/13/10 at 3:00 p.m., and two (2) on the " Physicians Orders " for 10/13/10 at 3:30 p.m. and 10/13/10 at 5:20 p.m. (1720). Further review of the verbal orders revealed the prescribing physician signed these verbal orders, but did not record the date/time that the physician clarified these orders.

In an interview on 10/27/10 at 3:55 p.m., S2DON indicated Patient #15 ' s verbal orders on 10/13/10 did not have the date/time that the prescribing physician authenticated the verbal orders.

Patient #17:
Review of the medical record for #17 revealed there were two (2) RBVO written on the " Admit Orders " for 10/14/10 at 3:30 p.m. (1530). There were two (2) RBVO " Physicians Orders " for 10/14/10 at 3:30 p.m. and 10/24/10 at 12:00 a.m. that did not have the date/time the physician authenticated the orders.

In an interview on 10/27/10 at 3:25 p.m., S2DON indicated Patient #17 ' s verbal orders on 10/14/10 and 10/24/10 did not have the date/time that the prescribing physician authenticated the verbal orders.

Review of the policy titled, "MD Phone/Verbal Orders", Policy No.: II-C.4.12, Issued date of 04/10, with no revised or reviewed dates, presented as the hospital's current "Verbal Orders" policy on 10/26/10 at 2:00 p.m., page 1 of 1, revealed to maintain a high level of accuracy and safety in following physicians' orders that all orders must be authenticated (signed) by the physicians' on the physician order sheet within 10 days.

The " Authentication " policy No:III-A.1.06, Issued date of 10/05, with no revised or reviewed dates, presented as the hospital's current "Authentication of Verbal Orders" policy on 10/26/10 at 2:00 p.m., page 1 of 3, was reviewed. The policy indicated each verbal orders are to be signed within 10 days.

Review of the policy titled, " Time Frames " , Policy No.: III-A.1.17, Issued date of 04/10, with no revised or reviewed dates, presented as the hospital's current "Time Frames" policy on 10/26/10 at 2:00 p.m., page 1 of 1, revealed Verbal Orders completion time was 10 days.

Review of the medical record for patient #5 reflected there were verbal orders written on 5/7/10, 5.8/10, 5/9/10 and 5/13/10.

Review of the medical record for patient #6 reflected verbal orders were written on 5/10/10, 5/11/10, 5/19/10 and 5/20/10. Review of patient #7's record reflected verbal orders written on 6/18/10 and 6/21/10.

Review of patient #9's medical record reflected verbal orders were written on 7/16/10, 7/18/10, 7/19/10, 7/20/10, 7/21/10, 7/22/10, 7/23/10, 7/24/10, 7/25/10, , 8/1/10, 8/2/10, 8/3/10 8/11/10 and 8/30/10.

Review of the medical record for patient #10 reflected verbal orders were written on 8/16/10, 8/17/10, 8/19/10, 8/23/10, 8/29/10, 8/31/10 and 9/3/10.

Review of patient #11's record reflected verbal orders were written on 8/28/10, 8/29/10, 9/1/10, 9/5/10, 9/6/10 and 9/13/10.

25059

Based on record reviews and interviews, the hospital failed to ensure the verbal/telephone orders and/or physicians orders were authenticated by the ordering practitioner as evidenced by having orders without the prescribing physician ' s date/time the orders were authenticated for 5 of 6 patient records reviewed for authentication of orders out of a total of 21 patient records (#1, #2, #11, #15, #17). Findings:

Patient #1:
Review of the medical record for #1 revealed there were two (2) RBVO (read-back verbal order) written on the " Admit Orders " for 10/12/10 at 5:00 p.m. (1700). There were three (3) " Physicians Orders " with RBVO for 10/12/10 at 5:00 p.m., 10/14/10 at 2:17 p.m. (1417), 10/21/10 at 3:40 p.m. (1540). There were eight (8) " Physicians Orders " written as phone /telephone orders on 10/16/10 at 6:55 a.m. (0655), 10/16/10 at 2:40 p.m. (1440), 10/16/10 at 2:50 p.m. (1450), 10/16/10 at 3:00 p.m. (1500), 10/20/10 at 11:20 a.m. (1120), 10/18/10 at 3:30 p.m. (1530), 10/12/10 at 5:00 p.m., 10/13/10 at 5:20 p.m. (1720). All of the above verbal/telephone orders did not have the date/time the physician authenticated the order.

In an interview on 10/27/10 at 3:55 p.m., S2DON confirmed the above verbal orders and phone/telephone orders written for Patient #1. S2 indicated these orders did not have the date/time that the prescribing physician authenticated them. S2 stated that the admitting physician is called every time a new patient is admitted into the hospital. She indicated the nurses write the physician ' s admission orders " Admit Orders " for the patients at this time.

Patient #2:

Review of the medical record for #2 revealed there were two (2) RBVO written on the " Admit Orders " for 10/13/10 at 1:30 p.m. (1330). There were two (2) other RBVO written on the " Physician ' s Orders " for 10/13/10 at 1:30 p.m., " Sliding Regular Insulin " orders for 10/13/10 at 1:30 p.m. (1330), " Physicians Orders " for 10/13/10 at 8:00 p.m. (2000) and 10/14/10 at 12:45 p.m. (1245). There was one (1) " Physicians Orders " PO (phone order) written on 10/14/10 with no time documented that the nurse spoke to the physician. Further review of the verbal/phone orders revealed the prescribing physician signed these orders, but did not authenticate the orders with the date/time.

In an interview on 10/27/10 at 3:45 p.m., S2DON indicated Patient #2 ' s verbal orders on 10/13/10 and 10/14/10 did not have the date/time that the prescribing physician authenticated the verbal orders.

Patient #11

Review of the medical record for patient #11 reflected the patient was admitted to the facility on 8/25/10. Further review of the orders from 8/25/10 to 9/13/10 reflected there were multiple verbal orders and/or physicians orders that were not authenticated as to the date and/or time of the orders.


Patient #15:

Review of the medical record for #15 revealed there were two (2) " Admit Orders) " , written RBVO for 10/13/10 at 3:00 p.m., and two (2) on the " Physicians Orders " for 10/13/10 at 3:30 p.m. and 10/13/10 at 5:20 p.m. (1720). Further review of the verbal orders revealed the prescribing physician signed these verbal orders, but did not record the date/time that the physician clarified these orders.

In an interview on 10/27/10 at 3:55 p.m., S2DON indicated Patient #15 ' s verbal orders on 10/13/10 did not have the date/time that the prescribing physician authenticated the verbal orders.

Patient #17:
Review of the medical record for #17 revealed there were two (2) RBVO written on the " Admit Orders " for 10/14/10 at 3:30 p.m. (1530). There were two (2) RBVO " Physicians Orders " for 10/14/10 at 3:30 p.m. and 10/24/10 at 12:00 a.m. that did not have the date/time the physician authenticated the orders.

In an interview on 10/27/10 at 3:25 p.m., S2DON indicated Patient #17 ' s verbal orders on 10/14/10 and 10/24/10 did not have the date/time that the prescribing physician authenticated the verbal orders.

Review of the policy titled, "MD Phone/Verbal Orders", Policy No.: II-C.4.12, Issued date of 04/10, with no revised or reviewed dates, presented as the hospital's current "Verbal Orders" policy on 10/26/10 at 2:00 p.m., page 1 of 1, revealed to maintain a high level of accuracy and safety in following physicians' orders that all orders must be authenticated (signed) by the physicians' on the physician order sheet within 10 days.

The " Authentication " policy No:III-A.1.06, Issued date of 10/05, with no revised or reviewed dates, presented as the hospital's current "Authentication of Verbal Orders" policy on 10/26/10 at 2:00 p.m., page 1 of 3, was reviewed. The policy indicated each verbal orders are to be signed within 10 days.

Review of the policy titled, " Time Frames " , Policy No.: III-A.1.17, Issued date of 04/10, with no revised or reviewed dates, presented as the hospital's current "Time Frames" policy on 10/26/10 at 2:00 p.m., page 1 of 1, revealed Verbal Orders completion time was 10 days.

Based on record review and interview, the hospital failed to ensure verbal/telephone orders were authenticated based upon Federal and State law within 48 hours as evidenced by not having verbal/telephone orders dated/timed and authenticated within 10 days as per the hospital ' s " MD/Verbal Orders " policy for 11 of 11 records reviewed for verbal/telephone orders authentication out of a total of 21 patient records reviewed, (#1, #2, #5, #6, #7, #8, #9, #10, #11, #15, #17). Findings:

Patient #1:
Review of the medical record for #1 revealed there were two (2) RBVO (read-back verbal order) written on the " Admit Orders " for 10/12/10 at 5:00 p.m. (1700). There were three (3) " Physicians Orders " with RBVO for 10/12/10 at 5:00 p.m., 10/14/10 at 2:17 p.m. (1417), 10/21/10 at 3:40 p.m. (1540). There were eight (8) " Physicians Orders " written as phone /telephone orders on 10/16/10 at 6:55 a.m. (0655), 10/16/10 at 2:40 p.m. (1440), 10/16/10 at 2:50 p.m. (1450), 10/16/10 at 3:00 p.m. (1500), 10/20/10 at 11:20 a.m. (1120), 10/18/10 at 3:30 p.m. (1530), 10/12/10 at 5:00 p.m., 10/13/10 at 5:20 p.m. (1720). All of the above verbal/telephone orders did not have the date/time the physician authenticated the order.

In an interview on 10/27/10 at 3:55 p.m., S2DON confirmed the above verbal orders and phone/telephone orders written for Patient #1. S2 indicated these orders did not have the date/time that the prescribing physician authenticated them. S2 stated that the admitting physician is called every time a new patient is admitted into the hospital. She indicated the nurses write the physician ' s admission orders " Admit Orders " for the patients at this time.

Patient #2:

Review of the medical record for #2 revealed there were two (2) RBVO written on the " Admit Orders " for 10/13/10 at 1:30 p.m. (1330). There were two (2) other RBVO written on the " Physician ' s Orders " for 10/13/10 at 1:30 p.m., " Sliding Regular Insulin " orders for 10/13/10 at 1:30 p.m. (1330), " Physicians Orders " for 10/13/10 at 8:00 p.m. (2000) and 10/14/10 at 12:45 p.m. (1245). There was one (1) " Physicians Orders " PO (phone order) written on 10/14/10 with no time documented that the nurse spoke to the physician. Further review of the verbal/phone orders revealed the prescribing physician signed these orders, but did not authenticate the orders with the date/time.

In an interview on 10/27/10 at 3:45 p.m., S2DON indicated Patient #2 ' s verbal orders on 10/13/10 and 10/14/10 did not have the date/time that the prescribing physician authenticated the verbal orders.

Patient #15:

Review of the medical record for #15 revealed there were two (2) " Admit Orders) " , written RBVO for 10/13/10 at 3:00 p.m., and two (2) on the " Physicians Orders " for 10/13/10 at 3:30 p.m. and 10/13/10 at 5:20 p.m. (1720). Further review of the verbal orders revealed the prescribing physician signed these verbal orders, but did not record the date/time that the physician clarified these orders.

In an interview on 10/27/10 at 3:55 p.m., S2DON indicated Patient #15 ' s verbal orders on 10/13/10 did not have the date/time that the prescribing physician authenticated the verbal orders.

Patient #17:
Review of the medical record for #17 revealed there were two (2) RBVO written on the " Admit Orders " for 10/14/10 at 3:30 p.m. (1530). There were two (2) RBVO " Physicians Orders " for 10/14/10 at 3:30 p.m. and 10/24/10 at 12:00 a.m. that did not have the date/time the physician authenticated the orders.

In an interview on 10/27/10 at 3:25 p.m., S2DON indicated Patient #17 ' s verbal orders on 10/14/10 and 10/24/10 did not have the date/time that the prescribing physician authenticated the verbal orders.

Review of the policy titled, "MD Phone/Verbal Orders", Policy No.: II-C.4.12, Issued date of 04/10, with no revised or reviewed dates, presented as the hospital's current "Verbal Orders" policy on 10/26/10 at 2:00 p.m., page 1 of 1, revealed to maintain a high level of accuracy and safety in following physicians' orders that all orders must be authenticated (signed) by the physicians' on the physician order sheet within 10 days.

The " Authentication " policy No:III-A.1.06, Issued date of 10/05, with no revised or reviewed dates, presented as the hospital's current "Authentication of Verbal Orders" policy on 10/26/10 at 2:00 p.m., page 1 of 3, was reviewed. The policy indicated each verbal orders are to be signed within 10 days.

Review of the policy titled, " Time Frames " , Policy No.: III-A.1.17, Issued date of 04/10, with no revised or reviewed dates, presented as the hospital's current "Time Frames" policy on 10/26/10 at 2:00 p.m., page 1 of 1, revealed Verbal Orders completion time was 10 days.




13225

Review of the medical record for patient #5 reflected there were verbal orders written on 5/7/10, 5.8/10, 5/9/10 and 5/13/10. There were no dates or times noted to reflect when the physician authenticated the verbal orders.

Review of the medical record for patient #6 reflected verbal orders were written on 5/10/10, 5/11/10, 5/19/10 and 5/20/10. However, there were no dates or times noted on the record to reflect when the physician authenticated the orders.

Review of patient #7's record reflected verbal orders written on 6/18/10 and 6/21/10, and there were no times or dates noted to reflect when the orders were authenticated by the physician. Further review of patient #8's record reflected verbal orders were written on 7/8/10, and there was no documentation to reflect the date and time the orders were authenticated by the physician.

Review of patient #9's medical record reflected verbal orders were written on 7/16/10, 7/18/10, 7/19/10, 7/20/10, 7/21/10, 7/22/10, 7/23/10, 7/24/10, 7/25/10, , 8/1/10, 8/2/10, 8/3/10 8/11/10 and 8/30/10; however, there were no dates or times noted to reflect when the physician authenticated the orders.

Review of the medical record for patient #10 reflected verbal orders were written on 8/16/10, 8/17/10, 8/19/10, 8/23/10, 8/29/10, 8/31/10 and 9/3/10 that were not dated and/or timed; however, there was no documentation to reflect when the physician authenticated the orders.

Review of patient #11's record reflected verbal orders were written on 8/28/10, 8/29/10, 9/1/10, 9/5/10, 9/6/10 and 9/13/10. There was no documentation to reflect orders were dated and/or timed by the physician.

Based on record review and interview the facility failed to ensure all records were documented appropriately by failing to ensure physician's history and physicals (H & P) and/or progress notes were dated and/or timed for 9 of 10 patients records reviewed in a total sample of 21 patients (#4, #5, #7,
#8, #9, #10, #11 and #13). Findings:

Patient #4
Review of the medical record for patient #4 reflected the patient was admitted to the facility on 5/4/10. Further review of the record reflected the physician's H&P, consultation report and discharge summary were not dated and/or timed. Review of progress notes dated from 5/5/10 through 6/14/10 reflected multiple notes that were not timed.

Patient #5
Review of the medical record for patient #5 reflected the patient was admitted to the facility on 5/7/10. Further review of the record reflected there were progress notes dated 5/10/10, 5/12/10 and 5/13/10 that were not timed. Review of the patient's H&P revealed there was no time or date noted to reflect when the physician authenticated the H&P.

Patient #7
Review of the medical record for patient #7 reflected the patient was admitted to the facility on 6/18/10. Further review of the record revealed there was no date or time noted on the H&P to reflect when the physician authenticated the note. Review of the patient's progress notes reflected there were multiple notes that were not dated and/or timed.

Patient #8
Review of the medical record for patient #8 reflected there were progress notes that were not dated and/or timed. Further review of the record revealed the patient's discharge summary was signed by the physician; however there was no date or time to reflect when the note was authenticated by the physician.

Patient #9
Review of the medical record for patient #9 reflected the patient was admitted to the facility on 7/15/10. Further review of the record reflected the H&P was signed, but there was no date or time noted for authentication. Review of progress notes for the patient reflected there were multiple notes from 7/17/10 to 8/3/10 that were not timed.

Patient #10
Review of the medical record for patient #10 revealed the patient was admitted to the facility on 8/16/10. Further review of the record reflected the H&P, discharge summary and multiple progress notes dated from 8/17/10 to 9/3/10 that were not dated and/or timed.

Patient #11
Review of the medical record for patient #11 reflected the patient was admitted to the facility on 8/25/10. Further review of the record reflected multiple orders and/or progress notes that were not dated and/or timed.

Patient #13
Review of the medical record for patient #13 reflected the patient was admitted to the facility on 9/23/10. Further review of the record reflected there were multiple progress notes dated from 9/26/10 to 10/13/10 that were not timed.

Interview with the DON on 10/27/10 at approximately 4:30 p.m. revealed all entries in the patient's medical records should be dated and timed.

Based on observation, record reviews, and interviews, the contracted pharmacy failed to develop and implement policies and procedures for the Omnicell System (Medication Dispensing System) as evidenced by: 1) having no policy and procedures to address the dispensing of controlled medications from the Omnicell System (Medication Dispensing System) and 2) having no policy and procedures to address the narcotic medication discrepancies in the Omnicell System. Findings:

1) Having no policy and procedures to address the dispensing of controlled medications from the Omnicell System (Medication Dispensing System):

Review of the "Pharmacy Services Agreement", dated July 1, 2007 read in part the Pharmacy would render all services in accordance with PHARMACY'S Policies and Procedures Manual. Further review of the " Pharmacy Services " revealed the agreement automatically renewed annually.

Review of the hospital ' s current Policy and Procedure Manuals revealed there was no documented evidence regarding the dispensing of controlled medications from the Omnicell System (Medication Dispensing System). Further review revealed there was no Pharmacy Policy and Procedure Manual to address the dispensing of controlled medications from the Omnicell System presented during the survey from 10/20/10 through 10/27/10.

In an interview on 10/27/10 at 2:30 p.m., S3, Pharmacy Director indicated the Omnicell system had been used by the hospital staff for about 3 years, (in 2007). He reported Pharmacy did not have a Policy and Procedure Manual. He indicated there was no policy developed and implemented regarding the dispensing of controlled medications from the Omnicell System used by the hospital staff since 2007.

2) Having no policy and procedures to address the narcotic medication discrepancies in the Omnicell System:

During an observation of the Omnicell System on 10/20/10 from 1:20 p.m. through 3:00 p.m. with S3 Pharmacy Director, there were 18 narcotic medication discrepancies noted in the Omnicell at this time. Further observation revealed the Omnicell kept a medication count of all narcotic medications in the system. The 18 narcotic medication discrepancies identified by the surveyor did not match the medication count in the Omnicell. The 18 narcotic medications had discrepancies with the Omnicell ' s medication counts as being short or over tablets of medication. The 18 narcotic medication count discrepancies were as follows:
Patient #1:
Percocet medication count was over 2 tablets on 10/17/10;

Patient #2:
Lortab medication count was over 25 tablets on 10/13/10,
Lortab medication count was over 10 tablets on 10/18/10,
Lortab medication count was short 24 tablets on 10/13/10,
Lortab medication count was short 10 tablets on 10/14/10;

Patient #14:
Lortab medication count was short 1 tablet on 10/13/10,
Tramadol (Ultram) medication count was 10 tablets over on 10/13/10,
Clorazepate (Tranxene) medication count was 1 tablet over on 10/14/10;

Patient #15:
Lortab medication count was over 10 tablets on 10/14/10;

Patient #17:
Lortab medication count was short 10 tablets on 10/18/10,
Lortab medication count was short 10 tablets on 10/19/10,
Lortab medication count was over 10 tablets on 10/19/10;

Patient #16:
Zolpidem (Ambien) medication count was short 10 tablets on 10/15/10,
Zolpidem (Ambien) medication count was over 10 tablets on 10/15/10;

Patient #17:
Zolpidem (Ambien) medication count was over 1 tablet on 10/15/10.

During the same observation of the Omnicell System on 10/20/10 from 1:20 p.m. through 3:00 p.m. with S3 Pharmacy Director, he verified there were 18 narcotic medication discrepancies in the Omnicell system. He confirmed the above findings for Patient #1, #2, #14, #15, #16, #17.

In another interview on 10/27/10 at 2:30 p.m., S3, Pharmacy Director indicated there was no " Narcotic Discrepancy" policy developed, revised, or reviewed by Pharmacy to resolve the 18 narcotic medication discrepancies identified by the surveyor on 10/20/10.

Further review of the hospital ' s current Policy and Procedure Manuals revealed there was no policy to address the narcotic medication discrepancies in the Omnicell System presented during the survey from 10/20/10 through 10/27/10.

Based on record reviews and interview, the Rehabilitative Services failed to obtain a written order from the practitioner prior to providing the patients with the written treatment plan as evidenced by providing patients with the written treatment plan for Physical Therapy, Occupational Therapy and Speech Therapy without a written physician's order for 6 of 6 patient records focused for rehabilitative services out of a total sample of 21 patient records reviewed, (Patient #1, #2, #3, #14, #16, #17).
Findings:

Patient #1:
Review of #1's medical record revealed the patient was admitted to the hospital on 10/12/10. Further review of the record revealed Physical Therapy treated the patient for 7 days (10/14, 10/15, 10/18, 10/19, 10/20, 10/21, 10/22), Occupational Therapy treated the patient for 9 days, (10/14, 10/15, 10/16, 10/18, 10/19, 10/20, 10/21, 10/22, 10/25) and Speech Therapy treated the patient for 12 days, (10/14, 10/15, 10/18, 10/19, 10/20, 10/21, 10/22, 10/25, 10/26, 10/27, 10/28, 10/29) without a physician's order to provide Physical Therapy, Occupational Therapy and/or Speech to Patient #1.
Patient #2:
Review of #2's medical record revealed the patient was admitted to the hospital on 10/13/10. Further review of the record revealed Physical Therapy treated the patient for 8 days (10/15, 10/16, 10/18, 10/19, 10/20, 10/21, 10/22, 10/25), Occupational Therapy treated the patient for 7 days, (10/15, 10/18, 10/19, 10/20, 10/21, 10/22, 10/25) without a physician's order to provide Physical Therapy and Occupational Therapy to Patient #2.
Patient #3:
Review of #3's medical record revealed the patient was admitted to the hospital on 10/8/10. Further review of the record revealed Physical Therapy treated the patient for 5 days (10/11, 10/12, 10/13, 10/14, 10/15), Occupational Therapy treated the patient for 9 days, (10/11, 10/12, 10/13, 10/14, 10/15, 10/18, 10/19, 10/20, 10/21) and Speech Therapy treated the patient for 7 days, (10/11, 10/12, 10/13, 10/18, 10/19, 10/20, 10/21) without a physician's order to provide Physical Therapy, Occupational Therapy and/or Speech to Patient #3.
Patient #14:
Review of #14's medical record revealed the patient was admitted to the hospital on 9/30/10. Further review of the record revealed Physical Therapy treated the patient for 13 days (10/2, 10/4, 10/5, 10/6, 10/7, 10/8, 10/11, 10/12, 10/13, 10/14, 10/15, 10/18, 10/19), Occupational Therapy treated the patient for 13 days, (10/2, 10/4, 10/5, 10/6, 10/7, 10/8, 10/11, 10/12, 10/13, 10/14, 10/15, 10/18, 10/19) and Speech Therapy treated the patient for 9 days, (10/4, 10/5, 10/6, 10/8, 10/11, 10/12, 10/13, 10/19, 10/20) without a physician's order to provide Physical Therapy, Occupational Therapy and/or Speech to Patient #14.
Patient #16:
Review of #16's medical record revealed the patient was admitted to the hospital on 10/8/10. Further review of the record revealed Physical Therapy treated the patient for 12 days (10/11, 10/12, 10/13, 10/14, 10/15, 10/18, 10/19, 10/20, 10/21, 10/22, 10/25, 10/26), Occupational Therapy treated the patient for 12 days, (10/11, 10/12, 10/13, 10/14, 10/15, 10/18, 10/19, 10/20, 10/21, 10/22, 10/25, 10/26) and Speech Therapy treated the patient for 13 days, (10/11, 10/12, 10/13, 10/14, 10/15, 10/18, 10/19, 10/20, 10/21, 10/22, 10/25, 10/26, 10/27) without a physician's order to provide Physical Therapy, Occupational Therapy and/or Speech to Patient #16.
Patient #17:
Review of #17's medical record revealed the patient was admitted to the hospital on 10/14/10. Further review of the record revealed Physical Therapy treated the patient for 6 days (10/18, 10/19, 10/20, 10/21, 10/22, 10/25), Occupational Therapy treated the patient for 6 days, (10/18, 10/19, 10/20, 10/21, 10/22, 10/25) and Speech Therapy treated the patient for 3 days, (10/18, 10/19, 10/21) without a physician's order to provide Physical Therapy, Occupational Therapy and/or Speech to Patient #17.
In an interview on 10/27/10 from 10:30 a.m. through 10:50 a.m., S16 Rehab Director indicated there was no physician ' s order for the rehabilitative services for Patients #1, #2, #3, #14, #15, #16, #17 prior to providing Physical Therapy, Occupational Therapy and/or Speech Therapy services as per the "Therapy " policy.
Review of the policy titled, "Therapy Orders" , Policy No.: II-E.6.00, Issued date of 10/05, Revised date of 4/10, with no reviewed date, page 1 of 1, revealed the therapist will check the medical record for order of therapy services. The policy indicated the therapy evaluates and recommends treatment plan with the physician and a physician's order for the plan of treatment will be obtained.

Based on record reviews, interviews, and observation, the facility failed to identify discrepancies of errors in medication administration with the use of the Omnicell electronic medication system resulting in inaccurate tracking of the Schedule II - IV medications. This failure to identify discrepancies resulted in the facility's failure to monitor the effectiveness of the facility's electronic medication system and to monitor the safety of the electronic medication system in providing quality patient care.
Findings:

During an observation of the Omnicell System on 10/20/10 from 1:20 p.m. through 3:00 p.m. with S3 Pharmacy Director, there were 18 narcotic medication discrepancies noted in the Omnicell at this time. Further observation revealed the Omnicell kept a medication count of all narcotic medications in the system. The 18 narcotic medication discrepancies identified by the surveyor did not match the medication count in the Omnicell. The 18 narcotic medications had discrepancies with the Omnicell ' s medication counts were short or over tablets of medication. The 18 narcotic medication count discrepancies were as follows:
Patient #1:
Percocet medication count was over 2 tablets on 10/17/10;

Patient #2:
Lortab medication count was over 25 tablets on 10/13/10,
Lortab medication count was over 10 tablets on 10/18/10,
Lortab medication count was short 24 tablets on 10/13/10,
Lortab medication count was short 10 tablets on 10/14/10;

Patient #14:
Lortab medication count was short 1 tablet on 10/13/10,
Tramadol (Ultram) medication count was 10 tablets over on 10/13/10,
Clorazepate (Tranxene) medication count was 1 tablet over on 10/14/10;

Patient #15:
Lortab medication count was over 10 tablets on 10/14/10;

Patient #16:
Zolpidem (Ambien) medication count was short 10 tablets on 10/15/10,
Zolpidem (Ambien) medication count was over 10 tablets on 10/15/10;

Patient #17:
Zolpidem (Ambien) medication count was over 1 tablet on 10/15/10.
Lortab medication count was short 10 tablets on 10/18/10,
Lortab medication count was short 10 tablets on 10/19/10,
Lortab medication count was over 10 tablets on 10/19/10.

During the same observation of the Omnicell System on 10/20/10 from 1:20 p.m. through 3:00 p.m. with S3 Pharmacy Director, he verified there were 18 narcotic medication discrepancies in the Omnicell system. He confirmed the above findings for Patient #1, #2, #14, #15, #16, #17.

In interview on 10/27/10 at 2:30 p.m., S3Pharmacy Director confirmed the following medication errors:
Patient #1 had 1 medication error for Percocet on 10/17/10.
Patient #14 had 2 medication errors for Tranxene on 10/14/10 and 10/15/10.
Patient #17 had 1 medication error for Ambien on 10/15/10.

During the same interview on 10/27/10 at 2:30 p.m., S3Pharmacy Director indicated the contracted Pharmacy needed a system in place to readily and promptly track and identify all narcotic medication discrepancies for overages as well as shortages.

On 10/27/10 at 3:11 p.m., an interview with S2DON was conducted. She stated there was only one documented medication error for the 2nd quarter (April, May, and June). She added there were no errors documented by the pharmacist for this quarter. S2DON also stated she had not identified any problems with the medication administration monitoring because the pharmacist had not provided her with any discrepancies. She stated, according to the QI committee, checking the MARs for discrepancies had improved since they now require the night nurse to conduct a 24 hr chart check each night. She confirmed that the mistakes on the MARs had improved this quarter since the previous quarter.

Based on record reviews, observation and interviews, the hospital failed to ensure narcotic medications were administered in accordance with Federal and State laws, the orders of the practitioners responsible for the patient's care specified as specified under ?482.12(c), and accepted standards of practice as evidenced by having 6 medication errors with no "Occurence Report" Forms completed in the specified timeframe of 24 hours as per the "Medication Administration Error" and "Risk Managemment" policies for 3 of 6 patient records focused for medication administration out of a total of 21 patient records reviewed, (Patient #1, #14, #17).
Findings:
During an observation of the Omnicell System on 10/20/10 from 1:20 p.m. through 3:00 p.m. with S3Pharmacy Director, there were 18 narcotic medication discrepancies noted in the system at this time. Further observation revealed the narcotic medication counts did not match the count kept by the Omnicell System. There were 4 medication errors identified out of the total 18 narcotic medication discrepancies observed in the Omnicell System. The 4 medication errors were as follows:
Patient #1:
Percocet medication count was over 2 tablets on 10/17/10.

Patient #14:
Clorazepate (Tranxene) medication count was 1 tablet over on 10/14/10.
Clorazepate (Tranxene) medication count was 1 tablet over on 10/15/10.

Patient #17:
Zolpidem (Ambien) medication count was over 1 tablet on 10/15/10.

During the same observation of the Omnicel System on 10/20/10 from 1:20 p.m. through 3:00 p.m. with S3 Pharmacy Director, he verified the narcotic medications for Patient #1, #14 and #17 were over tablets of medication.

In interview on 10/27/10 at 2:30 p.m., S3Pharmacy Director confirmed the following medication errors:
Patient #1 had 1 medication error for Percocet on 10/17/10.
Patient #14 had 2 medication errors for Tranxene on 10/14/10 and 10/15/10.
Patient #17 had 1 medication error for Ambien on 10/15/10.
At the time of this interview, the Pharmacy Director indicated there were no "Occurrence Report" forms completed for the 4 medication errors for Patient #1, #14, or #17 as per policy in 24 hours. He stated the nursing staff did not follow the "Medication Administration" policy to complete an "Occurrence Report" form for all missed medication administrations or medication errors within 24 hours.

A face-to-face interview was held on 10/27/10 at 3:30 p.m. with the Director of Nursing (DON), S2. S2 indicated Patient #1 had a missed medication administration of Percocet on 10/17/10. She stated a missed medication administration is a medication error. She indicated Patient #1 was not administered the Percocet medication because the medication count was over two (2) tablets at 11:05 p.m. on 10/17/10. The DON reported all missed medication administrations and medication errors both require an "Occurrence Report" form to be completed by the nurse within 24 hours that the discrepancy occurred as per the "Medication Error" policy. She reported the nurse, S7RN did not fill out an "Occurrence Report" form as per policy nor was the report form submit to Pharmacy in 24 hours as per policy. The DON stated Pharmacy did not send a copy of the " Occurrence Report " form to investigate whether or not the patient (#1) had a missed medication administration and medication error as of today, 10/27/10.
In the same face-to-face interview on 10/27/10 at 4:05pm, S2 indicated Patient #14 had 2 medication errors for the 2 missed medication administrations of Tranzene medications on 10/14/10 and 10/15/10. S2DON indicated the nurse did not follow the policy to complete an "Occurrence Report" forms for the 2 medication errors of Tranzene medications on 10/14/10 or 10/15/10.
During a face-to-face interview on 10/27/10 at 2:10 p.m., S3 Pharmacy Director indicated the Ambien medication count for Patient #17 was over one (1) tablet of medication on 10/15/10. He reported this is a missed medication administration or medication error that requires an "Occurrence Report" form to be completed as per policy within 24 hours. He indicated there was no " Occurrence Report " form submitted to Pharmacy as per policy.
An interview on 10/27/10 at 3:25 p.m. was conducted with S2DON. S2 indicated the Ambien medication count in the Omnicell system was over one (1) tablet of medication for Patient #17 on 10/15/10. She stated this is a medication error for #17 because the Ambien count in the Omnicell system was one (1) tablet over of medication on 10/15/10. S2DON stated a missed medication administration is a medication error that required an "Occurrence Report" form to be completed as per policy. S2DON indicated the staff did not follow the policy to complete an "Occurrence Report" form for #17's missed medication administration of Ambien on 10/15/10.
Review of the policy titled, " Medication Administration Error " , Policy No: II-F.7.08, page 1 of 2, page 2 of 2, Issued date of 10/05, with no revised or reviewed dates, presented as current " Medication Administration Error " policy on 10/25/10 at 12:00 pm revealed drug administration errors are written when drug is not given as it is ordered (must give the reason it is not given, except when refused, then see refused medication policy). The policy indicated when the medication is improperly administered, or the following procedure is used to notify Director of Nursing of Assistant Director of Nursing, notify physician immediately, record occurrence in nurses notes and complete " Medication Variance " forms and take to the Nursing Director ' s office. The Nursing Director will file it with the Incident Report form in the Administrative file and in the Nurses file. Patient is to be monitored as per physician ' s order. Consultant Pharmacist will be notified on next visit on all drug reactions.
The policy titled, "Risk Management Plan", Policy No: I-E.5.00, page 1 of 7, page 2 of 7, with no revised or reviewed dates, presented as current hospital policy, "Incident Reports", was reviewed. The policy section titled, "Reporting Occurrences" indicated all employees and health care providers of the hospital are required to report any "reportable incident" to the Risk Manager, Adm. (administrator), definition of the term "reportable incident" is as an act by a health care provider which is or may be below the acceptable standard of care and has reasonable probability of causing injury to a patient; or may be grounds for disciplinary action by the appropriate licensing agency. When a reportable incident is identified, the person with knowledge of the incident completes the hospital incident report form for the risk management program. The form is available to staff in each department of the facility. All reportable incidents are to be reported to the DON within 24 hours of their discovery.
Record review of the facility's policy titled, "Medication Errors", Policy #:I-E.5.05, Issued date of 10/05, with no revised or reviewed dates, page 1 of 4, page 2 of 4, page 3 of 4, presented on 10/26/10 as the hospital ' s current " Medication Errors " policy revealed a medication error is broadly defined as a dose of medication that deviates from the physician's orders as written in the patient's chart or from standard hospital policy and procedures. There were 11 types of errors. An " Omission Error " is defined as the failure to administer an ordered dose to a patient before the next scheduled dose, if any. Assumes no prescribing error--excluded would be: A patient's refusal to take the medication. A decision not to administer the dose because of recognized contraindications. If an explanation for the omission is apparent (e.g., patient was away from nursing unit for tests or medication was not available), that reason should be documented in the appropriate records. A " Monitoring Error " is defined as the failure to review a prescribed regimen for appropriateness and detecting of problems, or failure to use appropriate clinical or laboratory data for adequate assessment of patient responses to prescribed therapy. The policy indicated that medication errors will be further categorized according to one of the five steps in Medication-Use Process as follows: Prescribing, Dispensing, Administering, Monitoring, and Systems/Management Control.
Record review of the facility's policy entitled, "Management of Medication Errors", Policy No: I-E.5.06, page 1 of 3, page 2 of 3 and page 3 of 3, presented on 10/16/10 at 2:00 pm as the hospital ' s current " Medication Errors Management " policy defines Medication Error as any preventable event that may cause or lead to inappropriate medication uses or patient harm while the medication is in the control of the health care professional or patient. Such events may be related to professional practice, health care products, procedures and systems, including prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.
The policy titled, "Medication Administration" , Policy No: II-C.3.05, page 3 of 4, page 4 of 4, Issue date of 10/05 and revised date of 04/10, with no reviewed date, presented as the hospital' s current, "Medication Administration" policy on 10/27/10 at 2:00 pm, was reviewed. The policy section titled, "Documentation" indicated "all medication documentation will be listed on the patient' s MAR. If a PRN dose is given, the medicine name, strength, route, time and reason given should also be charted in the nurse's flow sheet. The patient's response to medication should be charted in a timely manner depending on medication given." The section titled, "PRN Medication" indicated "all PRN medications administered should be charted on both the MAR and nurses ' flow sheet." The section entitled, "Narcotics" indicated "Narcotics are all schedule II medications. Errors of discrepancies in the count must be reported to the charge nurse, supervisor, and contracted pharmacist. Any narcotic errors must carry an incident report, when errors in medication given-overage-shortage, etc. occur there will be evaluations done as minor and major. Occurrences will also require review by the contracted Pharmacy and/or DON/CEO."
The policy titled, "Patient Care Documentation (Nursing)", Policy No: II-C.4.00, page 2 of 4, presented as the hospital's current, "Patient Care Documentation" policy on 10/25/10 at 12:00 pm was reviewed. The policy indicated the "Acute Rehab Patient Care Flow Sheet", section "Notes/Interventions/Evaluation by the RN and/or LPN must document interventions and evaluations in an ongoing fashion (as they occur). The section titled, "Medication Administration Record (MAR)", indicated a missed dose will trigger an incident report for a medication error. The incident report is to be completed by the nurse who discovers the medication error.
The policy titled, "Record Keeping", Policy No: II-F.7.10, page 1 of 1, Issue date of 10/05, with no revised or reviewed dates, presented on 10/25/10 at 12:00 pm as current "Record Keeping" policy was reviewed. The policy section titled, "Charting Routine Drugs Administered and Charting PRN Drugs", indicated initial each medication given on the day it was given, When a PRN medicaiton is given, write it in the Nurses Notes: time, complaints, medications, dose, route, nurses, and response. Write PRN medication given on back of that same Mar. (MAR) Sheet: time, complaint, medication, nurses and response. When a PRN medication is not given for any reason, chart this in the Nurses Notes and circle the space on the medication sheet. The section titled, "Records for Controlled Drugs" indicated a narcotic record shall is maintained by the contracted pharmacy named via report of the Omnicell indicating the type and strength of narcotics. This record shall be recorded on the Nurses Notes unless ordered for a specific time. Review of the section titled, "Charting of Missed Drugs" indicated missed drugs are charted on the Nurses Notes as to time, reason drug not given. The nurse should also circle time on the medication sheet.
The policy titled, "Patient Care Documentation (Nursing)", Policy No: II-C.4.00, page 2 of 4, presented as the hospital's current, "Patient Care Documentation" policy on 10/25/10 at 12:00 pm was reviewed. The policy indicated the "Acute Rehab Patient Care Flow Sheet", section "Notes/Interventions/Evaluation by the RN and/or LPN must document interventions and evaluations in an ongoing fashion (as they occur). The section titled, "Medication Administration Record (MAR)", indicated a missed dose will trigger an incident report for a medication error. The incident report is to be completed by the nurse who discovers the medication error.
The policy titled, "Record Keeping", Policy No: II-F.7.10, page 1 of 1, Issue date of 10/05, with no revised or reviewed dates, presented on 10/25/10 at 12:00 pm as current "Record Keeping" policy was reviewed. The policy section titled, "Charting Routine Drugs Administered and Charting PRN Drugs", indicated "initial each medication given on the day it was given, When a PRN medication is given, write it in the Nurses Notes: time, complaints, medications, dose, route, nurses, and response. Write PRN medication given on back of that same Mar. (MAR) Sheet: time, complaint, medication, nurses and response. When a PRN medication is not given for any reason, chart this in the Nurses Notes and circle the space on the medication sheet." The section titled, "Records for Controlled Drugs" indicated "a narcotic record shall is maintained by the contracted pharmacy named via report of the Omnicell indicating the type and strength of narcotics. This record shall be recorded on the Nurses Notes unless ordered for a specific time." Review of the section titled, "Charting of Missed Drugs" indicated "missed drugs are charted on the Nurses Notes as to time, reason drug not given. The nurse should also circle time on the medication sheet."
The policy titled, "Patient Care Documentation (Nursing)", Policy No: II-C.4.00, page 2 of 4, presented as the hospital's current, "Patient Care Documentation" policy on 10/25/10 at 12:00 pm was reviewed. The policy indicated the "Acute Rehab Patient Care Flow Sheet", section "Notes/Interventions/Evaluation by the RN and/or LPN must document interventions and evaluations in an ongoing fashion (as they occur)." The section titled, "Medication Administration Record (MAR)", indicated "a missed dose will trigger an incident report for a medication error. The incident report is to be completed by the nurse who discovers the medication error."
Record review of the facility's policy titled, "Medication Errors", Policy #:I-E.5.05, Issued date of 10/05, with no revised or reviewed dates, page 1 of 4, page 2 of 4, page 3 of 4, presented on 10/26/10 as the hospital's current "Medication Errors" policy revealed "a medication error is broadly defined as a dose of medication that deviates from the physician's orders as written in the patient's chart or from standard hospital policy and procedures." There were 11 types of errors. An "Omission Error" is defined "as the failure to administer an ordered dose to a patient before the next scheduled dose, if any. Assumes no prescribing error--excluded would be: A patient's refusal to take the medication. A decision not to administer the dose because of recognized contraindications. If an explanation for the omission is apparent (e.g., patient was away from nursing unit for tests or medication was not available), that reason should be documented in the appropriate records. A "Monitoring Error" is defined as the failure to review a prescribed regimen for appropriateness and detecting of problems, or failure to use appropriate clinical or laboratory data for adequate assessment of patient responses to prescribed therapy." The policy indicated that "medication errors will be further categorized according to one of the five steps in Medication-Use Process as follows: Prescribing, Dispensing, Administering, Monitoring, and Systems/Management Control."
The facilities' policy titled, "Management of Medication Errors", was reviewed. The section titled, "Procedure" indicated "employees are expected to report medication errors and potential medication errors via the Medication Error and Adverse Drug Reaction Report. The Director of Nursing shall be responsible for investigating and documenting the circumstances of the error."

Record review of the facility's policy entitled, "Management of Medication Errors", Policy No: I-E.5.06, page 1 of 3, page 2 of 3 and page 3 of 3, presented on 10/16/10 at 2:00 pm as the hospital's current "Medication Errors Management" policy defines "Medication Error" as "any preventable event that may cause or lead to inappropriate medication uses or patient harm while the medication is in the control of the health care professional or patient. Such events may be related to professional practice, health care products, procedures and systems, including prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use."
Review of the policy titled, "Medication Administration Error" , Policy No: II-F.7.08, page 1 of 2, page 2 of 2, Issued date of 10/05, with no revised or reviewed dates, presented as current "Medication Administration Error" policy on 10/25/10 at 12:00 pm revealed "drug administration errors are written when a drug is not given as it is ordered (must give the reason it is not given, except when refused, then see refused medication policy)." The policy indicated "when the medication is improperly administered, or the following procedure is used to notify Director of Nursing of Assistant Director of Nursing, notify physician immediately, record occurrence in nurses notes and complete " Medication Variance " forms and take to the Nursing Director's office. The Nursing Director will file it with the Incident Report form in the Administrative file and in the Nurses file. Patient is to be monitored as per physician's order. Consultant Pharmacist will be notified on next visit on all drug reactions."
The policy titled, "Risk Management Plan", Policy No: I--E.5.00, page 1 of 7, page 2 of 7, with no revised or reviewed dates, presented as current hospital policy, "Incident Reports", was reviewed. The policy section titled, "Reporting Occurrences" indicated all employees and health care providers of the hospital are required to report any "reportable incident" to the Risk Manager, Adm. (administrator), definition of the term "reportable incident" is as an act by a health care provider which is or may be below the acceptable standard of care and has reasonable probability of causing injury to a patient; or may be grounds for disciplinary action by the appropriate licensing agency. When a reportable incident is identified, the person with knowledge of the incident completes the hospital incident report form for the risk management program. The form is available to staff in each department of the facility. All reportable incidents are to be reported to the DON within 24 hours of their discovery.
Review of the policy titled, "Risk Management Plan" , Policy No: I-E.5.02, page 4 of 7, Issued date of 10/05, with no revised or reviewed dates, presented as hospital's current "Risk Management Plan" on 10/25/10 at 2:00 pm, revealed the section titled, "Data Compilation and Analysis" indicated data collected by risk management falls into, but is not limited to, the following the Patient related Medication Error and policy and procedure not followed areas.