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Based on record review and interview the hospital failed to ensure a Registered Nurse supervise the nursing care provided for each patient by failing to ensure handoff communication was accurate for 1 of 8 sampled patients (Patient #5) . Findings:

Review of physician's orders for Patient #5 dated 1/15/10 at 7:00 a.m. revealed an order for Levoxyl (Levothyroxine) 175 micrograms by mouth daily.

Review of Pharmacy Courier Log dated 1/15/2010 at 9:27 a.m. revealed one Levothryoxine 25 microgram tablet and one Levothryoxine 150 microgram tablet was dispensed to the Emergency Department. Review of a log of medication dispensed by the pharmacy and/or the Pyxis dispensing machine revealed two Levothyroxine 150 microgram tablets and two Levothyroxine 25 microgram tablets were dispensed from pharmacy on 1/16/2010 for Patient #5.

Review of the Patient #5's entire medical record revealed no documented evidence of the administration of Levoxyl in the Emergency Department. The first documented dose of Levoxyl was located on the Medication Administration Record on 1/16/2010 at 6:45 a.m.

An interview was conducted on 1/25/2010 at 2:30 p.m. with Registered Nurse (RN) S34 and Licensed Practical Nurse (LPN) S35.
S35 indicated she was assigned to Patient #5 for several hours during the morning of 1/15/2010 but then transferred the care of Patient #5 to RN S34 (documented in the electronic medical record as 10:15 a.m.). LPN S35 indicated she administered morning medications to Patient #5 and documented the administration in the H.I.S. computerized system because the patient was a boarder at that time (admitted to the hospital with no beds available and being held in the Emergency Department). LPN S35 indicated she did not recall administering Levoxyl to Patient #5.
RN S34 indicated she recalled receiving report from LPN S35 on the morning of 1/15/10. RN S34 indicated a code was en route to the Emergency Department at the time and medications were being delivered for Patient #5 from the Pharmacy at the same time. RN S34 indicated she asked LPN S34 to placed dots on the order sheet in front of the medications that she had administered to Patient #5 in order to clarify which medications had already been given.
Review of Patient #5's physician's orders dated 1/15/2010 at 7:00 a.m. revealed dots in front of Plavix, Amlodipine, Isorbide, Simvastatin, Metoprolol, Levoxyl, and Hydroxychloroquine.
LPN S35 indicated she was the person that placed dots in front of Patient #5's physician's orders. She further indicated she did this as per the request from RN S34 to indicate which medications she had administered to Patient #5 in the Emergency Department. LPN S35 indicated she had no recall of administering Levoxyl to Patient #5. LPN S35 confirmed there was no documented evidence of Patient #5 receiving Levoxyl in the Emergency Department on 1/15/2010. LPN S35 also confirmed the delivery as per Pharmacy Courier of Levoxyl to the Emergency Department on 1/15/2010 at 9:24 a.m. LPN S35 indicated LPN S21 had assisted her in administering medications that morning.

During a speakerphone telephone interview in the presence of LPN S35 and RN S34 on 1/25/2010 at 2:40 p.m., Licensed Practical Nurse (LPN) S21 indicated she recalled the three nurses (S21, S34, and S35) having a conversation about Patient #5. S21 further indicated she remembered medications being delivered to the Emergency Department for Patient #5. S21 indicated she did not remember administering any medications to Patient #5. LPN S35 and RN S34 indicated they were uncertain if Patient #5 received the Levoxyl that was delivered to the Emergency Department. LPN S35 indicated she did not know if the dots placed on the Physician's orders were an accurate or inaccurate reflection of medications administered to patient #5.

Review of the hospital policy titled, "Consultation and Direct Admit Guidelines, #7010-21" presented by the hospital as their current policy revealed in part, "It is essential that the patient be moved to the assigned bed in the hospital once all the following criteria have been meet. . . 3. Report has been called/faxed to the unit nurse assuming responsibility for the patient."

Review of the hospital policy titled, "Transfers Between Inpatient Units, #8720-61" presented by the hospital as their current policy revealed in part, "The sending nurse must give report to the receiving nurse prior to transfer. However, if the sending nurse will accompany the patient to the receiving unit, the receiving nurse may elect to hear report at the bedside. Report should address the following: 1. Review of care plan/ active and potential problems, interventions, progress 2. Review of teaching done and patient response 3. Review of medical plan/ treatment, progress, physician orders, transfer packet 4. Review of pertinent physiologic parameters/ vital signs, IVs, medications, last pain medication and response. . . "

Review of a document titled, "Mosby's Nursing Skills, Change of Shift Report" presented by the hospital as their current protocol for hand-off communication between shifts and when transferred from one area to another revealed in part, "Critical Care areas use bedside rounding for report. Medical Surgical and other areas utilize Optivox as available. . . Use an organized format for delivering the report that includes a description of patient's needs and concerns. For each patient, the following information may be included: . . . Describe therapies or treatments administered during shift and expected outcomes. . . Clarify: Ask staff from oncoming shift if they have any questions regarding information reported. Do not leave until this has been done."

Based on record review and interview the hospital failed to ensure medications were administered in accordance with physician's orders and hospital policy for 3 of 8 sampled patients (#2, #3, #4). Findings:

Patient #2:

Review of Patient #2's medical record revealed an order dated 1/14/2010 at 8:13 a.m. for Zosyn 3.375 grams Intravenously x 1 now. Further review revealed a physician's order dated 1/14/2010 at 11:15 a.m. for Levaquin 500 milligrams by mouth daily, first dose now.

Review of Patient #2's entire medical record revealed no documented evidence the now dose of Levaquin was administered on 1/14/2010. Further review revealed the "now" dose of Zosyn was not started on Patient #2 until 11:47 a.m. on 1/14/10 (3 hours and 34 minutes after the medication was ordered).

During a face to face interview on 1/25/2010 at 12:30 p.m., Director of Pharmacy S7 indicated there was no indication in the pharmacy dispensing logs that Patient #2 ever received the now dose of Levaquin. S7 further indicated there was no policy in the hospital to indicated the administration time frames required for administering medications ordered to be given "now". S7 further indicated it did not seem timely to administered "now" medications 3 hours and 34 minutes after the order.

Patient #3:

The medical record of Patient #3 revealed the patient was admitted to the hospital on 1/14/10 and discharged on 1/19/10 with diagnoses that included Alcohol Withdrawal, Alcohol Abuse, and Rhabdomyolysis.

Review of Patient #3's physician's orders dated 1/15/10 at 0605 (6:05 a.m.) revealed an order for Micro K (Potassium) 50 milliequivalents by mouth now, Potassium Chloride 20 milliequivalents IVPB (Intravenous piggy back) , and repeat Potassium in 4 hours.

Review of Emergency Department Nursing Notes regarding Patient #3 revealed the following:
1/15/10 at 0544 (5:44 a.m.), Note: (Physician) paged for potassium of 2.9.
1/15/10 at 0615 (6:15 a.m.), Note: Spoke with (physician's name). Informed of low potassium and tachycardia. New orders given. Stat request for meds (medications) sent to pharmacy.
1/15/10 at 0810 (8:10 a.m.), Potassium Chloride 50 milliequivalents PO (by mouth) given (2 hours and 5 minutes after the "now" dose was ordered).
1/15/10 at 0815 (8:15 a.m.), Plan of Care: attempting to obtain K+ (Potassium) riders from pharmacy, unavailable at this time in Pyxis.
1/15/10 at 1230 (12:30 p.m.), KCL (Potassium Chloride) 10 meq (milliequivalents) in 100 cc of NS (Normal Saline) added at 100cc/h (per hour) (Order indicated 20 milliequivalents IVPB).
1/15/10 at 1416 (2:16 p.m.), KCL 10 meq in 100 cc NS added at 100 cc/h per pump.
1/15/10 at 1515 (3:15 p.m.), Repeat K+ sent (order written at 6:05 a.m. indicated Repeat Potassium in 4 hours).

During a face to face interview on 1/25/10 at 9:50 a.m., Pharmacy Director S7 and Director of Accreditation S8 indicated the hospital policy regarding administration of Potassium Intravenously required that any piggy back greater than 10 milliequivalents be given in a Central Line and not a peripheral line; therefore, since Patient #3 only had a peripheral line, he would only be able to receive 10 milliequivalents runs of Potassium.

Review of the hospital policy titled, "Electrolyte Preparation and Administration in Adult Patient Care Areas, #8610-PC-57" presented by the hospital as their current policy revealed in part, "Summary of Potassium Infusion Policy, Maximum amount in 100 ml. (milliliters) IVPB (Intravenous Piggy Back) Concentrations, Peripheral Line: 20 mEq/100 ml (20 milliequivalents in 100 milliliters)."

During a face to face interview on 1/25/10 at 1:45 p.m., Director of Pharmacy S7 indicated it had not been the practice of the pharmacy to administer Intravenous Piggybacks greater than 10 milliequivalents in Peripheral IVs. S7 further indicated she had thought hospital policy supported that practice. S7 confirmed that current hospital policy allowed up to 20 milliequivalents of Potassium to be administered in 100 cc of IVPB fluid in a peripheral IV. S7 confirmed that physician's orders to administer 20 milliequivalents of Potassium IVPB had not been followed. Director of Pharmacy S7 further indicated there was no policy in the hospital to indicate the time frame for administering a "now" medication. S7 indicated Patient #3's receipt of a "now" dose of Micro K 50 milliequivalents at 8:10 a.m. when the order was given at 6:05 a.m. did not seem timely (2 hours and 5 minutes after order was given).

Patient #4:

Review of Patient #4's medical record revealed an order dated 1/17/2010 with no documented time for Accupril 10 milligrams by mouth every morning. Further review revealed the first dosage of medication was administered on 1/17/2010 at 1400 (2:00 p.m.).

During a face to face interview on 1/25/2010 at 10:05 a.m., the Director of Pharmacy S7 indicated the time for administration of morning medications was 9:00 a.m. She further indicated if an order was received after the normal administration time, the nurse would need an order from the physician to give the first dose outside normal administration time as per hospital policy. S7 indicated it seemed to be the pharmacist that altered the first dose time on the Medication Administration Record. S7 indicated the Pharmacist should have followed hospital policy.

Review of the hospital policy titled, "Medication Administration Times, #8610-PC-48" presented by the hospital as their current policy revealed in part, "Medications given at times other than those on routine times must be ordered by the physician. If the standard time has passed and the physician would like the patient to receive the dose then they can write "today and routine. When it is not clear that an order should be started at the next standard time, the patient's nurse will contact the physician who wrote the order and clarify the time on the order. . . ".

Review of the hospital policy titled, "Medication Distribution for Inpatient Care Areas, #8610-PC-43" presented by the hospital as their current policy revealed in part, "In an effort to minimize turnaround time and promote timeliness of medication order processing the following criteria have been developed for processing medication orders. Order Status: STAT (immediately)/ Turnaround time: 30 minutes. Order Status: ASAP (As soon as possible)/ Turnaround time 60 minutes. Order Status: Routine/ Turnaround time 2 hours. Further review revealed no documented evidence of the turnaround time for "now" orders.

Based on record review and interview the hospital failed to ensure entries in the medical records were complete by:
1) failing to time entries for 2 of 8 sampled patients (#1, #4)
2) failed to ensure documentation errors were corrected according to hospital policy for 1 of 1 documentation error reviewed (Patient #4) out of a total sample of 8.
3) failing to ensure documentation of medications administered to Emergency Department patients, from admit orders, were documented in the H.I.S. system as directed by Emergency Department administration. Findings:

1) failing to time entries:

Review of Patient #1's physician's order dated 1/13/2010 revealed no documented evidence of the time the order was written.

Review of Patient #4's physicians' orders dated 1/15/2010 and 1/17/2010 revealed no documented evidence of the time the orders were written.

Review of the hospital policy titled, "Documentation, General Nursing, #8720-75" presented by the hospital as their policy to address physician's timing of entries (although titled indicates it is a nursing policy) revealed in part, "All entries will include the date (month/date/year) and the time (based on 24 hour military clock)".


2) failed to ensure documentation errors were corrected according to hospital policy:

Review of Patient #4's physician's orders dated 1/15/2010 (no documented time) revealed an order for Nexium. The order had 80 written on top of another entry that was not legible for the dosage of the medication to be administered. There was no documentation of the date, time, or who changed the original entry. This finding was confirmed by the Director of Pharmacy (S7) and the Director of Accreditation (S8) on 1/22/2010 at 2:40 p.m. who further indicated the person correcting the error should have initialed and drawn a line through the error and then written the correction as per hospital policy.

Review of the hospital policy titled, "Documentation, General Nursing, #8720-75" presented by the hospital as their policy to address correction of documentation errors revealed in part, "If an error is discovered in the process of charting, draw a single line through the error so that it can still be easily read, initial, and continue charting on the same line."


3) failing to ensure documentation of medications administered to Emergency Department patients, from admit orders, were documented in the H.I.S. (electronic medical record program) system as directed by Emergency Department administration.

Review of an e-mail addressed to All Emergency Department Nursing staff dated 10/29/2009 at 3:30 p.m. presented by the Emergency Department Unit Director (S9) as current protocol revealed in part, " If you give a medication off the admit orders, it must be documented in H.I.S. (electronic medical record program used for in-patients) not All-Scripts (electronic medical record program used for Emergency Department patients). "

During a face to face interview on 1/22/2010 at 3:35 p.m., Charge Nurse, RN S13 indicated she worked on the night of 1/15/2010. S13 indicated there were some nurses on the shift that indicated they did not recall how to document in the H.I.S. system. RN S13 indicated the Emergency Department was exceptionally busy that night due to hospital saturation and many admitted patients were being held as boarders in the Emergency Department. RN S13 indicated the All-Scripts program allows for free texting and therefore the decision was made to document all administered medications in the free text of the All-Scripts program. RN S13 indicated the nursing staff on duty did not follow the protocol for documenting medication administration from admit orders in the H.I.S. computer system because they did not know how.

Based on record review and interview the hospital failed to ensure a pharmacist supervise all the activities of the pharmacy by:
1) failing to ensure hospital policy was followed regarding administration of medications for 1 of 8 sampled patients (Patient #3).
2) failing to ensure a hospital policy was developed and enforced regarding the time frames for administration of medications ordered "now".


Patient #3:

Review of Patient #3's physician's orders dated 1/15/10 at 0605 (6:05 a.m.) revealed an order for Micro K (Potassium) 50 milliequivalents by mouth now, Potassium Chloride 20 milliequivalents IVPB (Intravenous piggy back) , and repeat Potassium in 4 hours.

Review of Emergency Department Nursing Notes regarding Patient #3 revealed the patient received Micro K 50 millequivelents at 8:10 a.m.. Patient #3 also received Potassium 10 millequivelents in 100 cc of Normal Saline at 12:30 p.m. and 2:16 p.m.

During a face to face interview on 1/25/10 at 9:50 a.m., Pharmacy Director S7 and Director of Accreditation S8 indicated the hospital policy regarding administration of Potassium Intravenously required that any piggy back greater than 10 milliequivalents be given in a Central Line and not a peripheral line; therefore, since Patient #3 only had a peripheral line, he would only be able to receive 10 milliequivalents runs of Potassium.

Review of the hospital policy titled, "Electrolyte Preparation and Administration in Adult Patient Care Areas, #8610-PC-57" presented by the hospital as their current policy revealed in part, "Summary of Potassium Infusion Policy, Maximum amount in 100 ml. (milliliters) IVPB (Intravenous Piggy Back) Concentrations, Peripheral Line: 20 mEq/100 ml (20 milliequivalents in 100 milliliters)."

During a face to face interview on 1/25/10 at 1:45 p.m., Director of Pharmacy S7 indicated it had not been the practice of the pharmacy to administer Intravenous Piggybacks greater than 10 milliequivalents in Peripheral IVs. S7 further indicated she had thought hospital policy supported that practice. S7 confirmed that current hospital policy allowed up to 20 milliequivalents of Potassium to be administered in 100 cc of IVPB fluid in a peripheral IV. S7 confirmed that physician's orders to administer 20 milliequivalents of Potassium IVPB had not been followed. Director of Pharmacy S7 further indicated there was not policy in the hospital to indicate the time frame for administering a "now" medication. S7 indicated Patient #3's receipt of a "now" dose of Micro K 50 milliequivalents at 8:10 a.m. when the order was given at 6:05 a.m. did not seem timely (2 hours and 5 minutes after order was given).