Observations:
Based on clinical record and pharmacy record reviews, and staff interview, it was determined that the facility failed to ensure residents were free from significant medication error for three of the 22 residents reviewed (Residents 3, 67, and 81).
Findings include:
Review of Resident 3's clinical record revealed a diagnosis of seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain that can affect behavior, movements, feelings and consciousness.)
Review of Resident 3's physician orders from admission revealed an order for Phenytoin (medication used to control and prevent seizures) 100 milligrams (mg) once daily in the morning and 200 mg at bedtime.
Review of Resident 3's March 2024 Medication Administration Record (MAR) and progress notes revealed the resident missed Phenytoin doses due to awaiting pharmacy delivery on the following dates:
March 10, 2024, 100 mg in the morning March 11, 2024, 100 mg in the morning and 200mg at bedtime March 13, 2024, 100 mg in the morning March 14, 2024, 100 mg in the morning March 15, 2024, 100 mg in the morning
Review of the pharmacy documentation revealed Phenytoin was available on the facility's automated dispensing machine (Omnicell).
Interview with the Director of Nursing on March 15, 2024, at 2:30 p.m. confirmed Resident 3 should have received the abovementioned doses of Phenytoin.
Review of Resident 67's clinical record revealed Resident 67 was re-admitted on January 26, 2024, with Osteomyelitis (Infection to the bone) on the sacrum (tailbone).
Review of Resident 67's physician's order sheet (POS) dated January 26, 2024, at 7:38 p.m., revealed an order for Piperacillin Sod-Tazobactam (Antibiotic) Intravenous Solution 3.375 gm intravenously every six hours for wound infection. The medication administration was scheduled every 6:00 a.m., 12 noon, 6:00 p.m., and 12:00 a.m.
Review of Resident 67's January 2024 Medication Administration Record (MAR) revealed Resident 67 was not administered the ordered medication until January 28, 2024, at 6:00 p.m. The MAR revealed Resident 67 missed seven doses of the ordered Piperacillin (January 27, 2024, at 12:00 a.m., 6:00 a.m., 12 noon, 6:00 p.m., January 28, 2024, at 12:00 a.m., 6:00 a.m., and 12 noon).
Review of Resident 67's pharmacy documentation revealed medication Piperacillin was available on the facility's automated dispensing machine (Omnicell).
Review of Resident 67's clinical record failed to reveal the reason why medication was not administered.
Interview with Employee E3 was conducted on March 15, 2023, at 1:00 p.m. Employee E3 was not able to provide a reason as to why medication Piperacillin was missed seven times.
The facility failed to ensure Resident 67's medication to treat wound infection was administered as ordered.
Review of Resident 81's clinical record revealed Resident 81 was admitted to the facility on February 1, 2024, with an infected surgical wound to the mid-upper back. The resident had an order for Intravenous (Medication administered into a vein) Vancomycin (antibiotic) and Vancomycin trough (a Vancomycin check at least eight hours after the last dose).
Review of Resident 81's physician order revealed an order for Vancomycin HCL intravenously two times a day, scheduled at 9:00 a.m., and 9:00 p.m.
Review of Resident 81's laboratory results dated February 29, 2024, reported at 8:24 p.m., revealed a critical Vancomycin trough result of 27.7 (normal range 10-20).
Review of Resident 81's nursing progress notes dated March 1, 2024, at 3:22 a.m., revealed on call NP (nurse practitioner) was notified of the critical Vancomycin trough result and ordered to hold the IV Vancomycin, recheck Vancomycin level in the morning before next administration and have the in-house physician/NP see the resident and review blood work in the morning.
Review of Resident 81's NP's telehealth notes dated March 1, 2024, at 6:07 a.m., revealed laboratory result was reviewed, the Vancomycin trough was 27.7, recommended holding Vancomycin, repeating the Vancomycin trough, and checking the result before the next dose.
Review of Resident 81's physician order dated March 1, 2024, at 3:48 a.m., revealed an order for Vancomycin through, check result before IV administration.
Review of Residente 81's March 2024, Medication Administration Record (MAR) revealed Resident 81's IV Vancomycin was not administered on March 1, 2024, at 9:00 a.m., but was administered on March 1, 2024, at 9:00 p.m.
Review of Resident 81's clinical record failed to reveal a Vancomycin trough level was done/checked before administering the IV Vancomycin on March 1, 2024, at 9:00 p.m.
Review of the NP's progress notes dated March 2, 2024, at 4:29 p.m., revealed a "Medication Error", The resident's Vancomycin trough was 27.7 on February 29, 2024, the note stated to hold Vancomycin and ordered Vancomycin trough. Per the nurse, it was not held, Vancomycin was given, and laboratory was not done.
Interview with Employee E3 on March 15, 2024, at 1:00 p.m., confirmed that Vancomycin was administered as documented in MAR. There was no incident report/statements completed for the medication error incident, the nurse involved no longer works in the facility.
The facility failed to ensure Resident 81's Vancomycin medication was administered as ordered.
28 Pa. Code 211.5(f) Clinical Records
28 Pa. Code 211.12(d)(1)(5) Nursing Services
| | Plan of Correction - To be completed: 04/16/2024
1. CORRECTIVE ACTION FOR AREAS AFFECTED: Patient R3 was discharged from the facility on 3/19/2024. Patient R67 Piperacillian order will be reviewed by physician and stop date adjusted if indicated by physician. Patient R81 was discharged from the facility on 3/19/2024.
2. OTHER AREAS AFFECTED: An initial audit will be completed by the Director of Nursing/Designee on current patients to ensure no medications were missed within the last 3 days, if any missed doses identified, the pharmacy and physician will be notified.
An initial audit will be completed by the Director of Nursing/Designee on current patients over the last 7 days with IV vancomycin orders to ensure vancomycin was not administered prior to reviewing that the vancomycin trough level was within normal limits.
3. SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES: Licensed nursing staff will be re-educated by the Director of Nursing or designee on Pharmacy services procedure 5.1- Delivery and Receipt of Routine Deliveries with emphasis on If any item ordered by the facility is not received in the delivery, facility staff should check for a pharmacy communication slip and contact Pharmacy for an explanation for the missing items or medications and notify doctor of any missed doses of medications. Licensed nursing staff will be re-educated on omnicell location, access and contents.
Licensed nursing staff will be re-educated by the Director of Nursing or designee on reviewing Vancomycin trough level prior to administration of IV Vancomycin.
4. MONITORING OF CORRECTIVE ACTION: The Director of Nursing/designee will conduct weekly random audits for the next 90 days to ensure no medications were missed, if any missed doses are identified, the pharmacy and physician will be notified.
The Director of Nursing/designee will conduct weekly random audits for the next 90 days patients with IV vancomycin orders to ensure vancomycin was not administered prior to reviewing that the vancomycin trough level was within normal limits.
Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
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