Deficiency Details, Complaint Survey, April 24, 2012

PFI: 4407
Regional Office: MARO--New York City Area

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Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 31, 2012

The facility must ensure that residents are free of any significant medication errors.

Citation date: April 24, 2012

Based on interviews and record review during an abbreviated survey, the facility did not ensure a resident was free of a significant medication error. This was evident for 1 out of 3 sampled residents (Resident #1). The Physician's order for Resident #1 stated to administer Spironolactone (diuretic) once daily. The medication was administered twice daily from 12/28/11-1/27/11.

This resulted in potential for harm that is not Immediate Jeopardy.

Complaint # NY00111810

The findings include:

Resident # 1 was an 85 year old male admitted to the facility on 11/1/2011. His diagnoses included Chronic Respiratory Failure, Atrial Fibrillation, Hypertension, Diabetes Mellitus, Pressure Ulcer and Tracheostomy.

The Minimum Data Set 3.0 (a resident assessment tool) dated 1/13/12 documented that the resident had impaired short and long term memory. The resident was moderately impaired in cognitive skills for daily decision making.

The Comprehensive Care Plan (CCP) for Hypertension/Hypotension , dated 11/2/11 documented that the resident was at risk for fluctuating blood pressure due to use of anti-hypertensive medication.

The Physician's order dated 12/19/11 10:11PM documented Spironolactone 25 mg by Gastrostotomy Tube (GT) BID (two times daily).

The Physician order dated 12/27/11 at 3:41 PM revealed that the Physician changed the Spironolactone ordered. The Physician documented in the Electronic Medical Record (EMR) Spironolactone 25 milligram (mg) tablet " give 1 tablet (25mg) by g-tube route once daily (decreased from 25 mg BID to address ongoing episodic hypotension) . "

The Medication Administration Record (MAR) from 12/28/11 -1/27/12 included an order for Spironolactone 25 mg once daily. The MAR order included the Physician's clarification that stated " (decreased from 25mg BID to address ongoing episodic hypotension). " The MAR documented that Spironolactone was administered twice daily at 9:00AM and 9:00PM. Although the order is for once daily, the EMR MAR included prompts for entries of administration both at 9:00AM and 9:00PM.

A Nurse Practitioner (NP) progress note dated 1/29/12 at 1:47PM documented that at approximately 12:00PM on 1/28/11, the nurse (RN #1) asked her to clarify the order for Spironolactone 25 mg tablet. The NP evaluated the resident and ordered laboratory work.

On 3/30/12 at 3:00PM a telephone interview was conducted with Registered Nurse (RN) #1, who worked 7:00AM-3:00PM on 1/28/12. She stated that on 1/28/12 the Pharmacy Consultant called the unit and informed her that the Spironolactone 25 mg order had been changed since 12/27/11 and was still being given twice daily instead of once daily.

On 2/14/12 at 2:10PM RN # 2 was interviewed. RN #2 worked on the 3:00PM-11:00PM shift. She stated that the EMR prompts the nurses to administer medications at specific times. RN # 1 stated that she never noticed the medication error because she was not aware, during her administration times, that the medication had already been administered at 9:00AM. She was not aware that the Spironolactone was administered by the 7:00AM-3:00PM shift.

On 2/14/12 at 4:00PM RN # 3 was interviewed. RN #3 worked on 1/19/12 from 3:00PM- 11:00PM. RN #3 stated that it was her first time working on the unit. She stated that on 1/19/12 she saw the order for Spironolactone 25 mg was decreased from twice daily to daily due to Hypotension, but she " thought the order was put for 9:00PM purposely to prevent orthostatic Hypotension. " She stated that had she noticed the medication was given at 9:00AM, she would not have administered the medication.

On 2/14/12 at 4:15PM RN # 4, who worked 1/11/12, was interviewed. She stated that on 1/11/12 she read the physician order but did not notice that the physician documented that the order was a decrease from BID. RN #4 stated that she did not fully read the whole order in the EMR.

On 2/14/12 at 4:55PM RN # 5 was interviewed. RN #5 administered the medications 11 times between December-January 2011. She stated that she checked the order, but did not notice what was in the parenthesis. RN #5 stated that she should have paid attention to the complete order as opposed to administering the medication as per schedule.

On1/14/12 at 3:50PM Licensed Practical Nurse (LPN) # 1 was interviewed. LPN #1 administered the medication 5 times between the months of December-January 2011. She stated that if she had followed the policy and procedures then the error would not have occurred.

A telephone interview was conducted with Resident #1's Physician on 3/29/12 at 11:15AM. He stated that he made the order clear by writing the clarification that the order was decreased from BID in parenthesis.

On 2/14/12 at 12:25PM the Assistant Director of Nursing (ADON) was interviewed. She stated that the 3:00PM-11:00PM shift nurses did not follow nursing policy and procedures. The staff nurses did not ensure that the medication was administered according to the Physician's orders. The Physician order stated to administer once daily, but the medication was given twice daily. The ADON stated that the nurses took full responsibility for the error.