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Based on interviews, and document review, the hospital failed to provide medical direction, consultation, and supervision for the healthcare staff which were managing patients who were leaving against medical advise (AMA).

Findings:

During the course of the survey, the surveyors reviewed twenty-three medical records. In four of these records, the patient/family/representative chose to leave the hospital against medical advise (AMA). (AMA is a term used in health care institutions when a patient leaves a hospital against the advice of their practitioner often occurs before their medical end point had been reached.)

On 08/15/2016 at 12:00 p.m., the hospital's AMA process was discussed with Staff C. Staff C stated that if a patient/family/representative communicated the desire to leave the hospital before the provider determined them ready for discharge, the nurse would usually contact the physician's assistant. Staff C stated the nurse would explain the benefits of remaining in the hospital and risk of leaving the hospital. Staff C said the nurse would have the patients/family/representative sign the hospital form, titled, "Against Medical Advice".

The AMA form consisted of the patient/family/representative's declaration of refusing to consent to examination and/or treatment, risk and benefits with blanks to be completed, Qualified Medical Professional signature, signature of the patient and/or person responsible for patient, and witness signature.

The surveyors reviewed the AMA documentation for Patient #1. Staff C confirmed that no physician or physician assistant signed the release form, there was no documentation the provider was notified, and no note from the provider regarding the event.
~ Hospital's Medical Staff Bylaws documented, "If a patient desires to leave the Hospital against advice of the attending practitioner, or without proper discharge, the attending practitioner shall be notified, the patient will be requested to sign the appropriate release form."
~Hospital's policy titled, "Consent 06/2016" documented "When a patient refuses a proposed treatment, the following persons should be notified immediately... physician's assistant working in ER."

Hospital's policy titled, "Consent 06/2016" documented "The PA must discuss the circumstances of the refusal with the patient. The discussion must be witnessed by the nurse or other professional staff member and include: the diagnosis, an explanation of the proposed treatment and the consequences of the refusal."
~The 02/16/2016 AMA form within the medical record of Patient #1 was completed by Staff T, a charge nurse. Staff T had written the principle potential benefits and the principle potential risks on the form as follows (respectively): "Treatment of present condition" and Disability or/and Death".
~The 03/01//2016 AMA form within the medical record of Patient #15 was completed by Staff T, a charge nurse. Staff T had written the principle potential benefits and the principle potential risks on the form as follows (respectively): "Continued treatment and tx [therapy]" and the "Death and Disability".
~The surveyor asked Staff C to discuss the method for completing the "Principle Potential Benefit" and the "Principle Potential Risk" on the AMA form. Staff C stated the nurse filled in the benefits/risk based on their own judgement. Staff C stated the providers had not instructed the nursing staff as what to write, nor did the hospital have a protocol addressing the issue.

It is beyond the nurse's scope of practice to assess and explain the individual risk and benefit to a patient.

Based on observation, interview, and document review, the hospital failed to manage drug and biologicals according to the following accepted professional principles:
a. secure medication from unauthorized access,
b. provide proper handling and labeling,
c. administrated properly, and
d. establish a quality program to monitor, evaluate, and improve outcomes.

Findings:

1. On 08/11/2016 at 11:45 a.m., the surveyor observed the medication dispensing room. At the entrance of this room, there was door jamb, but no door. Within this room were stock bottles of oral medication, and medication designated for specific patients (both oral and intravenous). During the course of the survey, the medication dispensing room was observed to be frequently unattended by staff.

The drugs and biologicals in the medication dispensing room were not secure from authorized people including unlicensed staff.

Hospital policy titled, "Drug Diversion 01/2016" documented, "The handling of any medication in the hospital is to be by a Registered Nurse or Licensed Practical Nurse." The policy did not define the security expectations for the medication dispensing room.

2. On 08/11/2016 at 11:45 a.m., the surveyor observed the contents of the patients' medication drawer within the medication dispensing room. Amongst other medication, the drawer contained two small bags of intravenous fluid with a non-manufacturer label. The label listed the drug name, dose and date and time to be administered. There was no patient name or staff initials on the bags. The date and time on the bags were "08/11/16 at 1500" and "08/11/16 at 1647".

The Chief Nursing Officer (CNO) stated the staff reconstituted intravenous medications, and that those type of medications must be administered within one hour of mixing. The time frames on the intravenous bags seen in the medication drawer exceeded the time frame defined by the CNO.

On 08/12/2016 at 1:23 p.m., the surveyor interviewed Staff I. Staff I self identified as the staff responsible for preparing the intravenous medication seen by the the surveyor on 08/11/2016. Staff I stated although the "added" medications' names were written on the bag's label, the bags did not contain any added medication. Staff I stated it was practice that when the medication was added to the bag, and then write the patient's name and staff initials on the labeling signaling that medication was actually in the bag and ready to be administered.

Hospital policy titled, "Medication administration and Medication Error 04/2016" documented, "Labeling occurs when any medication or solution is transferred from the original packaging to another container... labels include the name and strength of the medication of solution the date, and the initials of the person preparing the label."

3. On the morning of 08/11/2016, the CNO provided medication incident reports for the past year.

~ An incident was reported in February 2016. A nurse prepared to administer an intravenous medication for Patient #4, and noticed the same type of medication hanging from twelve hours prior. The medication had not been infused.

Patient #4's medical record was reviewed and the CNO confirmed all doses of medication were documented as administered. Staff C and CNO reviewed the medical record for patient #4, and confirmed that no physician notification of the incident was documented.

The hospital policy titled, "Medication administration and Medication Error 04/2016" documented, "Doctor/physician assistant (PA) must be notified as soon as possible of medication errors that have reached the patient...."

~ A second incident was reported in February 2016. A nurse prepared to administer an intravenous medication for Patient #5, and noticed the same type of medication hanging from twelve hours prior. The medication had not been infused.

Patient #5's medical record was reviewed and the CNO confirmed all doses of medication were documented as administered. Staff C and CNO reviewed the medical record for patient #5, and confirmed that no physician notification of the incident was documented.

~ An incident was reported in May 2016. The report documented "medication errors, no charting..." by an agency nurse. No patients were identified in the report. The surveyor requested the names of the patients involved and none were provided. The incident also documented there was medication error involving a controlled substance.

The hospital provided a document titled, "P & T [Pharmacy & Therapeutic] Committee Report, dated 06/02/2016, Report Month: May". The signatures of the document included the pharmacist. This report documented, "individual patient medication: no problems reported.

Surveyor requested the medication errors identified for June and July 2016, and none were provided.

4. On 08/15/2016, the CNO stated all medication errors were routed to "Quality". The surveyor asked if the Pharmacist participated in quality improvement activities, and the CNO replied that he did not.

Hospital policy titled, "Medication administration and Medication Error 04/2016" documented, "The medication error form is the forwarded to the QA Department...The QA department will track, file, and follow up to ensure completion of the medication error form".

On the afternoon 08/15/2016, the CNO provided a blank copy of a hospital document titled, "Medication Error Report". Neither this form nor its format was used for any of the medication error documentation that was provided to the surveyors. The Medication Error Report required a full description of a medication error, description of the outcome to the patient, corrective action taken, physician notification, measures taken to prevent the reoccurrence of similar events, and assessment and summary of the error.

The medication incident documentation provided to the surveyor, contained incomplete information such as missing date and time of occurrence , missing patients and staff involved. The hospital did not provide evidence that medication errors were analyzed and action taken to minimize the risk of reoccurrence.

Based on observations, interviews, and document review, the hospital failed to administer drug and biologicals according to the following accepted standard of practice:
a. adherence to the limitations and rules of verbal orders,
b. properly executed physician orders,
c. accurate documentation of medication administration, and
d. adherence to critically timed medication.
(Also See Provision of Care TAG: C-0276 )

Findings:

On 08/11/2016 at 11:45 a.m., Staff C discussed the hospital's hybrid system for managing physician's/ physician's assistant's orders. Staff C stated the orders were written on a paper order form and placed in a hard chart kept at the nursing station. A registered nurse then transcribed the orders into the electronic medical record. Staff C stated the nurses perform "chart check" every twenty four hours to verify that paper chart orders have been initiated correctly.

1. The surveyors reviewed twenty three medical records. Within these medical records, the type of orders documented from the hospital's Physician / Physician Assistant (PA) consisted almost exclusively of verbal / telephone orders.

A sample size of medical records (Patient #1, #6, #15, #18, #19, #20, and #23) were randomly selected to evaluate the extent of the use of verbal / telephone orders. The dates of service for the patients selected were from 02/2016 to 08/2016.

The sample medical records were also reviewed for the documentation of the "read back" of each verbal /telephone order. (In the read back process, the nurse taking the verbal order from the prescriber reads the order back to assure the order was written as it was intended.)

The surveyors talleyed the total use of verbal /telephone orders and read back for all of the sample patients, and the finding were as follows:
~ 87 orders were written by the nursing staff as verbal / telephone orders. Only one of the total 88 orders reviewed was written by the physician personally.
~ Of the 87 verbal orders written by the nurses, 50 orders failed to have documentation of being read back to order to assure accuracy.

Hospital policy titled, "Verbal / Telephone Orders (no effective or revision date)" documented, "Verbal communication of prescription or medication orders and test results is limited to urgent situations in which immediate written or electronic communication is not feasible... verbal orders and test results, when allowed, will be immediately written down by the recipient, read back by the recipient, and confirmed or corrected by the prescriber, the order must be written before it is read back."

On 08/12/2016 at 2:00 p.m., the surveyor observed the facility's physician's assistant standing at the nursing station dictating orders to a nurse who was acting a scribe by writing them on a chart order form. (Medical scribing is a process in which patient's medical information is written or entered into the electronic medical record by another authorized individual at the direction of the physician or licensed independent practitioner.)

On 08/15/2016 in the afternoon, Staff C stated that many verbal orders were written due to the poor penmanship of the physician.

2. In the same verbal /telephone orders sampling, the surveyors also evaluated the extent that the orders with authenticated by the physician or licensed independent practitioner. 87 of 88 verbal/ telephone orders were not signed or co-signed by physician or licensed independent practitioner.

Hospital policy titled, "Verbal / Telephone Orders (no effective or revision date)" documented, "Prescribers will verify, sign, date orders within 48 hours."

Review of the hospital's 2016 P & T Committee [Pharmacy & Therapeutic] report did not show discussion regarding the practice of excessive verbal/telephone orders, lack of read back practices, or absence of prescribers' order authentication signatures.

3. On 08/12/2016 in the afternoon, Staff I discussed issues that had been identified with the computer's medication administration record (MAR). Staff I stated the computer software that the hospital used was not flexible enough to be modified when medication documentation issues/difficulties had been identified. Staff I and the Chief Nursing Officer stated several medications, such as Gabapentin, Demerol, Albuterol and others, had dosage selections in the computer that did not match the doses on hand.

Surveyor requested the medication errors identified for June and July 2016, and none were provided.

4. Review of the hospital's document titled, " P & T Committee [Pharmacy & Therapeutic] Report- date: 04/06/2016- Report Month: March" documented "1 stop date missed on Klonopin...Continuing to have difficulty with some stop dates." The report documented the newly hired staff and agency staff had been educated on 24 hour chart checks and to check reorder stop dates.

No further information was provided to the surveyors to verify the issues had improved.