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Based on interview and documentation review it was determined the Hospital failed to ensure that ongoing patient safety activities related to checking emergency equipment carts, were consistently maintained in accordance with established schedules.

Findings included:

The MICU Nurse Manager said the Ventricular Drain Insertion Cart was checked weekly by MICU nursing staff.

Review of the Ventricular Drain Insertion Cart check list documentation indicated the Cart was checked on February 8, 2010 and was not checked again until March 8, 2010.

The MICU Nurse Manger said the Defibrillator was checked every week.

Review of defibrillator test strips indicated a test was run February 15, 2010 and the next test was run on March 1, 2010.

Based on documentation review it was determined the Hospital failed to ensure there was documented evidence on file of a nursing staff members specialized qualifications in one of one personnel file reviewed.

Findings included:

When the incident was reported to the Department of Public Health it was communicated that the MICU Staff Registered Nurse (RN #2) who had inadvertently started an IV in the Patient ' s right wrist artery had been an IV therapy nurse prior to joining the MICU staff.

Review of Personnel file documentation indicated RN #2 on the employment application, had self identified as a Certified IV Nurse and was hired, in 2001, to work on the Hospital ' s IV team. There was however no certificate or written confirmation from the certifying authority to verify RN #2 ' s was a certified IV nurse.

Based on documentation review it was determined the Hospital failed to ensure the medical record contained information that described the patient 's response to medications in one of one applicable medical record reviewed.

Review of the 2/25/10, 12:00 AM admission note and physician orders indicated IV Fentanyl was also ordered as a continuous infusion of 0 to 150 micrograms (mcg) per hour, titrated to maintain pain control/sedation and a continuous infusion of Versed at a rate of 0 to 10 mg per hour to maintain sedation was also ordered. A one time dose of 50 mcg of Fentanyl (pain medication) was ordered administered.

Review of 2/25/10 12:00 AM-6:10 AM nursing documentation indicated the Patient was agitated and trying to pull at the endotracheal tube upon arrival in the MICU. IV Fentanyl, 50 mcg was administered as ordered. At 1:00 AM an IV Versed drip was started at 2 milligrams (mg) per hour and an IV Fentanyl drip at a rate of 25 mcg per hour was also initiated. Nursing documentation did not indicate the affect the administered medications had or if sedation was achieved.

Based on documentation review it was determined the Hospital failed to ensure all medical record entries included a date and time in one of one applicable medical record reviewed.

Findings included:

The following medical record entries did not include a time;

2/25/10 Dialysis Consult note

2/25/10 Initial ID Note.

2/26/10 Hemodialysis note

3/1/10 Wound Car Consult

3/1/10 Infectious Disease consultation

2/26/10, 2/27/10, 2/28/10, 3/1/10, 3/2/10, 3/3/10, 3/4/10, 3/5/10, 3/12/10 Nephrology Staff Note

2/27/10, 2/28/10, 3/1/10, 3/2/10, 3/3/10, 3/4/10, 3/5/10, 3/8/10, 3/9/10, 3/10/09, 10/11/10, 3/12/10, 3/13/10, 3/14/10, 3/15/10 Renal Fellow Note

3/2/10, 3/3/10, 3/10/10 Infectious Disease Consult

3/4/10 Cardiology consultation

3/5/10 Pain Consultation

3/6/10 Staff HD Note

3/8/10 Pain Consultation

3/10/2010 MS 4 Endocrine Follow-up.

3/11/10 Hemodialysis Notes

3/12/10 Interventional Radiology progress notes

3/12/10 MICU Attending notes

3/13/10 hemodialysis nursing notes

3/15/10 Pain Service Staff progress note

The following entries did not included a date or time:

An anesthesia chronic pain consultation

Based on documentation review it was determined the Hospital failed to ensure all orders were timed in one of one applicable medical record reviewed.

Findings included

The following orders did not include a time to indicate when the order was written:

An order written on 2/25/10 for Insulin drip at 1 unit an hour.

An order written on 3/3/10 to please change sliding insulin to FS 181-320 drip 0.2 units per hour.