HospitalInspections.org

Based on medical record review, interviews, and facility policy documentation, the hospital policy failed to address the responsibilities of the physician for postoperative patients by specialty physicians. As a result, when Patient Identifier (PI) # 1 was admitted to the hospital postoperatively, and assigned to a hospitalist, he (PI# 1) did not receive his home medications for the first two days post surgery. Additionally, facility staff failed to document the home medication omissions as ordered by the surgeon on December 20, 2009, and failed to investigate the reason these medications were not given postoperatively.
This deficient practice effected PI# 1, one of ten sampled patients.

Findings include:

1. Medical Record:

PI# 1 was admitted to the hospital on 12/17/09 following surgery for an elective hip replacement.

The surgeon's Pre-Op Orders, dated 12/17/09, include:
"...1. Admitted inpatient to Dr. (name of surgeon)...
2. List home medications on the home medications form.. (Orders signed by surgeon)..."

The Medication Reconciliation Record / Order Sheet, dated 12/17/09 at 6:35 AM, includes:
"Source of Information: Patient (PI# 1)
1. Albuterol Inhalation "Nebs " 1 x day. Time last dose: 12/17 4:30 AM
2. Albuterol "Sulf" (Sulfate) ER 8 mg (milligrams) oral AM & PM. Time last dose: 12/16
3. Singulair 10 mg 1 oral AM & PM. Time last dose: 12/16
4. Pravastatin 20 mg 1 oral AM. Time last dose: 12/16
5. Doxazosin 8 mg 1 oral PM. Time last dose: 12/16
6. Tramadol 50 mg 2 oral PM. Time last dose: 12/16
7. Omeprazole 20 mg 1 oral AM. Time last dose: 12/16
8. Symbicort 160/4.5 1 oral AM & PM. Time last dose: 12/16
9. Plavix 75 mg 1 oral AM. Time last dose: 12/11"

The surgeon signed and checked "yes" to continue home medications in the hospital on 12/17/09. The form is signed by an RN on 12/17/09. A telephone order from the surgeon, dated 12/20/09 and signed by an RN, is also noted on this form. (See Physicians Orders dated 12/20/09)

PI# 1's Post Op Orders dated 12/17/09 include:
"...1. Admit as inpatient to Dr. (name of surgeon)...
....24. Consult Hospitalist for medical management..."

Orders written and signed by the Hospitalist on 12/17/09 at 5:30PM include:
"1. Albuterol and Atrovent nebulizers every 4 hours or as needed for SOB (shortness of breath)..."

On 12/20/09 at 12:00 PM, the surgeon ordered:
"1. Order home meds [medications] and give NOW
2. Incident report on fact home meds not started as ordered postop
3. Contact (Name of Chief Nursing Officer/CNO) in AM and ask him to talk to patient and family."
These orders are signed by a Registered Nurse as noted and / or transcribed.

The Medication Administration Records (MAR), dated 12/17/09 - 12/18/09, revealed Albuterol and Atrovent were hand written on the MAR.
No other medications from the Medication Reconciliation Record Order Sheet (home medications) are documented on the this MAR.

The MAR, dated 12/20/09, reveals the following medications were hand written on the MAR:
Plavix 1 po daily
Albuterol Sulfate ER 8 mg 1 AM & PM
Singulair 10 mg 1 po daily
Pravastatin 20 mg 1 po hs
Doxazosin 8 mg 1 po hs
Nexium 20 mg 1 po daily
Symbicort 150/4.5 mg Inhaler 1 puff AM & PM
ASA 81 mg 1 po daily

2. Interviews:

PI# 1, interviewed on 2/4/2010 at 12:00 PM, stated his home medications were not given to him until the surgeon made rounds on Sunday (12/20/09) and ordered the medications. PI# 1 stated he reported his concerns to the CNO.

The Chief Quality Officer (CQO), interviewed at 12:45 PM on 2/4/2010, reviewed the grievance log (with the surveyor) and verified no complaint / grievance, regarding PI# 1, was documented in the Grievance Log. The CQO stated staff may use a complaint/grievance form, or an event report form, to document patient / family / others concerns and/or occurrences.

During an interview at 9:45 AM on 2/5/2010, the Chief Quality Officer stated no event report or complaint form had been completed for PI# 1.

During an interview with the Chief Nursing Officer (CNO), on 2/4/2010 at 4:00 PM, the CNO stated he did not remember PI# 1 and had no written information about the patient's concerns.

On 2/5/2010 at 11:05 AM, the 8th Floor / Orthopedic Unit RN, who signed PI# 1's orders dated 12/20/09, said the hospitalist did not resume PI# 1's home medications postoperatively. This RN did not remember completing an incident report and said PI# 1's home medications were resumed as ordered on 12/20/09. According to this RN, her signature on the physician orders indicates these surgeon's orders were done. The RN stated she notified the nurse manager about the surgeon's order to contact the CNO, as noted on orders dated 12/20/09 (Sunday).

The Director of Pharmacy, interviewed at 3:30 PM on 2/5/2010, was asked who is responsible for the decision to continue or discontinue a patient's home medications. The Director stated it is the responsibility of the "physician in charge." The surveyor asked for the policy that defines the physician in charge. The policy titled, "Blanket Reinstatement," does not address the "physician in charge." None of the polices (provided to the surveyor) identified or clarified the "physician in charge" and / or physician responsibilities. This Director stated all orders stop at surgery and "We don't know if the hospitalist did not want the meds (PI# 1's home medications) or if the hospitalist failed to look at the home medications and order." This Director stated the failure of PI# 1 to receive his home medications until 12/20/2010 is a "prescriptive error."

This Director explained the medication reconciliation process:
-the nurse obtains a list of the patient's home medications;
- the physician makes the decision to continue or not continue the medications;
- medications may be added during hospitalization;
- At discharge, the home medications and current medications should be reconciled.

3. Policies:

The Medical Staff Rules and Regulations (September 2008) incudes:
"1.0 Admission and Discharge of Patients...
1.3 A Physician member of the Medical Staff shall be responsible for the medical care and treatment of each patient in the hospital, for prompt completion and accuracy of the medical record..."

The Policy, Blanket Reinstatement, effective 3/1/05 and revised 3/7/08 includes:
"Affected Departments: Medicine, Nursing, Surgery
Purpose: To ensure that the patient's treatment plan is re-evaluated whenever there is a significant change in the patient's clinical status or location in the hospital - such as when a patient undergoes a major surgical procedure requiring general anesthesia..."

The Policy, Medication Administration Record, Automated Policy # Nur [?Nursing General]. Gen. .089 written 11/95 and reviewed 5/08 includes:
"1. Policy Statement: To provide accurate transcription of medications, dosages, routes and times on the Medication Administration Record. To ensure that the patient's treatment plan is re-evaluated whenever there is a significant change in the patient's clinical status or location within the hospital - such as when a patient undergoes a major surgical procedure requiring general anesthesia.
...11. Procedures:
A. A MAR for the current 24 hour period is maintained on each patient. New medication orders shall be specifically written following surgery..."

PI# 1 did not receive his home medications for two days: December 18, 2009 and December 19, 2009. The medications were not resumed until December 20, 2009 when a now order was written by the surgeon to give PI# 1 his home medications.