HospitalInspections.org

Based on record review and staff interview, it has been determined that the hospital failed to administer medications in accordance with physician orders for 2 of 3 sampled patients (ID #'s 1 and 2).

Findings are as follows:

1. Review of Patient ID #1's medical record revealed that the patient presented to the Emergency Department (ED) on 8/12/2019 with impetigo (a contagious bacterial skin infection forming pustules and yellow crusty sores).

Further review revealed a physician's order dated 8/12/2019 at 9:30 PM to administer Chehalexin (Keflex) oral suspension 500 milligrams (mg) x 1 dose. The record indicates the patient was administered this medication by a nurse (Staff A) on 8/12/2019 at 9:56 PM and was discharged home.

Review of ED "Provider Notes" dated 8/13/2019 at 4:06 AM revealed Patient ID #1 returned to the ED on 8/13/2019 with abdominal pain, nausea/vomiting and blood in urine.

An ED Provider Note dated 8/13/2019 at 4:06 AM states, in part, "...Before laboratory assessment is returned, a phone call is fielded from the child's mother who...asserts that the child is there to be evaluated for a Keflex overdose stating that the child was encouraged to drink an entire bottle of Keflex while in the emergency department... The father then comes forward with a picture on his cell phone of a Keflex bottle demonstrating a concentration of 250 milligrams per 5 milliliters and a total volume of 100 milliliters. He additionally asserts that that when he and his son/daughter were in the emergency department on his/her initial visit his son/daughter was given the bottle and encouraged to 'check (sic) the whole thing'...it appears the patient ingested ...5000 milligrams Cephalexin."

Further review of the 8/13/2019 ED Provider Note revealed that poison control was called and toxicology was consulted. The patient was sent from the ED to the children's hospital with a diagnosis of Keflex overdose.

During an interview with the Director of the ED and the Clinical Coordinator on 9/4/2019 at 8:45 AM, they revealed that during their investigation of the incident, ED nurse (Staff A) acknowledged that he did not administer Keflex to patient ID #1 according to the physician's order.

2. Medical record review for Patient ID #2 revealed the patient presented to the ED on 2/8/2019 with lower abdominal pain, diarrhea and low urine output. The ED Provider Note indicates that on arrival the patient had vomited brownish material and appeared significantly dehydrated. The patient's blood pressure on 2/8/2019 at 4:24 AM was 69/37 which indicates low blood pressure.

Record review revealed a physician's order dated 2/8/2019 for Levophed (treats life-threatening conditions such as shock and low blood pressure) 4 mg in Dextrose 5% 250 ml infusion, start at 0.02 microgram (mcg)/kilograms (kg)/minute (min), titrate (adjust according to response) by 0.01 mcg/kg/min, Interval: 2 minutes Maximum Dose: 1 mcg/kg/min.

A nurse's progress note dated 2/8/2019 at 4:45 AM indicates the Levophed was started at 3 mcg/min, instead of 1.612 mcg/min which would have been the correct starting dose based on the patient's weight in kilograms.

A nurse's progress note dated 2/8/2019 at 4:59 AM stated that the IV Levophed was infusing. The nurse's notes further indicated Patient ID #2 had vomited bile, and that the heart monitor noted both fast and irregular heartbeats. Another nurse on the unit entered the patient's room and noted the IV Levaphed was infusing at the wrong dose and immediately discontinued the infusion.

During an interview with the Clinical Coordinator on 9/4/2019 at approximately 9:00 AM, she revealed that during her investigation of the incident, she learned by record review and interviews with staff nurse that the IV Levophed had been infusing at 3 mcg/minute for approximately 15 minutes. The dosage error was recognized and the medication was turned off. She acknowledged that the medication should have been infusing at 1.612 mcg/minute and was not administered according to the physician's order.