HospitalInspections.org

Based on staff interview, employee file review, policy and procedure review, medication record review, patient medical record review and document review, the hospital failed to ensure Patient #1 received care in an environment that a reasonable person would consider to be safe. The patient was given an expired drug by the wrong route and without a physician's order.


Findings include:


On 09/29/17 the State Agency Complaint Unit received a self reported incident from Hospital #1. The report stated, "Date of Alleged Event: 9/19/2017. It was reported by a nurse that another nurse was giving a patient propofol IVP (Intravenous Push), without an order & expired in an attempt to keep the patient from being agitated."

An unanounced visit was made to Hospital #1 on 10/03/17 at 9:00 a.m. A meeting was held with the Chief Nursing Officer (CNO) and the Director of Nurses Adult Services (DNAS) to discuss the reason for the survey. They were both aware of the incident concerning a nurse giving a patient the expired sedative propofol IVP without a physician's order.


At 9:15 a.m. an interview was held with the Director of Nursing QA (DON QA) regarding the medication incident. She stated, "On 9/19/17 at shift change ICU (Intensive Care Unit) RN (Registered Nurse) (#1) gave his report to oncoming (RN #2) regarding (Patient #1). (RN #1) told (RN #2) that he had been giving (Patient #1) propofol IVP for agitation. He showed her where he had been keeping it in a cabinet in the patient's room, wrapped up in a diaper. He had a syringe with propofol drawn up in it and gave it to (Patient #1) IVP. (RN #2) said the patient went slack immediately, the drug in the vial was yellowish in color, had an expired date, and the Physician's order had been discontinued. (RN #2) reported the incident to her Charge Nurse. She and the Charge Nurse reported the incident to their Nurse Manager." The DON QA stated that RN #1 had been suspended pending investigation and had ultimately been terminated. The hospital reported the incident to the Board of Nursing.


At 9:25 a.m. an interview was held with the Nurse Manager regarding the 9/19/17 incident. She confirmed what the DON QA reported. She also stated that RN #2 was "not working her usual shift. She waited until end of shift and reported the incident to her regular supervisor in the a.m. of 9/20/17. (RN #1) was suspended in the a.m. of 9/20/17 and has not worked another shift. The hospital investigation concluded that he was guilty of giving the patient an expired drug without a physician's order and he was terminated 9/24/17." The Nurse Manager stated that she had talked to RN #1 three (3) different times and he denied the incident.

Review of Patient #1's medical record revealed that she was admitted to Hospital #1's Critical Care Unit on 8/17/17 after suffering a brain aneurysm. Propofol (Diprivan) was ordered Intravenously on 9/6/17 at 3:00 p.m. and had ended on 9/16/17 at 3:08 p.m.

Review of a handwritten signed statement from RN #2 revealed, " On Tuesday September 19 I had Bed 9 in the NSICU for day shift. The night shift nurse returned from his 7th night with my patients and while we were exchanging report the patient in Bed 9 got very agitated. She was already on Precedex and Fentanyl for agitation. (RN #1) told my student to leave the room to go get something and proceeded to pull out a diaper that was hidden up in the corner of the room above the cabinets. He pulled an old bottle of propofol out and a syringe already filled with propofol and gave it to the patient in her left IJ line. My patient has not been on propofol for at least 5 days and I could see the liquid had changed to a yellowish color. When I returned to work this AM (Sept 20th) the propofol bottle had been thrown away in the red sharps box container. I called my Charge Nurse... after work on Tuesday to tell him about the incident and then we both informed (the Nurse Manager) today."


Review of a handwritten signed statement from RN #2's Charge Nurse revealed, "On Sept 19, 2017 I received a call from (RN #2) at 2037 (8:37 p.m.) Tuesday night. She proceeded to tell me about her report exchange from (RN #1) earlier that evening... (RN #1) asked (RN #2's) student to leave the room to get supplies in order to privately show.. that he a secret bottle of propofol that he was using to calm the patient down (Bed 9). Propofol was not ordered on this patient. The bottle was in a diaper in the patient cabinet... was discolored. She then questioned him of why he was pushing the propofol and the age of the bottle. By that time the student walked in and (RN #1) asked her for a flush, while ignoring (RN #2's) concerns. (RN #2) was very shocked and caught off guard... The following morning, Wednesday 9/20/17, after (RN #2) and (RN #1) exchanged report, I found a clean unused diaper at the top of the trash can in Bed 9 and a bottle of propofol in the sharps box. The box was fairly new... The sharps box was recovered and set in (Nurse Manager) office."


Review of an Email from the hospital pharmacy to Human Resources, dated 9/26/17, revealed: "Propofol is not a controlled substance at the Mississippi state level or at the national level. It has been practice for a number of years at (Hospital #1), to have a few enhanced security measures concerning this medication. These include requiring a count remaining upon dispense from the medication cabinet and requiring a witness upon waste. There is no formal (Hospital #1) policy that requires propofol to be treated similarly to a controlled substance. The (Hospital #1) procedural sedation policy states that nurses should not push propofol... spiked vials of propofol should be changed/discarded every 12 hours. This is to prevent microbial growth and infection control issues."


Review of RN #1's employee file revealed he had been hired on 2/23/15 as a RN1 to work in the Critical Care Unit. His original RN license was issued 6/4/14. All orientation and training was noted.
Review of a handwritten signed statement by RN #1 revealed, "...on the morning of September 19, 2017, I did not give Diprivan to my patient in bed 9. I also am not aware of this alleged propofol being in a diaper in a cabinet."


At 10:00 a.m. a phone interview was held with Physician #1 via speaker phone with the DNAS present. Physician #1 stated that she had been notified of the incident concerning Patient #1, had assessed the patient and had noted no problems. She stated she had called the patient's aunt and told her of the medication incident. When Physician #1 was asked about any repercussions that might have happened when the patient was given propofol IVP she stated, "A blood stream infection would have been the only thing." The DNAS stated that several blood panels had been performed for Patient #1 and they had all been clear.


At 10:30 a.m. an interview with the DON QA revealed that the hospital has routine monthly RN meetings. Medications/drugs were always discussed. She discussed the uses of propofol and stated, "Propofol has a very short half life and can only be given by an RN through an IV with fluids. A MD (Medical Doctor) or an anesthesiologist are the only ones allowed to give the drug intramuscular or IV push." She shared the hospital's Action Plan to prevent this from happening again.


During an interview at 10:55 a.m. the Adult Nursing Director Critical Care discussed the training for medication in the ICU. She discussed propofol and confirmed that a RN is not allowed to give it IVP. "It is outside a RN's scope of practice. There are always doctors and Nurse Practitioners in the ICU. If you need a new order you can always get it."

Review of the hospital's "Patient Rights and Responsibilities" policy revealed, "You have the right to..receive a considerate, respectful delivery of care..."

Review of the hospital's "Medication Administration Guidelines" policy (Revised Date 3/21/2016) revealed: "1. Purpose: To provide guidelines in ensuring safe practices during medication administration... ll. Policy: ...B. Medications Guidelines/Safety 1. Medications shall not be given with a licensed practitioner's order... 5. Medications are not to be left... anywhere in patient's room..."


Review of the hospital's investigation report involving RN #1 revealed: "...The investigation determined there is clear evidence that (RN #1) maintained a supply of Propofol in the patient's room and that he administered the medication to the patient in her neck IV in order to sedate and calm her. Our concerns are:
1) This drug had been discontinued for the patient several days. There was no active order. (RN #1) administered medication outside his scope of practice.
2) Propofol has a short shelf life, 12 hours. After that it becomes discolored and is an infection risk to the patient. (RN #1) was reminded of that by (RN #2) before he injected the drug.
3) Propofol is not to be "pushed" or administered by syringe. It is to be hung as an infusion.
4) (RN #1) denied administering the Propofol to the patient when our investigation determined that he did..."

Based on staff interview, employee file review, policy and procedure review, medication record review, patient medical record review and document review, the hospital failed to ensure drugs are administered in accordance with Federal and State laws, the orders of the practitioner(s) responsible for the patient's care and accepted standards of practice and in accordance with the approved medical staff policies and procedures. Patient #1 was administered the expired medication propofol by a Registered Nurse without a physician's order and by the wrong route which was outside his scope of practice.


Findings include:


Cross Refer to A144 for the hospital's failure to ensure drugs are administered in accordance with Federal and State laws, the orders of the practitioner(s) responsible for the patient's care and accepted standards of practice and in accordance with the approved medical staff policies and procedures.

Based on staff interview, employee file review, policy and procedure review, medication record review, patient medical record review and document review, the hospital failed to ensure the outdated, unusable drug propofol was not available for patient use for Patient #1.


Findings include:


Cross Refer to A144 for the hospital's failure to ensure the outdated, unusable drug propofol was not available for patient use for Patient #1.