HospitalInspections.org

Based on document review, medical record review and interview, in 5 of 10 medical records (Patient's #2, #3, #4, #5, #6) reviewed, nursing staff initiated patient care plans on admission, however, there was no documentation that care plans were reviewed and updated. This could cause untoward patient outcomes.

Findings include:

-- Review of the facility's policy and procedure titled "Patient Care Plans," reviewed 2/2023, indicated all problem lists (patient care plans) must be reviewed and updated every 24 hours and as needed.

-- Review of Patient #2's medical record revealed Patient #2 was admitted on 12/6/2023 at 11:50 am with a diagnosis of change in mental status, hypothermia and hypotension. The care plan was initiated on admission, there was no documentation that the care plan had been reviewed/updated as of 12/13/2023 (7 days later).

-- Review of Patient # 3's medical record revealed Patient #3 was admitted on 12/8/2023 at 4:23 pm with a diagnosis of altered mental status, cystitis, and sepsis. The care plan was initiated on admission, there was no documentation that the care plan had been reviewed/updated as of 12/13/2023 (5 days later).

-- Review of Patient # 4's medical record revealed Patient #4 was admitted on 12/7/2023 at 2:50 pm with a diagnosis of hip fracture. The care plan was initiated on admission, there was no documentation that the care plan had been reviewed/updated as of 12/13/2023 (6 days later).

The same lack of care plan review/update documentation was noted for Patient #5 and Patient #6.

-- During interview of Staff A, Peer Review Coordinator, on 12/14/2023 at 1:20 pm, he/she/they acknowledged the above findings.

Based on document review, medical record review and interview, (1) in 1 of 10 medical records (Patient #1) nursing staff did not administer medications as ordered by a provider. (2) In 5 of 7 medical records (Patient's #2, #4, #7, #6, #8) in patients who received pain medication, nursing staff did not document pain reassessment after pain medication was provided. This could lead to untoward patient outcomes and cause patients pain to not be controlled sufficiently.

Findings related to (1) include:

-- Review of the hospital's policy and procedure titled "Medication Administration Overview," reviewed 4/2023, indicated to bring the eMAR (electronic Medication Administration Record) via computer workstation and the medications to the bedside. Follow the rules of the 6 rights: Right Drug, Right Dose, Right Dosage Form, Right Patient, Right Time and Right Route. Before administration, check the medication label three times and check the eMAR three times. Prior to administration, scan all required medications and visually confirm that the correct dose, correct medication, and correct patient ID (identification) are displayed on the eMAR screen.

-- Review of Patient #1's medical record revealed on 11/16/2023 at 9:00 pm a medication order for Olanzapine 10 milligrams (Zyprexa). Give 2.5 milligrams every 12 hours intramuscular. Comments: Dose 2.5 milligrams = 0.5 milliliters. Reconstitute with 2.1 milliliters sterile water injection - Final concentration is 5 milligrams/milliliter. (This is the same medication order for administration on 11/28/2023 at 9:00 pm.)

-- Review of Patient #1's medical record revealed on 11/16/2023 at 9:00 pm a medication order for Lorazepam (Ativan) 2 milligrams/1 milliliter. Dose 1 milligram/0.5 milliliters intravenously twice a day. Comments: look-alike, sound-alike drug please verify high risk medication please verify caution medication may cause cognitive impairment, delirium, falls, and fractures in elderly population. (This is the same medication order for administration on 11/28/2023 at 9:00 pm.)

-- A patient safety event (concerning Patient #1) dated 11/28/2023 at 2:37 am documented a medication occurrence for Olanzapine (Zyprexa) 2.5 milligrams ordered to be administered intramuscular was administered intravenously. Contributing factors: Nurse administered 2.5 milligrams of Zyprexa intravenous instead of ordered intramuscular route. This was the wrong route of administration.

-- A patient safety event (concerning Patient #1) dated 11/28/2023 at 2:40 am documented a medication occurrence for Lorazepam (Ativan) 1.0 milligrams ordered intravenously, 2.0 milligrams was administered intravenously. Contributing factors: Failure to follow policy, procedure, or protocol. This was the wrong dose of administration.

-- Per interview of Staff B, Registered Nurse, Nurse Educator on 12/13/2023 at 11:20 am, there is a yearly medication recredentialing for staff which was started the second week of November (prior to the medication errors). Staff B has a spreadsheet to track who has been recredentialed and uses a competency to clinically evaluate a staff member being signed off. For example, the competency includes observations of intravenous medications drawn at a patient's bedside so the patient knows what they are being given, that secondary intravenous lines are dated, medication is administered properly with a pump, and proper disposal of sharps. Staff B will be recredentialing the traveling nurses and coming in at night to meet with the night staff. At the time of the survey, not all nursing staff and traveling nurses had received the yearly medication recredentialing.

-- During interview of Staff C, Nurse Manager, on 12/13/2023 at 9:10 am, he/she/they stated morning huddles starting 11/29/2023 included education on the administration of Zyprexa and its reconstitution, dosing, and intramuscular. Staff C acknowledged the above findings.

Findings related to (2) include:

-- Review of hospital's policy and procedures titled "Acute Pain Assessment and Pain Control," reviewed 7/2022, indicated reassessment and documentation to evaluate the effectiveness of pain intervention should occur within one hour after the intervention and should include the pain score when the patient is awake.

-- Review of the hospital's policy and procedure titled "Medication Administration Overview," reviewed 4/2023, indicated to monitor the patient and document the response to any medication given for pain or to accomplish immediate effect.

-- Review of Patient # 2's medical record revealed on 12/6/2023 at 8:46 pm, Patient #2 complained of pain of a level 4 (on a scale of 0 to 10, 0 indicating no pain and 10 indicating severe pain). Tylenol 650 milligrams was administered, there was no documentation of a pain reassessment.

-- Review of Patient #4's medical record revealed on 12/12/2023 at 6:30 am, Patient #4 complained of pain of a level 8. Morphine 2 milligrams intravenously was administered, there was no documentation of a pain reassessment. On 12/12/2023 at 10:37 am Patient #4 complained of pain of a level 10. Morphine 2 milligrams intravenously was administered, there was no documentation of a pain reassessment.

-- Review of Patient #7's medical record revealed on 12/14/2023 at 8:47 am, Patient #7 complained of pain of a level 8. Hydrocodone 5 milligrams and Acetaminophen 325 milligrams was administered, there was no documentation of a pain reassessment.

The same lack of documentation of pain reassessment was noted for Patient #6 (pain level 4) and Patient #8 (pain level 10).

-- During interview of Staff A, Peer Review Coordinator, on 12/14/2023 at 1:20 pm, he/she/they acknowledged the above findings.

Based on document review and interview, the hospital did not ensure emergency equipment was maintained and readily available for treatment of emergency cases. Specifically, the adult crash carts on both medical/surgical units lacked documentation of routine checks. This could cause the hospital to not be prepared for an emergency situation and could cause untoward patient outcomes.

Findings include:

-- Review of the hospital's policy and procedure titled "Cardio-Pulmonary Crisis Response Codes and Equipment," reviewed 12/2021, indicated a nurse is assigned to check the contents of each crash cart for completeness and intubation equipment for proper function. Checks are performed daily and documented in the record provided for this purpose. All defibrillators are tested daily as per manufacturer guidelines.

-- Review of the forms titled "Crash Cart Checklist", dated 1/2023 - 12/2023 on unit 2 East revealed multiple days lacked documentation that the crash cart checklist was completed. For example from 12/1/2023 - 12/13/2023, 5 days lacked documentation that the crash cart was checked.

-- Review of the forms titled: "Crash Cart Checklist", dated 5/2023 - 12/2023 on unit 2 North revealed multiple days lacked documentation that the crash cart checklist was completed. For example from 11/1/2023 - 11/30/2023, twenty days lacked documentation that the crash cart was checked.

-- During interview of Staff C, Nurse Manager, on 12/13/2023 at 11:25 am, he/she/they acknowledged the above findings.