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MULTICARE AUBURN MEDICAL CENTER
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on review of hospital polices and procedures, a previously written Statement of Deficiencies, the hospital's Plan of Correction and Progress report for the Statement of Deficiencies and inteveiw with hospital staff, it was determined that the hospital failed to assure that all patients received care in a safe setting. The hospital's failure to do so placed all patients at risk for receiving incorrect medications and placed victims of abuse/neglect/exploitation at risk for unreported and uninvestigated events.
Findings include:
Medication Orders
Medication Orders Written in Cursive
Review of patient medical records revealed that 8 of 8 patients (Patients 1, 2, 3, 4, 5, 6, 7 and 8) medical records contained medication orders that were written in cursive, and/or notations by practioners who were implementing medication orders, which were written in cursive.
Examples of medication orders and/or medications on medication administration records, which were written in cursive included, but were not limited to, the following:
-Patient #1: Ativan, Seroquel and Haldol
-Patient #2: [illegible], prednisone and vancomycin
-Patient #3: [illegible], hydrocortisone and morphine
-Patient #4: Ambien, [illegible]
-Patient #5: Flagyl, levaquin, fluoroxetine
-Patient #6: Magnesium sulfate, potassium, [illegible]
-Patient #7: Morphine, oxycodone, oxycontin
-Patient #8: Morphine, [illegible], [illegible], inderal
Review of the hospital's policy and procedure for "Administration of Medications: General Guidelines" and "Verbal/Telephone Orders" revealed that neither policy contained directives for practioners to neither accept or write orders for medications in cursive. Interviews with the Chief Nursing Officer and the Director of Pharmacy confirmed the omission.
The Director of Pharmacy stated that s/he was under the impression that if the pharmacist found the prescription that was written in cursive to be legible, the pharmacist could accept the order.
Discussion was held around the actual language in the RCW [Regulatory Code of Washington]
which states, in part:
RCW 69.41.010 Definitions.
As used in this chapter, the following terms have the meanings indicated unless the context clearly requires otherwise:
(13) "Legible prescription" means a prescription or medication order issued by a practitioner that is capable of being read and understood by the pharmacist filling the prescription or the nurse or
other practitioner implementing the medication order. A prescription must be hand printed, typewritten, or electronically generated.
The Director stated that the issues identified in 2011, and written as deficiencies in August, 2011, were not currently being tracked and there was no mechanism in place for assuring compliance with the RCW, in spite of the hospital's progress report which stated:
"1. ...orders which are illegible or improperly written will not be carried out until rewritten or
clarified..."
The Director also stated that she/he had not been involved or informed of the deficiency written
August 25, 2011 regarding the use of cursive prescriptions. S/he stated that s/he had not seen
the Statement of Deficiencies written in 2011, nor had s/he been involved with developing the plan of correction or the progress report pertaining to the deficiency until the investigator interview of 7/17/2012, even though the plan of correction stated that the Director would be responsible for the required corrections.
The Chief of Staff, who was also an Emergency Room physician, stated that s/he had sent a
memo to physicians on the issues around prescriptions written in cursive, and the issue had
been discussed in some meetings, but s/he had not identified any system to evaluate physician/prescriber compliance with the RCW requirement.
Review of the hospital's deficiency written August 25, 2011, revealed the following findings:
Medication Orders Written in Cursive
Review of patient medical records revealed that 6 of 10 (Patients 31, 3, 6, 7, 8 & 9) inpatient
medical records and contained medication orders that were written in cursive and/or notations by
practioners who were implementing medication orders, which were written in cursive.
The medications written in cursive included, but were not limited to, medications such as Levaquin [an intravenous antibiotic], vicodin [a pain medication], calcium chloride [a powerful
intravenous medication which had the potential for cardiac arrhythmias] and medication orders in cursive that were illegible.
RCW 69.41.010 Definitions.
As used in this chapter, the following terms have the meanings indicated unless the context clearly requires otherwise:
(13) "Legible prescription" means a prescription or medication order issued by a practitioner that
is capable of being read and understood by the pharmacist filling the prescription or the nurse or
other practitioner implementing the medication order. A prescription must be hand printed, typewritten, or electronically generated.
Failure to assure that all prescriptions in compliance with RCW 69.41.010 resulted in hospital-wide unsafe prescription-writing practices, that were unmonitored and uncorrected for approximately one year. This is a repeat, and uncorrected, deficiency.
Reporting of Suspected Abuse and Neglect
Review of the hospital's policy "Abuse", dated 9/22/2011, revealed the following:
"I. Definition of groups:
2.Elder Abuse: Adults aged sixty or older with a functional, mental or physical inability to care for
himself or herself...
3. Other Vulnerable Adults:
a. A vulnerable adult includes a person:
b. Sixty years of age or older who has the functional, mental, or physical inability to care for himself or herself: or
c. Found incapacitated under Chapter 11.88 RCW or or
d. Who has a developmental disability as defined under RCW...; or
e. Admitted to any facility; or
f. Receiving services from home health, hospice or home care agencies licensed or required to be licensed...
g. Receiving services from an individual provider.
The hospital's did not include all definitions included in the WAC definition of "vulnerable
adult". Definitions omitted from the hospital's definition are in bold:
72) "Vulnerable adult" means, as defined in chapter 74.34
facility (an adult family home, boarding home or nursing home); an adult living in their own or a
family's home receiving services from an agency or contracted individual provider; or an adult
self-directing their care under RCW 74.39.050
Further review of the policy on the reporting of abuse revealed the following:
"V. POLICY
All licensed health care professional are required by law to report a suspected incident of non-accidental injury, neglect, sexual abuse or cruelty to a child, elderly or other vulnerable adult by a person or pesons who appear to be legally responsible for that individual's welfare, including
members of the health care team. Reports should be made to Children's Protective Services...or
Adult Protective Services..."
The policy did not direct staff regarding when allegations of abuse should be reported to the
Department of Health.
"VI. PROCEDURE
A. Identification of Abuse or Neglect
1. Abuse is the willful infliction on a child, elderly or other vulnerable adult, spouse of Significant
Other.
2. The abuser may be a spouse, another child, a family member, legal guardian or a primary
caregiver."
The hospital definition did not identify hospital staff/employees, contract workers, volunteers,
clergy or visitors as potential abusers.
C. Good Faith Suspicion...
3. Make referral to Social Work Services working hours (as defined by hospital policy).
a. During off hours, the nurse caring for the patient will report to CPS or APS and notify the house superior [sic].
b. Refer to Social Work Services for follow-up as needed."
The policy did not state when Social Work Services were available, again mentioned only
CPS and APS, not the Department of Health; and did not state when or how to refer to Social Work Services for "follow-up as needed".
4. If the allegation of abuse involves a staff member:
...b. Contact the Department of Health at 1-800-527-0127."
That directive was the only time the Department of Health (DOH) was mentioned in the policy.
Review of the DOH website revealed that the correct phone numbers for filing a complaint with
the DOH are: 1-800-633-6828 and 1-360-236-4700.
"5. Make referral to appropriate agency within one Administrative day.
a. Children's Protective Services...
b. Adult Protective Services...
DOH was not identified as "an appropriate agency".
c. Law enforcement if indicated (911)
The policy and procedure did not direct reporters as to when to call local law enforcement, nor did it identify when such reporting would be "indicated".
Review of the Statement of Deficiencies written in August, 2011 revealed the following:
Review of the hospital's policy "Abuse", revealed that the hospital had definitions for "child abuse", "elder abuse", "other vulnerable adults", "adult dependents" and "domestic abuse". None of the definitions were consistent with the WAC definition of "vulnerable adult", which states in
part, "...it shall also include hospitalized adults".
Further review of the policy revealed the following:
"VI. Procedure
A. Identification of Abuse or Neglect
...2. The abuser may be a spouse, another child, family member, legal guardian or a primary
caregiver".
The definition exluded any potential abuser who did not fall into any of the named categories, for
example a friend, neighbor, romantic partner, caregiver, hospital employee, etc.
Review of the policy stated that during "working hours", which were not defined, the reporter was
to make a referral to Social Work Services. During "off hours", also not defined, "...the nurse
caring for the patient will report to CPS or APS..."
The policy also directed reporters to notify "law enforcement if indicated (911)", but did not define or describe which circumstances would constitute "indicated" reporting.
No where in the policy were reporters directed to notify the Department of Health, nor was there any guidance as to when to notify which branch of State Government, such as Department of Health vs. Department of Social and Health Services.
Failure to develop and implement a correct, complete and accurate policy for the reporting of
suspected abuse/neglect/exploitation placed all victims of same at risk for unreported and
uninvestigated events for approximately one year. This is a repeat, and uncorrected, deficiency.
Discussion was held with the Chief Nursing Officer and the Chief Executive Officer, both of
whom stated that they had reviewed the previously written Statement of Deficiencies. Both acknowledged that the hospital had not corrected the deficiencies identified in the previous report, and the progress report submitted to the Department of Health, which stated that the
deficiencies had been corrected, was not accurate.