HospitalInspections.org

Based on review of hospital policies and procedures, review of clinical records, review of hospital documentation including Quality Improvement, it was determined the governing body was not effective in carrying out the functions of the hospital to ensure compliance with the Conditions of Participation for:

A-263 - QAPI (Quality Assurance Performance Improvement) The hospital's quality program did not have an organized and effective system to identify, analyze and track medication errors and implement changes to minimize the risk of the errors recurring. For 6 of 12 clinical records reviewed for medication errors in the total sample of 25, multiple medication errors were not documented and reported to the Chief Quality Officer. This deficient practice poses the risk of patient harm from a medication administration error;

A-385 - Nursing Services hospital did not provide quality nursing care in a safe manner as evidenced by:

(A-395):

1. Failure to ensure the nursing care of patients with changes in condition was directed and evaluated by a Registered Nurse (RN) for 5 of 5 patient records reviewed for nursing assessments of patients with changes in condition. (Patients #1, #2, #4, and #14.) The deficient practice posed the high risk of patients not receiving the level of nursing care based on their acuity.

2. Failure to ensure physician orders were clarified for the type of tube feeding and the amount and frequency of water flushes were clarified prior to starting and adjusting tube feedings for 1 of 11 patients receiving tube feedings in the total sample of 25. (Patient #1) The deficient practice posed the high risk of the patient not receiving the specific formula and water to meet their nutritional and hydration needs.

3. Failure to ensure physician orders were clarified for the route of administration of medications to patients who were unable to take medications by mouth. (Patient's #1, and #3.) The deficient practice posed the high risk of harm to a patient if medications are not administered by the route ordered by the physician.

4. Failure to ensure skin breakdown was identified promptly on one patient (Patient #4) and failure to ensure wound care was provided according to physician orders and policies and procedures for 3 of 7 focused reviews of patient records with skin breakdown in the total sample of 25. (Patients #4, #15, #21.) The deficient practice posed the high risk of worsening of skin breakdown without appropiate treatment.

5. Failure to ensure patient weights were obtained following physician orders for 3 of 10 focused reviews of patient records for weight documentation in the total sample of 25. (Patients #2, #10, and #15.) The deficient practice posed the high risk of unplanned weight loss or weight gain not identified and addressed by the physician.

6. Failure to ensure patient intake and output records were accurate and/or completed for 3 of 12 focused reviews of patient records for I & O documentation in the total sample of 25. (Patients #2, #4, #14.) The deficient practice posed the risk of pertinent clinical information not documented, monitored, and provided to physicians.

(A-405):

1. Failed to ensure medications were administered in accordance with physician orders for 5 of 10 focused record reviews for medication administration in the total sample of 25. (Patients #2, #5, #16, #17, and #19.)

2. Failed to ensure incomplete and/or inaccurate physician orders for 6 of 15 focused review of patient records for completed physician orders in the sample of 25 were clarified with the prescribing physicians prior to implementing the orders. (Patients #2, #4, #5, #7, #14, and #17.)

3. Failed to ensure the actual times of medication administration were documented on the MAR's for 25 of 25 patients.

4. Failed to ensure two nurses verified and documented insulin doses prior to administration for 4 of 6 focused record reviews for nurse verification of insulin doses (Patients #2, #5, #7 and #17); and

A-489 - Pharmaceutical Services

1. The hospital failed to ensure incomplete physician orders were identified and clarified by pharmacy staff for 6 of 6 patients in the total sample of 25. (Patients #2, #3, #4, #5, #14, and #19)

2. The hospital failed to have effective policies and procedures implemented to minimize medication administration errors. The medication errors identified in 6 of 6 patients' clinical records during the survey had not been identified or reported. (Patients #2, #3, #5, #16, #17, and #19).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of safe and quality health care.

Based on review of hospital policies and procedures, review of clinical records, review of documented hospital quality improvement activities, and staff interviews, it was determined:

A-286: The hospital's quality program did not have an organized and effective system to identify, analyze and track medication errors and implement changes to minimize the risk of the errors recurring. For 6 of 12 clinical records reviewed for medication errors in the total sample of 25, multiple medication errors were not documented and reported to the Chief Quality Officer. This deficient practice poses the risk of patient harm from a medication administration error.

The effect of this systemic problem resulted in the hospital's inability to ensure the provision of safe medication administration practice.

Based on review of the hospital's policies and procedures, review of clinical records, and staff interviews, it was determined the hospital did not provide quality nursing care in a safe manner as evidenced by:

A-395:

1. Failure to ensure the nursing care of patients with changes in condition was directed and evaluated by a Registered Nurse (RN) for 5 of 5 patient records reviewed for nursing assessments of patients with changes in condition. (Patients #1, #2, #4, and #14.) The deficient practice posed the risk that patients did not receive the level of nursing care based on their acuity.

2. Failure to ensure physician orders were clarified for the type of tube feeding and the amount and frequency of water flushes was obtained prior to starting and adjusting tube feedings for 1 of 11 patients receiving tube feedings in the total sample of 25. (Patient #1) The deficient practice posed the risk that the patient not receiving the specific formula and water to meet their nutritional and hydration needs.

3. Failure to ensure physician orders were clarified for the route of administration of medications to patients who were unable to take medications by mouth. (Patient's #1, and #3.) The deficient practice posed the risk of harm to a patient if medications are not administered by the route ordered by the physician.

4. Failure to ensure skin breakdown was identified promptly on one patient (Patient #4), and failure to ensure wound care was provided according to physician orders and policies and procedures, for 3 of 7 focused reviews of patient records with skin breakdown in the total sample of 25. (Patients #4, #15, #21.) The deficient practice posed the risk of worsening of skin breakdown without appropiate treatment.

5. Failure to ensure patient weights were obtained following physician orders for 3 of 10 focused reviews of patient records for weight documentation in the total sample of 25. (Patients #2, #10, and #15.) The deficient practice posed the risk of unplanned weight loss or weight gain not identified and addressed by the physician.

6. Failure to ensure patient intake and output records were accurate and/or completed for 3 of 12 focused reviews of patient records for intake and output (I & O) documentation in the total sample of 25. (Patients #2, #4, #14.) The deficient practice posed the risk of pertinent clinical information not documented, monitored, and provided to physicians.

A-405:

1. Failure to ensure medications were administered in accordance with physician orders for 5 of 10 focused record reviews for medication administration in the total sample of 25. (Patients #2, #5, #16, #17, and #19.) This deficient practice poses the risk of harm to patients if they do not receive physician ordered medications.

2. Failure to ensure incomplete and/or inaccurate physician orders for 6 of 15 focused reviews of patient records for completed physician orders in the sample of 25 were clarified with the prescribing physicians prior to implementing the orders. (Patients #2, #4, #5, #7, #14, and #17.) This deficient practice poses the risk of medication administration errors.

3. Failure to ensure the actual times of medication administration were documented on the MAR's for 25 of 25 patients. This deficient practice poses the risk of medications not administered within time frames identified in hospital policies and procedures.

4. Failure to ensure two nurses verified and documented insulin doses prior to administration for 4 of 6 focused record reviews for nurse verification of insulin doses. (Patients #2, #5, #7 and #17.) This deficient practice poses the high risk of inaccurate doses of Insulin being given to patients when verification of the required dose is not done by a second RN, which then could potentially result in complications related to Hyper or Hypoglycemia related to wrong insulin doses being administered to patients .

The cumulative effect of these systemic problems resulted in the hospital's inability to provide quality and safe nursing care.

Based on review of hospital policies and procedures, review of clinical records, review of Pharmacy, Nutrition and Therapeutics Committee Meeting Minutes, and staff interviews it was determined:

A-491

1. The hospital failed to ensure incomplete physician orders were identified and clarified by pharmacy staff for 6 of 15 patients in the total sample of 25. (Patients #2, #3, #4, #5, #14, and #19)

2. The hospital failed to have effective policies and procedures implemented to minimize medication administration errors. The medication errors identified in 6 of 6 patients' clinical records during the survey had not been identified or reported. (Patients #2, #3, #5, #16, #17, and #19).

The deficient practices identified above posed the high potential risk of medication errors resulting in possible harm to the patients.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of safe medication administration practices.

Based on review of hospital policies and procedures, review of clinical records, review of documented hospital quality improvement activities, and staff interviews, it was determined for 6 of 12 clinical records reviewed for medication errors in the total sample of 25, the hospital's quality program did not have an organized and effective system to identify, analyze and track medication errors and implement changes to minimize the risk of the errors recurring. (Patients # 2, #3, #5, #16, #17, and #19). This deficient practice poses the risk of patient harm related to unidentified medication administration errors.

Findings include:

The hospital's Quality Improvement Plan 2017 included: "The Governing Body is ultimately responsible for assuring that high quality care is provided to our patients. The Governing Body delegates the implementation of the plan to Administration and the Medical Staff through the Quality Council, Medical Executive Committee and the hospital's Leadership Team."

The hospital's policy and procedure titled "Event Reporting System" H-ML 04-001 included: "Policy...Curahealth is committed to providing quality health care to its patients. Despite committed efforts to provide and improve patient care, adverse events sometimes occur. In order to understand the causes of these events and opportunities to prevent them, Curahealth utilizes the Division's Event Reporting System (ERS) to track and analyze patient and visitor events...Rationale...To improve patient care and improve patient safety. To understand how and why an event occurred and to prevent a similar event from occurring in the future...An 'event' is defined as any occurrence or situation not consistent with the routine operation of the facility and which may have caused or may have the potential for causing injury to patients...Hospital personnel are responsible for reporting in a timely and efficient manner, patient and visitor events...Examples of events reportable...Medication variances...."

A review of the hospital's "Quality and Performance Improvement Monitoring-Summary Report" revealed the numbers of medication "occurrences" reported by month from January 2017 through April 2017. The CQO and the Director of Pharmacy stated medication administration errors were discussed during Quality Meetings and Medical Executive Committee (MEC) meetings. A review of the Quality Meeting Minutes dated 10/21/2016, 11/23/2016, 12/22/2016, 01/20/2017, and 03/08/2017 revealed no documentation of a review and discussion of medication administration errors. A review of the Medical Executive Committee Meeting minutes dated 11/28/2016, 01/24/2017, and 04/24/2017 revealed no documentation that medication administration errors were reviewed.

Multiple medication errors were identified in clinical record reviews of 6 patients during the survey. Refer to Tag A-395 for specific details. The CQO reported during interviews that the errors identified by the surveyor had not been documented, reported, or investigated.

The above policy addressed reporting of events into an electronic system, however, the CQO stated they are currently using a paper process. There was no policy that addressed how and when medication administration error reports were delivered to him, how the occurrences were investigated/analyzed or how they would be tracked and trended.

The CQO reported he had recently assumed the position and only had data collection documentation at the time of the survey.

Based on review of the hospital's policies and procedures, review of clinical records, and staff interviews, it was determined that nursing care was not evaluated and directed by a Registered Nurse (RN) throughout admission as evidenced by:

1. failure to ensure the nursing care of patients with changes in condition was directed and evaluated by a Registered Nurse (RN) for 6 of 6 patient records reviewed for nursing assessments of patients with changes in condition. (Patients #1, #2, #3, #4, #14, and #16) The deficient practice posed the high risk patients not receiving the level of nursing care based on their acuity.

2. failure to ensure a physician's order was clarified for the type of tube feeding and the amount and frequency of water flushes was obtained prior to starting and adjusting the tube feeding for 1 of 11 focused review of clinical records of patients receiving tube feedings in the total sample of 25. (Patient #1) The deficient practice posed the high risk that the patient did not receive the specific formula and water flushes to meet the nutritional and hydration needs.

3. failure to ensure physician orders were clarified for the route of administration of medications to patients who were unable to take medications by mouth. (Patient's #1, and #3.) The deficient practice posed the high risk of harm to a patient if medications are not administered by the route ordered by the physician.

4. failure to ensure skin breakdown was identified promptly on one patient (Patient #4), and failure to ensure wound care was provided according to physician orders and policies and procedures, for 3 of 7 focused reviews of patient records with skin breakdown in the total sample of 25. (Patients #4, #15, #21.) The deficient practice posed the high risk of worsening of skin breakdown without appropriate treatment.

5. failure to ensure patient weights were obtained following physician orders for 3 of 10 focused reviews of records for documented weights in the total sample of 25 and failure to notify physicians of significant weight discrepancies. (Patients #2, #10, and #15.) The deficient practice posed the high risk of unplanned weight loss or weight gain not identified and addressed by the physician.

6. failure to ensure patient intake and output (I & O) records were accurate and/or completed for 3 of 15 focused review of clinical records for I & O documentation patients. (Patients #2, #4, and #14.) The deficient practice posed the high risk of pertinent clinical information not documented, monitored, and provided to physicians.

Findings include:

1. The hospital's policy titled "Assessment-Reassessment Interdisciplinary Patient", PolicyStat ID: 3599377, included: "An admission assessment is performed by a Registered Nurse and is recorded in the patient medical record within 12 hours of admission...The RN admission assessment of the patient will included: a. Biophysical, Psychosocial, Cognitive Environmental, Self-Care Needs Assessment, b. Wound Risk Assessment, Pain, Fall Risk, Educational Needs Assessment...The admission assessment data is a primary source for the RN to determine and prioritize nursing care needs specific to the patient...The admitting RN will screen each patient during the initial assessment process to identify those patients requiring further specialized interventions, and/or possible referral to and assessment by other appropriate disciplines...Patients are re-evaluated by a licensed nurse (RN, LPN/LVN-according to state specific practice acts) at a minimum every 12 hour shift-based on level of care and patient care needs...An RN directs the nursing care of every patient through delegation and supervision to other nursing and non-nursing personnel. The extent of that delegation is defined by individual state nurse practice acts...An RN reassessment of the patient shall occur, at a minimum of once every other 12-hour shift...An LPN/LVN may gather clinical data and make clinical observations in between the RN assessments. The clinical data and clinical observations are reported to the RN for evaluation and determination of needed changes in the patient plan of care...Patient reassessment is based on but not limited to the following...To evaluate patient response to care, treatment, and services...To respond to a significant change in status and/or diagnosis or condition...All nursing assessment(s)/reassessments are recorded in the patient medical record by a licensed nurse...An acute change of condition is a clinically important change from a patient's established and documented baseline in physical, cognitive, behavioral, or functional domains. An acute change in condition may occur abruptly or over several hours to several days, presenting as physical changes or as changes in function , mood, cognition, or behavior...The nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the patient's primary physician or designee using appropriate channels and chain of command for assuring that this is physician response."

Patient #1:

Patient #1's "Nursing Admission Assessment" was signed and dated by an RN on 02/17/2017 at 7:50 p.m. The care of the patient was assigned to Licensed Practical Nurses (LPN) from 02/17/2017 at 7 p.m. until 02/19/2017 at 7 a.m., a period of 36 hours. There was no documentation that the patient was assessed by an RN during that time. The patient's care had been assigned to LPN's for the night shift on 02/22/2017 and again on the day shift on 02/23/2017. There was no documentation that the patient was assessed by an RN between 02/22/2017 at 8:30 a.m. until he was discharged AMA on 02/23/2016 at 11:30 a.m. with a family member.

A Respiratory Therapy (RT) documented in a progress note dated 02/19/2017 at 5 a.m. that the patient was found to have removed his tracheostomy tube at 10 p.m. on 02/18/2017 and that the the RN was notified. A review of the Daily Nursing Assessments revealed the patient's care was assigned to an LPN on 02/19/2017 on the 7 p.m. to 7 a.m. shift. There was documentation by the LPN that the patient removed his tracheostomy tube and no documentation that the patient was evaluated by an RN during that shift.

Another RT progress note dated 02/21/2017 at 8:50 p.m. included: "Alerted by nurse that pt pulled of (sic) 4 x 4 from under trach as well as the trach cap. When checking pt, the trach was found to be out. Unknown how long. It was approx 1.5 hrs since this RT saw pt last & trach was intact. The #6 Shiley trach would not pass back through the stoma. It was almost completely closed. Was able to pass a sxn (suction) catheter through then a #6 TTS Bivona was sucessfully (sic) placed & recapped." A review of the Daily Nursing Assessments dated 02/21/2017 revealed an LPN was assigned to the patient's care on the 7 p.m. to 7 a.m. shift. There was no documentation by the LPN of the patient pulling out his tracheostomy and there was no documentation of an assessment by an RN during that shift.

An LPN documented on 02/23/2017 at 8 a.m. that the patient's feeding tube was replaced. There was no documentation as to why it was replaced. At 11:25 a.m. the LPN documented that the patient left AMA with a family member. There was no documentation that clarified why the patient left or the status of the patient at the time the patient left. There was no documentation that there was oversight and direction by an RN during the shift prior to the patient leaving.

Patient #2

Patient #2's care was assigned to an LPN on the day shift of 05/01/2017. Documentation on the MAR's revealed the patient's BG on 05/01/2017 was "77" mg/dL at 6 a.m. and "57" mg/dL at 7 a.m. and no insulin coverage was required. The 9 a.m. scheduled dose of Levemir 20 units insulin was: "held D/T (due to) low blood sugars." At 11:50 a.m. the patients BG was "171" mg/dL and should have received 4 units of insulin, however, the nurse documented the insulin coverage was not given because the patient had been hypoglycemic. There was no documentation that the nurse notified the physician and obtained an order to hold the insulin. The RN leader of the patient care team acknowledged by signature at 3:45 p.m. on the Daily Nursing Assessment that the care provided was reviewed and the RN concurred with the care provided to the patient by the LPN even though there was no documentation that the physician was notified of two separate orders for insulin were not given.

A review of the Daily Nursing Assessments revealed the patient's care was assigned to an LPN for the day and nights shifts from 05/02/2017 until 7 a.m. on 05/04/2017, a period of 48 hours. The patient was assigned to an LPN from 7 p.m. on 05/06/2017 until 7 p.m. on 05/08/2017, a period of 48 hours.

An LPN was assigned to the care of the patient for the night shift of 05/03/2017 (7 p.m. to 7 a.m. 05/04/2017). The patient's BG at midnight of 05/04/2017 was "163" mg/dL and should have received 4 units of HumulinR insulin. A line was marked through "0:00" and "WNL" (within normal limits) written next to it. There was no documentation that the patient received the 4 units of insulin. The RN leader of the patient care team acknowledged by signature at 4 a.m. on 05/04/2017 on the Daily Nurse Assessment that the care provided was reviewed and that the RN concurred with the care provided to the patient by the LPN assigned to the patient even though the midnight coverage of insulin was not administered.

An LPN was assigned to the care of the patient for the day shift on 05/07/2017. There was no nursing assessment for that shift, however, the RN leader of the patient care team signed the RN Oversight of Patient care section of the form indicating that he/she reviewed the impact of care on the patient and concurred with the current plan.

The patient's care was assigned to an LPN for the day shift of 05/08/2017. There was no documentation that the patient was assessed and monitored throughout the shift related to the low BG's. There was no documentation that explained what happened between 12 noon when the patient's BG was "53 and when the physician wrote the orders at 3:33 p.m.; no documentation of what happened between 3:33 p.m. and when the physician ordered medications were actually administered at 6:30 p.m., 2.5 hours later; and no documentation of why the Novolog insulin was not given with the other medications.

There was no documentation that the patient's BG was rechecked until 6 p.m., and it was "15" mg/dL. Blood glucose levels below 40 mg/dL are considered critical.The patient's care was assigned to an LPN for the day shift of 05/08/2017. There was no documentation that the patient was assessed and monitored throughout the shift related to the low BG's. There was no documentation that explained what happened between 12 noon when the patient's BG was "53 and when the physician wrote the orders at 3:33 p.m.; no documentation of what happened between 3:33 p.m. and when the physician ordered medications were actually administered at 6:30 p.m., 2.5 hours later; and no documentation of why the Novolog insulin was not given with the other medications.

The patient's sliding scale insulin orders included a "Hypoglycemic Protocol." For a blood glucose level less than 50 mg/dL, 25 ml of Dextrose 50% injectable was to be administered intravenously and the physician was to be notified Documentation on the Vital Signs form dated 04/30/2017 revealed the patient's blood glucose level was 48. The LPN assigned to the patient's care documented on the MAR that she gave the patient "Juice & sugar." The LPN documented in the Daily Nursing Assessment notes that the physician was in and aware of the low blood glucose level, however, there was no physician order for the patient to receive juice and sugar rather than IV Dextrose. The RN leader of the patient care team signed the RN Oversight of Patient Care section of the Daily Nursing Assessment form at 5:25 p.m. with a check-mark in the box next to "Concur with the current plan." There was no documentation by the RN to clarify why the physician ordered hypoglycemic protocol was not followed. A nursing note at 9 p.m. revealed the patient had a BG of "36" and Dextrose was administered IV following the protocol. There was no documentation that the physician was notified of the low BG.

Patient #3

A "Dietary Recommendation" dated 05/08/2017 at 3:43 p.m. was documented on a physician's order sheet to increase the water flushes through the patient's PEG-tube to 115 ml every 6 hours. There was no documentation that the order was noted and implemented by a nurse and no documentation that the recommendation was brought to the attention of a physician.


Patient #4

The patient's care was assigned to an LPN on the day shift of 05/11/2017. The LPN received and documented a physician's telephone order. The order did not include the name of the drug nor the route. The LPN's documentation on the MAR revealed she administered 500 cc of intravenous normal saline for the patient's low blood pressure at 2:30 p.m. There were two blood pressures documented on the 24 Hour Intake Ouput Totals form at 2 p.m.: 64/32 and 74/32. The next set of vital signs documented was not until 11:30 p.m., 9.5 hours later. It was also noted that the 500 cc of normal saline administered at 2:30 p.m. was not documented on the I & O form and included in the 24-hour totals. There was no documentation in the Daily Nursing Assessment that addressed the patient's low blood pressure or the status of the patient after the intravenous fluids were administered.

A physician's telephone order dated 05/12/2017 at 5:53 p.m. was received and documented by an RN. The order read: "0.5 mg Ativan x 1." The order did not include the route. The order was not transcribed onto the MAR and there was no documentation of a nursing assessment that clarified why the order was obtained and whether or not it was administered and if not, why.

Patient #14

The patient had a tracheostomy and was being weaned off of the ventilator since 05/01/2017. A pulmonologist's progress note on 05/03/2017 dictated at 1:25 p.m. included: "I walked in the patient's room. She was lying pretty flat and was short of breath. I could hear audible wheezes/rhonchi. I sat her up and she already felt better. RT was called and we suctioned some mild to moderate slightly creamy secretions."

A review of the Daily Nursing Assessment form dated 05/03/2017 revealed the patient's care was assigned to an LPN for the day shift. The physical assessment was completed by the LPN at 8 a.m. who documented the patient's breath sounds were clear and unlabored. There was no documentation that the patient was reassessed during the day shift. The RN assigned to the patient on the night shift documented an assessment at 7:50 p.m. which revealed the patient's breathing was irregular, labored and wheezes could be heard in the upper right and left lobes of her lungs.

A physician documented in a progress note dated 05/04/2017 at 4 p.m. that the patient had increased abdominal pain and when the patient was turned, the abdominal midline surgical scar opened with fluid/blood draining. The physician ordered the patient be transferred to an acute care hospital for evaluation. The last physical assessment of the patient by the RN assigned to the patient was at 8:15 a.m. There was no documentation that the RN assessed the patient's wound and the status of the patient at the time of transfer.

Patient #16

The patient was admitted on 05/15/2017. There was no documentation of a nursing assessment during the 7 p.m. 05/15/2017 to 7 a.m. 05/16/2017 shift.

The CQO reported during interviews that patient's were assigned to an RN at least once every 24 hours so that every patient had an assessment by an RN. He explained that RN Supervisors made staff assignments and LPN's assigned to a patient's care did not perform assessments but rather "collected information" with oversight and responsibility by the RN on the team.

An RN interviewed on 05/18/2017 acknowledged that she not only had her patient assignments but also was responsible to oversee the LPN's patient assignments for up to a total of 12 patients for the RN. The RN reported that she received report from the off-going nurse specific to the patients she was assigned to but did not receive reports on the patients assigned to the LPN on her team.

2. The hospital's policy and procedure titled "Administration of Enteral Nutrition" Policy H-PC 05-006 PRO included: "Procedure: Continuous Enteral Feeding...Verify the practitioner's order...Gather and prepare the necessary equipment and the enteral feeding formula...Fresh tap water is used to flush tubing and provide extra water as needed to the patient...Flush the feeding tube as ordered...Flush the tubing with water during a continuous feeding as ordered by the practitioner."

Patient #1 was admitted to the hospital on 2/17/2017 at approximately 4:40 p.m. Documentation in the clinical record revealed the patient had a nasogastric tube through which he received nutrition and fluids. The Nursing Admission Assessment signed by an RN at 7:50 p.m. revealed the patient was 5'7" in height and weighed 144 pounds. The physician's Admission Orders signed at 2:15 p.m. did not include the type of tube feeding the patient was to receive nor the amount and frequency of water flushes. The order did include a rate of 55 milliliters (ml) per hour. A physician documented in a "Night Call note" dated 02/17/2017 at 8:30 p.m. that the patient had nausea and vomiting and the tube feedings were decreased to a rate of 10/ml until the following morning.

Documentation in the patient's clinical record related to the patient's tube feedings included the following:

The "24 Hours Intake Output Totals" (I & O's) form revealed tube feedings were started on 02/17/2017 between 9 to 10 p.m. through 11 a.m. on 02/18/2017. According to documentation in the I & O's dated 02/18/2017, the rate was increased to 20 ml/hour at 11 a.m. until 8 p.m. when it was increased to 30 ml/hour until 6 a.m. on 02/19/2017. There was no physician's order to increase the tube feedings to 30 ml/hour. The rate was decreased to 20 ml/hr at 6 a.m. on 02/19/2017 through 9 a.m. on 02/20/2017. There was no physician's order to decrease the rate. There was no documentation that the patient received any water flushes during that time. The Registered Dietician (RD) identified in the Initial Nutrition Assessment dated 02/20/2017 at 8:10 a.m. that the patient had received no water flushes from the time of admission until the time of the assessment, a period of approximately 63.5 hours. The RD documented the patient's "thin appearance" and that the amount of tube feedings the patient was receiving was "suboptimal." The RD recommended increasing the tube feeding rate along with routine water flushes. The recommendations were implemented at 9 a.m. on 02/20/2017 and documented on the I & O record. There were no tube feedings or water flushes recorded on the I & O between 6 a.m. and 4 p.m. on 2/22/2017. A nursing note dated 02/22/2017 at 10:15 a.m. revealed the patient cut off the tubing of the feeding tube after returning from an outside appointment. There was no prior documentation as to what time the patient left for the hospital nor the exact time the patient returned. There was no documentation as to when the tube was replaced, however, a chest x-ray report at 12:06 p.m. revealed the end of the tube was appropriately positioned. There was no documentation as to why the tube feedings were not resumed until 4 p.m. as recorded in the I&O. There were no tube feedings recorded after 3 a.m. on 02/23/2017. A nursing note dated 02/23/2017 at 8 a.m. revealed the feeding tube was replaced. There was no documentation that clarified why the feeding tube was replaced. A chest x-ray result at 8:06 a.m. revealed the end of the tube was appropriately positioned, however, there was no documentation as to why the tube feeding was not resumed. The patient was discharged at 11:25 a.m. against medical advice with a family member who was taking the patient to another hospital.

The surveyor obtained the patient's clinical records from the hospital where the patient was taken. Documentation in the record revealed the patient had "severe malnutrition." The patient was admitted. The patient's documented weight at the time of admission was 120 pounds, a 24 pound weight loss from 144 pounds recorded at the time of admission to Curahealth Tucson on 02/17/2017.

The patient's record was reviewed with the Chief Quality Officer (CQO) on May 9, 2017 and he acknowledged tube feedings were administered without complete physician orders; the patient did not receive water flushes for over two days; and that nursing documentation was not complete or consistent regarding tube feedings.

3.

Patient #1

The physician's Admission Orders for Patient #1 dated 02/17/2017 revealed the patient was to have nothing by mouth "except tube feeding," however, the route of medication administration printed on the patient's Medication Administration Records (MAR) was "oral." For example, "doxazosin 2 mg tab oral once a day...haloperidol 1 mg tab oral at bedtime." There was no documentation that the nursing staff clarified route of medication administration with the physician and no documentation that medications were administered through the feeding tube on each day of admission.

Patient #3

The Admission Orders and Medication Reconciliation were documented as a verbal order received and documented by a pharmacist. The route of administration of medications was documented as "per NG" (nasogastric tube). For example: furosemide 20 mg "per NG" every morning and prednisone 10 mg "per NG" daily. The physician documented in the History and Physical on 05/07/2017 that the patient had a PEG (Percutaneous Endoscopic Gastrostomy) tube placement on 05/04/2017.

There was no documentation that the route of administration was clarified with the physician and changed from nasogastric to PEG.

The CQO and the Director of Pharmacy reported that pharmacy staff perform the medication reconciliation with the admitting physician prior to the patient's admission for those patients that are scheduled to be admitted after the pharmacy is closed. The medications including route of administration were taken from the medications and routes at the sending hospital.


4. The hospital's policy and procedure titled "Skin & Wound Care Program Overview" Policy H-WC 00-001 included: "Nursing...Directs the development and implementation of an individualized plan of care based on assessed needs. Focuses on risk assessment, early problem identification, preventive measures to promote skin integrity and responses to treatments. Documents and reports change of condition and revises plan of care as necessary...Documentation Standards...Assessment of wound characteristics completed with each routine dressing change...Wound dressing site assessed every shift, not scheduled for dressing change...Skin assessment/inspection at time of admission and each shift."

Patient #4

Patient #4 was admitted on 04/20/2017. Documentation in the patient's record revealed she had a neurosurgical and orthopedic intervention for a spinal fracture prior to admission. The patient wore a cervical collar as well as a "CTSO" (Cervical-Thoraco-Lumbo-Sacral Orthosis) brace at all times. The hospital's wound care nurse assessed the patient on 04/21/2017 and documented that the patient had a sutured spinal incision which was covered with a dressing and was unable to be visualized because of the CTSO brace. There was no documentation that nursing staff obtained an order to remove the back brace and the dressing over the surgical incision to assess it.

The hospital's wound care physician's documentation in a Progress Noted dated 05/03/2017, 13 days later, included: "...still wearing the collar and back brace. The dressing on her back has not been removed which apparently was what was wanted by the transferring surgeons, however, it has been on for so long that I felt it needed to be evaluated. Upon evaluation, I found some dehiscence of the wound on the back with some thick eschar (necrotic tissue) in various areas...I have asked for Silvadene to be placed twice a day on the thick eschar areas, hopefully soften them up so that they can be debrided at some point in the near future." The wound was cultured on 05/07/2017 and the results revealed an infection.

There was no documentation that nursing staff attempted to get a physician's order to remove the back brace in order to observe the surgical site. The wound care physician noted this in the progress note documented above which was 13 days after the patient's admission. When the back brace and dressing were removed, the incision site had areas of opening as well as areas of "thick eschar."

Patient #15

The patient was admitted on 04/13/2017 for wound care after surgical removal of the left leg at the hip. A physician's order for wound care to the patient's right ischium was written on 05/11/2017 at 5 p.m. A "Wound Care Status Report" dated 05/13/2017 included: "Unstageable pressure injury to right ischium with adherent soft eschar. The wound care nurse reported during an interview on 05/18/2017 that the right ischium pressure sore was identified on 05/11/2017 when the patient told her the area was hurting.

A review of the skin assessment section of the Daily Nursing Assessments revealed inconsistent documentation of a pressure sore on the patient's right ischium. For example, on 05/14/2017 there was no documentation of the right hip pressure sore on either shift; on 05/15/2017 there was documentation of the area by the nurse on day shift but no documentation by the nurse on night shift. On 05/16/2017 the day shift nurse did not identify the pressure sore on the right, however the nurse on the night shift did; and on 05/17/2017, neither the day shift or night shift nurses identified the right ischium pressure sore.

Patient #21

The patient was admitted on 05/18/2017 and an evaluation of his skin was made by the wound care nurse on 05/19/2017. The wound care nurse identified several areas of skin breakdown including a pressure with necrotic tissue on the back of the patient's head; a large area of contact dermatitis over the patient's sacrum with yellow slough; sutures and necrotic areas in the patients right groin; and a large draining skin tear on the patient's right arm. The wound care nurse consulted with the physician and wound care orders were written for wound care to the sacrum twice a day and daily wound care to the right groin and the back of the patient's head.

On 05/22/2017 the surveyor requested documentation that wound care was being provided as ordered. The CQO reported that he was not able to locate that documentation because the orders had not been transcribed onto a Treatment Record by nursing staff. He acknowledged there was no documentation of wound care for the period from 05/19/2017 to 05/22/2017.

5. The hospital's policy and procedure titled "Weight Measurement" included: "Weight is an anthropometric measurement used in conjunction with other information to calculate estimated energy, protein, and fluid needs; body mass index; the patient's ideal/desired weight range; and dose of medications, anesthetics, and contrast agents. Weight change over time is an important indicator of nutritional status and fluid status...Self-reported weight and weights from another facility are not used in lieu of actually weighing the patient...Weight measurement is scheduled as follows...Weight with 24 hr of admission...Weekly thereafter, or Physician's Order...."

Patient #2

Patient #2's Weight Record revealed a weight of 144.6 pounds on the day of admission, 04/28/2017. There was no weight documented after that when the record was reviewed by the surveyor on 05/09/2017, eleven days later, and the nursing staff was not able to locate documentation that the patient was reweighed after the admission date. The patient's record was reviewed again by the surveyor on 05/10/2017, and documentation on the Weight Record revealed the patient was reweighed at 6 a.m. that morning and the recorded weight was 107.6 pounds, a weight loss of 37 pounds. There was no documentation in the nursing notes that addressed the significant weight loss or that the physician was notified. The RN assigned to oversee the patient's care on the 7 a.m. to 7 p.m. shift reported she was not aware of the weight loss. The CNO stated the patient should have been reweighed because of the weight discrepancy and requested staff to reweigh the patient which was done at 9:20 a.m. That weight was 115 pounds, an increase of 7.4 pounds from the weight recorded just three hours earlier.

Patient #10

Patient #10 was originally admitted on 04/03/2017 and the weight documented. There was no other weight documented up to the date the patient was transferred to an acute care hospital on 04/22/2017. The patient's weight documented on the current MAR's was 175.26 pounds. The patient's weight documented on 05/10/2017 was 136.2 pounds and 128.5 pounds on 05/14/2017.

Patient #15:

The patient's weight on the day of admission was 192.4 pounds. The patient was not weighed again until 27 days later at which time she weighed 173.2 pounds, a loss of 13.2 pounds.

The CQO and CNO acknowledged the above. The surveyor was told that the pharmacy used the patient's weight from the records of the sending hospital.

6.

Patient #2

The patient was on continuous tube feedings and had an indwelling urinary catheter. The admission orders included an order to record I&O's. A review of the hospital's I & O forms revealed no documentation of intake and/or output as follows:

-No water flushes through tube feeding documented from 6 p.m. on 05/03/2017 to 6 a.m. 05/04/2017;
-No intake documented from 6 a.m. to 6 p.m. on 05/04/2017;
-No output documented from 6 p.m. on 05/06/2017 to 6 a.m. on 05/07/2017;
-No intake or output documented from 6 p.m. on 05/07/2017 to 6 a.m. on 05/08/2017; and
-No intake documented from 6 p.m. on 05/04/2017 to 6 a.m. on 05/05/2017

Patient #4

Patient #4 had 500 cc intravenous Normal Saline administered on 05/11/2017 at 2:30 p.m. and on 05/12/2017 at 07:55 a.m. Neither of these were recorded on the I & O form for those dates. There was no documentation of any form of intake on the day shift of 05/15/2017, and no documentation of I&O on the night shift.

Patient #14

The patient was on continuous tube feedings, had an indwelling urinary catheter and received IV Lasix for bilateral pleural effusions. A review of the I & O forms revealed the following:

-Undated form with no documentation of any form of intake between 6 a.m. and 6 p.m.;
-04/29/2017: No documentation of any intake between 6 p.m. and 6 a.m. 04/30/2017; and
-04/27/2017: No documentation of any intake between 6 a.m. and 6 a.m. on 04/28/2017. No documentation of output from 6 p.m. to 6 a.m. on 04/28/2017.

The pulmonologist's documentation in a progress note dated 04/28/2017 included: "We cannot find her input and output...despite a vigorous search alert."

The CQO acknowledged during interviews that I&O's were not consistently and/or accurately documented.

Based on review of hospital policies and procedures, review of clinical records, and staff interviews, it was determined the hospital:

1. Failed to ensure medications were administered in accordance with physician orders for 5 of 10 focused review of patient records for medication administration in the total sample of 25. (Patients #2, #5, #16, #17, and #19.) This deficient practice poses the risk of harm to patients if they do not receive physician ordered medications.

2. Failed to ensure incomplete and/or inaccurate physician orders for 6 of 15 focused review of patients records for completed physician orders in the sample of 25 were clarified with the prescribing physicians prior to implementing the orders. (Patients #2, #4, #5, #7, #14, and #17.) This deficient practice poses the risk of medication administration errors.

3. Failed to ensure the actual time of medication administration was documented on the MAR for 25 of 25 records. This deficient practice poses the risk of medications not administered within time frames identified in hospital policies and procedures.

4. Failed to ensure two nurses verified and documented insulin doses prior to administration for 4 of 6 focused record reviews for nurse verification of insulin doses. (Patients #2, #5, #7 and #17.) This deficient practice poses the high risk of inaccurate doses of Insulin being given to patients when verification of the required dose is not done by a second RN, which then could potentially result in complications related to Hyper or Hypoglycemia related to wrong insulin doses being administered to patients .


Findings include:

1. The hospital's policy and procedure titled "Administration of Medications" H-MM 05-001 PRO included: "The 7 'R's' (rights) of administering medications will be followed with each medication administration...'Right'...patient...medication ... dose...time...route...reason...documentation...Double-check the medication with the MAR (Medication Administration Record) for accuracy."

Patient #2

Documentation in Patient #2's clinical record included the following events:

-04/29/2017: The patient's blood glucose (BG) level recorded at 6:30 a.m. was "221" mg/dL. According to the physician's sliding scale insulin order, the patient should have received 6 unit subcutaneously (sq) of Humulin R (regular) insulin. There was no documentation on the MAR that the patient received insulin coverage at that time.

A physician's order dated at 12:45 p.m. included an order for a one time administration of Lasix (diuretic) 40 mg intravenously (IV). Documentation in the MAR revealed the medication was administered at 9 p.m., a period of over eight hours after the order was written. There was no documentation that explained the delay in administering the medication.

-04/30/2017: A physician's order at 3 p.m. included another one time administration of Lasix 40 mg IV. There was no documentation in the MAR's for the period from 04/30/2017 to 05/01/2017 at 7 a.m. that the Lasix was administered nor was there documentation that explained why it was not administered.

-05/01/2017: The patient's BG was "77" mg/dL at 6 a.m. and "57" mg/dL at 7 a.m. and no insulin coverage was required. The LPN assigned to the patient documented on the MAR that the 9 a.m. scheduled dose of Levemir 20 units insulin was: "held D/T (due to) low blood sugars." At 11:50 a.m. the patients BG was "171" mg/dL and should have received 4 units of insulin, however, the LPN assigned to the patient's care documented on the MAR that insulin was not given because the patient had been hypoglycemic. There was no documentation that the nurse notified the physician and obtained an order to hold the insulin.

The 9 p.m. scheduled dose of Levemir 20 units was circled meaning it was not administered. There was no documentation that explained why it was not given and no physician's order to hold the insulin.

-05/04/2017: The patient's BG was "163" mg/dL at midnight and according to the insulin sliding scale protocol, the patient should have received 4 units of insulin. A line was marked through "0:00" and "WNL" (within normal limits). There was no documentation that the patient received the 4 units of insulin. The patient's BG was "397" mg/dL at 5 a.m. The patient's care had been assigned to an LPN for the 7 p.m. (05/03/2017) to 7 a.m. (05/04/2017) shift. The RN leader of the patient care team acknowledged by signature at 4 a.m. on 05/04/2017 on the Daily Nurse Assessment that the care provided was reviewed and that the RN concurred with the care provided to the patient by the LPN assigned to the patient.

A physician's progress note dictated at 1:21 p.m. revealed the patient's recent labwork showed a high potassium level of 5.3, and the physician's order at 1:30 p.m. included a one-time order for Kayexalate 30 gm through the patient's feeding tube to treat the high potassium level. The order was transcribed on to the MAR, however, there was no documentation that it was administered.

-05/05/2017: There was no documentation that the 6 a.m. scheduled BG was obtained. The Vital Signs record for that date revealed a BG was obtained/documented at 9 a.m. and was "367" mg/dL, however, there was no documentation that the patient received insulin coverage following the sliding scale protocol. There was no nursing documentation whatsoever that addressed the high (367) BG. The LPN assigned to the patient documented on the MAR that the patient's BG at 12 noon was "346," however, that value was not documented on the Vital Signs record nor on the glucometer print out provided to the surveyor. The BG recorded on the glucometer print out at 12:01 p.m. was "414 mg/dL." The patient received insulin coverage for the "346" documented by the LPN.

-05/06/2017: The patient's BG at 6 a.m. was "89" mg/dL and did not require any insulin coverage. The RN assigned to the patient's care during the day shift documented that the scheduled 9 a.m. Levemir 16 units was not administered because of the "89" BG obtained at 6 a.m. There was no documentation that the nurse notified the physician that the Levemir was held.

-05/07/2017: The patient's BG at 6:09 a.m. was "165" mg/dL, and the patient should have received 4 units of Humulin R insulin coverage. There was no documentation on the MAR that the patient received it nor documentation to explain why it was not given.

-05/08/2017: The patient's BG at 12 noon was "53" mg/dL. There was no documentation that thepatient was given Dextrose 50% IV push in accordance with the hypoglycemic protocol. A physician's progress note dictated at 3:33 p.m. revealed the patient's potassium level was 5.7 and his orders timed at 3 pm. included Dextrose 50% IV one time, then Novolog Insulin 10 units IV one time, Kayexalate 30 grams through the feeding tube one time, "now" and then Lasix 20 mg IV one time. A BG of "15" mg/dL was recorded at 6 p.m. Documentation on the MAR revealed the Kayexalate was given at 6:30 p.m., the IV Dextrose was administered at 6:35 p.m., and the IV Lasix was administered at 6:40 p.m. There was no documentation that the Novolog Insulin was given. A physician's telephone order at 7:45 p.m. included: "D/C (discontinue) all insulin."

-05/09-10/2017: Documentation on the MAR revealed the patient's noon BG was "382" mg/dL and received 12 units of Humulin R insulin. There was no physician's order to restart the insulin.

-05/10/2017: At midnight the patient received 15 units of Humulin R insulin for a BG of "407" mg/dL. There was no physician's order to restart insulin after it was discontinued the evening before until a physician's Telephone Order was obtained by the nurse at 2:10 a.m. At 6 p.m. the patient's BG was "458" mg/dL and documentation on the MAR revealed the patient received "12u" (12 units) of regular insulin. According to the sliding scale, the patient should have received 15 units.

-05/11/2017: The patient's BG was "349" mg/dL at 6 p.m. and documentation on the MAR revealed the patient received "12 unit coverage." According to the sliding scale, the patient should have received 10 units.

Patient #5

A physician wrote an order on 05/14/2017 at 10:28 a.m. for 40 mg of Lasix IV to be administered one time "now" and to decrease IV Solumedrol to 40 mg every 12 hours. There was no documentation that the orders were transcribed onto the MAR and no documentation that the IV Lasix was administered.

The RN who was on duty and noted the above order acknowledged during an interview on 05/18/2017 that she missed the order.

Patient #16

The patient was admitted on the day shift of 05/15/2017. A review of the patient's MAR revealed no nursing initials documented indicating physician ordered medications were administered as scheduled on the night shift as follows:

9 p.m.: Metoprolol Tartrate 25 mg (for hypertension)
Pravastatin 80 mg (for high cholesterol)
Calcium-Vitamin D (vitamin supplement)
Docusate 100 mg (stool softener)
Heparin 5000 units subcutaneously (anticoagulant)
10 p.m.: Neurontin 300 mg

The CQO acknowledged the above on 05/17/2017.

Patient #17

A physician's order dated 04/13/2017 at 9 a.m. included: "Regular insulin 15 units sq x 1 now." There was no documentation that the order was transcribed onto the MAR and administered.

The CNO and CQO reviewed the clinical record on 05/18/2017, and acknowledged there was no documentation that the above order for insulin was given.

Patient #19

A nursing note dated 05/20/2017 at 8:25 a.m. identified as a "Late Entry" for 05/19/2017 at 3:30 p.m. The RN documented that the patient complained of feeling lightheaded, cold and clammy. The patient's BG was checked and was 45 ml/dL. The physician was notified who ordered IV Dextrose 50 and: "Hold insulin until future orders." The patient's BG was "224" mg/dL at 9 p.m. and documentation on the MAR revealed the patient was given 6 units of regular units. There was no documentation that the physician was notified and an order received to resume the sliding scale protocol prior to the administration of the 6 units of insulin.

The CQO reviewed the record and acknowledged there was no physician's order to resume insulin.

2. The hospital's policy and procedure titled "Ordering of Medications" H-MM 03-001 included: "All medication orders must be entered into the patients' medical record (computerized or manual) and must include: drug name, strength, form, route, dosage, frequency, date, time of order, and name of prescribing licensed practitioner...Incomplete medication orders: medication orders identified to be missing any of the required elements as outlined in this policy are considered incomplete. The ordering prescriber will be contacted for clarification prior to implementation of the medication order.

The hospital's policy and procedure titled "Differentiation Between Verbal and Written Orders" H-IM 02-021 included: "A 'Telephone' order is any order received via telephone from a staff physician or Licensed Independent Practitioner (LIP) spoken to licensed or certified staff to transcribe. The telephone order takes place in the event the staff physician or LIP cannot be on premises to write the order in the patient's paper or electronic medical record."

Patient #2

A telephone physician's order dated 05/13/2017 at 11:42 a.m. read: "levemir 16 units q day @ 0900." The nurse who took the order and documented that it was read back (RB) to the physician failed to include the route of the medication (insulin).

A physician's order dated 05/07/2017 at 12:10 p.m. included: "Increase insulin Levemir to 16 units q 12 hours." The order did not specify the route and the nursing staff did not clarify the order prior to transcribing it onto the MAR.

Patient #4

The physician orders included a telephone order dated 05/11/2017 at 2:50 p.m. The LPN who received and documented the order wrote: "1 bolus 500ml/hr x 1." The order did not include the name of the drug to be administered nor the route. The LPN documented on the MAR that she gave the patient 500 ml of 0.9% "NS" (normal saline) because of low blood pressure.

The next physician order on the page was "1 Bolus 500 ml/hr x 1." The order was not timed or dated and was noted by a nurse on 05/12/2017 at 6:20 a.m. This order also did not include the name of the drug to be administered nor the route. The order was not transcribed onto the MAR or recorded on the 24 Hour Intake Output Totals form. A nursing note dated 05/12/2017 at 7:55 a.m. revealed the patient was give a bolus of 500 cc NS for a low blood pressure.

A physician's telephone order dated 05/12/2017 at 5:53 p.m. read: "0.5 mg Ativan x 1." The order did not include the route. The order was not transcribed onto the MAR and there was no documentation of a nursing assessment that clarified why the order was obtained and whether or not it was administered and if not, why.

Patient #5

A telephone order documented by an RN read: PO Ativan 0.5 mg q 4 (hours) PRN (as needed) PO (by mouth)." The order was not dated, timed, or noted by the RN.

Patient #7

A telephone order was taken by a nurse on 05/12/2017. The order included: "10 units regular insulin IV" and "Kayexalate 30 g per peg tube." The nurse failed to obtain and/or document the frequency for these two medications.

Patient #14

A telephone order documented by an RN was for Miralax, Lactulose and Fleets enema for constipation. The order was not dated, timed or noted by the RN.

Patient #17

A physician's order dated 04/13/2017 at 9 a.m. included: "Levemir 40 units q am & qhs." The order did not include the specific route of administration.

3. The hospital's policy and procedure titled "General Documentation Guidelines" H-IM 02-001 included: "All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated...."

The MAR's for each patient are preprinted with the scheduled time of administration following physician orders and their policies and procedures for medication administration times. 25 of 25 records reviewed revealed the majority of nursing staff crossed out and initialed next to the scheduled time rather than entering the actual time of administration.

The CQO said that most of the nurses put a line through the preprinted scheduled time of administration rather than documenting the actual time of administration. He acknowledged that based on current practice, he was unable to determine if medications are being administered within time frames established in policies and procedures.

4. Documentation on the MARs for all patients receiving insulin included: "HIGH ALERT - 2 Nurse Verification." Clinical record reviews of patients receiving insulin revealed inconsistent documentation of the 2-Nurse Verification of insulin doses including the following patients:

-Patient #2: On 05/03/2017 at 12 noon and 6 p.m., the patient received insulin with no initials of the administering nurse or the nurse verifying the dose.
-Patient #5: On 05/13/2017 at midnight and 6 a.m., the patient received insulin with no initials of the administering nurse or the nurse verifying the dose.
-Patient #7: On 05/12/2017 at 6:30 a.m., the patient received IV insulin with no initials of the verifying nurse.
-Patient #17: On 04/03/2017 at midnights and 6 a.m., the patient received insulin with no initials of the verifying nurse

The CQO acknowledged the inconsistent documentation of 2-Nurse Verification of insulin administration.

Based on reviews of hospital policies and procedures, review of clinical records, and staff interviews, it was determined the hospital failed to ensure policies and procedures to minimize medication errors were followed in the pharmacy department as evidenced by:

1. Failure of the pharmacy staff to identify and correct/clarify incomplete physician orders for 6 of 15 focused record reviews in the total sample of 25. (Patients #2, #3, #4, #5, #14, and #19)

2. Failure to identify multiple medication administration errors identified during the survey for 6 of 6 patient focused record reviews in the total sample of 25. (Patients #2, #3, #4, #5, #14, and #19)

The deficient practices identified above posed the high potential risk of medication errors resulting in possible harm to the patients.

Findings include:

1. The hospital's policy and procedure titled "Ordering of Medications" H-MM 03-001 included: "All medication orders will undergo a final verification by a pharmacist...All medication orders must be entered into the patients' medical record (computerized or manual) and must include: drug name, strength, form, route, dosage, frequency, date, time of order, and name of prescribing licensed practitioner...Incomplete medication orders: medication orders identified to be missing any of the required elements as outlined in this policy are considered incomplete. The ordering prescriber will be contacted for clarification prior to implementation of the medication order. The pharmacist, when on duty is primarily responsible for contacting the physician to correct any incomplete or unclear medication order submitted for final verification into the pharmacy system...'Hold' medication orders are not valid orders. If medications are not to be administered, they must be discontinued. Orders written to 'hold' medications will result in the medications being discontinued. If the medication order is to be initiated again, the physician must give a new order."

Patient #2

A telephone physician's order dated 05/13/2017 at 11:42 a.m. read: "Levemir 16 units q day @ 0900." The order did not included the specific route the insulin was to be administered.

A physician's order dated 05/07/2017 at 12:10 p.m. included: "Increase insulin Levemir to 16 units q 12 hours." The order did not specify the route.

Patient #3

The Admission Orders and Medication Reconciliation were documented as verbal orders received and documented by a pharmacist. The route of administration of medications normally administered orally was documented as "per NG" (nasogastric tube). For example: furosemide 20 mg "per NG" every morning and prednisone 10 mg "per NG" daily. The physician documented in the History and Physical on 05/07/2017 that the patient had PEG (Percutaneous Endoscopic Gastrostomy) tube placement on 05/04/2017.

There was no documentation that the route of administration was clarified with the physician and changed from nasogastric to PEG.

Patient #4

A telephone order dated 05/11/2017 at 2:50 p.m. read: "1 bolus 500ml/hr x 1." The order did not include the name of the drug to be administered nor the route. The LPN documented on the MAR that she gave the patient 500 ml of 0.9% "NS" (normal saline) because of low blood pressure.

The next physician order on the page was "1 Bolus 500 ml/hr x 1." The order was not timed or dated and was noted by a nurse on 05/12/2017 at 6:20 a.m. This order also did not include the name of the drug to be administered nor the route. A nursing note dated 05/12/2017 at 7:55 a.m. revealed the patient was give a bolus of 500 cc of normal saline.

A physician's telephone order dated 05/12/2017 at 5:53 p.m. read: "0.5 mg Ativan x 1." The order did not include the route the medication was to be administered.

Patient #5

A telephone order documented by an RN read: "PO Ativan 0.5 mg q 4 (hours) PRN (as needed) PO (by mouth)." The order was not dated, timed, or noted by the RN.

Patient #14

A telephone order documented by an RN was for Miralax, Lactulose and Fleets enema for constipation. The order was not dated or timed.

Patient #19

A physician's telephone order dated 05/19/2017 at 3:35 p.m. included: "Hold insulin until future orders." There was no documentation that pharmacy staff advised the physician that "Hold" orders were not valid orders as documented in policies and procedures.

There was no documentation that the incomplete orders were identified and clarified by pharmacy staff.

The Director of Pharmacy acknowledged during interviews that incomplete orders should be identified, addressed, and clarified when the orders are received in the pharmacy department.

2. Numerous medication "events" were identified during the complaint investigation survey which included physician ordered medications not administered and/or medications administered without a physician's order. There was no documentation in the records of the affected patients that physicians were notified nor documentation that the events were reported. Refer to Tag A-395 for details of the medication errors.

The CQO reported that medication errors were documented on paper forms and given directly to him for investigation. Medication errors that involved pharmacy were provided to the Director of Pharmacy for review and follow up.

The Director of Pharmacy was asked to provide the Pharmacy &Therapeutics activities specific to addressing medication errors. She reported that she gets the numbers of medication errors by month from the CQO, however, she had no documentation of pharmacy activities to address and decrease medication administration errors.

There was no documentation in the Pharmacy, Nutrition and Therapeutics Committee Meeting Minutes dated 12/27/2016, 01/17/2017, 04/24/2017 that addressed any review and discussion of medication errors.