HospitalInspections.org

Based on record review and interview, the hospital failed to ensure their quality process was followed for reporting a medication error for 1 of 3 patients (Patient #1) who were under the care of Physician #10 on 6/17/13.

FINDINGS INCLUDED

Electronic Medical Record
The patient #1 had an outpatient procedure for laparoscopic gastric sleeve, liver biopsy and cholecystectomy on 6/17/13. The "History and Physical Update" dated 6/17/13 reflected the patient had a diagnosis of Diabetes Mellitus and was taking "Byetta" (a medication for this diagnosis) and signed by Physician #10. The laboratory results dated 6/17/13 reflected the blood glucose results were 227 at 6:53 AM and 308 at 10:02 AM. The "Vital Signs Flowsheet" dated 6/17/13 reflected the first vitals recorded on the inpatient floor at 11:13 AM. The "Shift Assessment Flowsheet" dated 6/17/13 reflected no initial nursing assessment. The physician "Orders" dated 6/10/13 included "Admit to Med/Surg Inpatient...Diagnosis: Morbid Obesity, Diabetes, HTN" at 1:28 PM with pre-op orders. The physician "Orders" dated 6/17/13 included "D5W 1/2 NS + KCL 20 mEq 1000 ml...change to 1/2NS + 20 mEq KCL if patient is diabetic..." at 9:53 AM and "Transfer to/Level of Care Changes...Med/Surg, Special instructions: inpt" at 10:13 AM. The "Medication Administration Record" dated 6/17/13 reflected "D5W 1/2 NS + KCL 20 mEq IV" administered at 11:12 AM by Personnel #5 (Dextrose 5% Water 1/2 Normal Saline + Potassium Chloride 20 milliequivalent intravenously).

Incident Report Log
The incident report log was reviewed from 6/17/13 - 1/09/14. There was no medication error reported for the above findings.

QA/Governing Board Minutes
The "Best Care Minutes" were reviewed from July to December 2013. They did not reflect this patient's complaint, medication error, or the changes to the ordering system that had been mentioned in the hospital's response to the patient's grievance letter.

In an interview on 1/18/14 at 3:40 PM, Personnel #5 (Primary care nurse) was informed of the above findings and she confirmed the patient had received D5W 1/2 NS + KCL 20 mEq IV instead of 1/2 NS + KCL 20 mEq which was ordered by the physician. Personnel #5 stated she did not file an incident report for the medication error.

In an interview on 1/16/14 at 4:00 PM, Personnel #1 (Patient Safety Officer) was informed of the above findings and confirmed the findings. She was asked if there was an incident report for the medication error. Personnel #1 stated there was none. The surveyor asked why one was not filed. Personnel #1 stated it was reported as a patient complaint instead of a medication error. The surveyor asked if this medication error was discussed in the Quality Assessment Meeting. Personnel #1 stated it was not.

In an interview on 1/16/14 at 4:35 PM, Personnel #3 (Inpatient Floor Nurse Manager) was informed of the above findings. Personnel #3 stated she was notified of the patient complaint and did not tell the nurse to put in an adverse occurrence for the medication error.

Healthcare Improvement, Risk Management and Patient Safety Plan FY 2013 undated reflected "Philosophy...Safety and quality are accepted as personal responsibilities and work together to minimize any harm that might result from unsafe or poor equability of care, treatment and services."

The hospital's policy "Adverse Event Policy and Procedure" last revised 4/12/11 required "Unanticipated event reports will be completed...before the end of the shift...unanticipated situation which cause harm or could or would cause harm to any person including...medication occurrences...take appropriate corrective action to resolve any issues...process to analyze events, determine root cause, implement action plans, and monitor follow up, and to assist the facility's Quality Committee in its efforts to minimize the risks..."

Based on records review and interview, the registered nurse failed to supervise and evaluate the nursing care of 1 of 5 inpatients (Patient #1) who were admitted from 6/17/13 to 1/9/14, in that, no initial nursing assessment was conducted for Patient #1.

FINDINGS INCLUDED

Electronic Medical Record
The patient #1 had an outpatient procedure for laparoscopic gastric sleeve, liver biopsy and cholecystectomy on 6/17/13. The "History and Physical Update" dated 6/17/13 reflected the patient had a diagnosis of Diabetes Mellitus and was taking "Byetta" (a medication for this diagnosis) and signed by Physician #10. The laboratory results dated 6/17/13 reflected the blood glucose results were 227 at 6:53 AM and 308 at 10:02 AM. The "Vital Signs Flowsheet" dated 6/17/13 reflected the first vitals recorded on the inpatient floor at 11:13 AM. The "Shift Assessment Flowsheet" dated 6/17/13 reflected no initial nursing assessment. The physician "Orders" dated 6/10/13 included "Admit to Med/Surg Inpatient...Diagnosis: Morbid Obesity, Diabetes, HTN" at 1:28 PM with pre-op orders. The physician "Orders" dated 6/17/13 included "D5W 1/2 NS + KCL 20 mEq 1000 ml...change to 1/2NS + 20 mEq KCL if patient is diabetic..." at 9:53 AM and "Transfer to/Level of Care Changes...Med/Surg, Special instructions: inpt" at 10:13 AM. The "Medication Administration Record" dated 6/17/13 reflected "D5W 1/2 NS + KCL 20 mEq IV" administered at 11:12 AM by Personnel #5 (Dextrose 5% Water 1/2 Normal Saline + Potassium Chloride 20 milliequivalent intravenously).

In an interview on 1/17/14 at 11:50 AM, Personnel #2 (Interim Chief Nursing Officer) was informed of the above findings. Personnel #2 confirmed there was no intiail nursing assessment.

In a telephone interview on 1/18/14 at 3:40 PM, Personnel #5 (Primary Care Nurse) stated, she did not complete the initial nursing assessment.

The hospital's policy "Clinical Nursing Documentation Policy" origination date 11/08/12 required "Documentation of inpatient care: Assessment: within 2 hours of admission...patient safety needs...fall risk assessment...skin assessment...within 4 hours of admission: Inpatient shift assessment."