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Based on a review of the quality program and interviews with administrative staff it was determined the governing body was not aware of medical errors including medication errors, the quality of contracted services, or the effectiveness of the discharge planning process.

The findings are:

1. Throughout the survey process from 4/12/11 through 4/15/11, one focus of the survey and information requested was the hospital's quality assessment and performance improvement (QAPI) activities. Throughout the survey, the hospital's management team was asked to provide any and all documentation or evidence that the hospital's quality program incorporated items related to patient safety, medication errors, discharge planning and contracted dialysis services. It was further requested throughout the survey that evidence be provided that these same elements were reported to the governing body. At the end of the survey, no evidence had been provided that these three elements of service were monitored through the QAPI program or made known to the governing body therefore making it impossible for trends to be identified, improvements to be suggested and approved, or actions/evaluations to be taken.

2. For additional details related to this deficiency see tag A-0263.

Based on staff interviews it was determined the governing body failed to ensure the contracted dialysis services were provided in a safe and effective manner.

The findings:

On 4/14/11 at 10:00 a.m. the Chief Nursing Officer (CNO) was asked to provide evidence the hospital's QAPI program incorporated the contracted service for dialysis. On the morning of 4/15/11, the CNO only provided the contracted dialysis center's culture reports from 2008 and 2009. At the time of exit, no further culture reports were provided and the CNO was unable to provide any other evidence that contracted services were a component of the hospital's QAPI program.

Based on staff interviews and committee meeting minutes it was determined the facility's Quality Assurance Performance Improvement (QAPI) program failed to include the quality and effectiveness of discharge planning and contracted services as well as the safety and accuracy of medication administration.

The findings include:

The Performance Improvement Committee meeting minutes were reviewed for meetings occurring both January 20, 2011 and March 24, 2011. The minutes failed to address discharge planning, contracted services and medication errors. No evidence was found that these three areas of service were a part of the facility's efforts to identify trends, analyze data and provide opportunities for improvement in patient care and safety. The findings related to these specific areas are listed below.

1. Medication Errors:

The Pharmacy and Therapeutics (P&T) Committee meeting minutes from 1/25/2011 were reviewed on 4/12/2011. The minutes reflected 82 medication errors occurring during October 2010, 36 medication errors occurring during November 2010 and 47 medication errors occurring during December 2010. The minutes failed to document that the committee was provided with information or details other than the number of errors per month.

The P&T Committee meeting minutes from 3/22/2011 were reviewed on 4/12/2011. The minutes reflected 32 medication errors occurring in January 2011, and 31 medication errors in February 2011. There was no evidence the committee analyzed data to show trending or causative factors in medication errors which would be utilized to determine a plan for improvement.

The Director of Risk Management (RM) was interviewed on 4/12/11 at 3:45 p.m. regarding Pharmacy and Therapeutics (P&T) committee meeting minutes from January & March 2011. The RM informed the survey team that she provides the statistics related to medication errors to the P&T committee, however, she may not be aware of medication errors identified through the pharmacy. The RM acknowledged that since there were two mechanisms by which medication errors could be identified, it was possible the pharmacy would be aware of medication errors that did not get reported via the Patient Safety Report (PSR), therefore the number of medication errors she reported (derived from the PSR only) to the P&T committee may not be accurate. When asked who is responsible to ensure that all information related to medication errors was being reported, tracked, and trended she replied, "I'm not sure."

The Chief Nursing Officer (CNO) was interviewed related to medication error reporting on 4/12/11. She stated the director of pharmacy sends a monthly medication discrepancy report to each department director and the errors are investigated within the department in which they occurred. When the CNO was questioned regarding where the quality component of medication errors and identified trends was reported, she stated that it was specific to the nurse, the unit or the doctor.

The Director of Pharmacy was interviewed on 4/13/11 at 1:50 p.m. She stated that all medication errors identified through the pharmacy are forwarded to the RM. She explained that the number of the medication errors reported to the P&T committee may not be an accurate number. She described that each unit manager investigates medication discrepancies occurring on their unit and often determine what initially appeared as a medication error was later found not to be an actual error. An example would be if a medication was initially tracked as given without an order, the investigation may conclude that at the time the medication error was reported, the verbal order existed but had not been authenticated by the physician; when the physician authenticates the verbal order, it would no longer be considered a medication error. The director of pharmacy acknowledged there is currently no process in place to identify trends in medication errors or to use data collected to improve processes. The director of pharmacy stated that as a result of this survey process, the facility has identified a need to improve their follow-up on medication errors.

The Quality Manager was interviewed on 4/13/11 at 3:15 p.m. She informed the survey team that as part of her role, she is a member of the Quality Committee and acknowledged that medication errors are not reported to the quality committee.

The RM was reinterviewed at 4:00 p.m. on 4/13/11 and she confirmed that she is unaware of any process (other than P&T committee) to track and analyze the data related to medication errors.

The CNO was reinterviewed at 4:30 p.m. on 4/13/11 and stated that although the facility has a Clinical Safety Committee and a P&T Committee that review medication errors in addition to other data, she acknowledged the data regarding medication errors is not accurate and not reported to QAPI or the governing body (GB). She stated there is no global sharing of the data to allow trending and that the hospital needs to look at their process to prevent and reduce medication errors.

2. Contracted Services:

On 4/14/11 at 10:00 a.m. the Chief Nursing Officer (CNO) was asked to provide evidence the hospital's QAPI program incorporated the contracted service for dialysis. On the morning of 4/15/11, the CNO only provided the contracted dialysis center's culture reports from 2008 and 2009. At survey exit, no further culture reports were provided and the CNO was unable to provide any evidence that contracted dialysis services were a component of the hospital's QAPI program.


3. Discharge Planning:

On 4/14/11 at 4:35 p.m. an interview took place with the Corporate Director of Patient Resource Management. After describing the facility's discharge planning process, she was asked to describe the QAPI process for discharge planning. She was unable to describe how the facility's QAPI program assessed the discharge planning program for effectiveness and adequacy.

During the exit conference on 4/15/11, the CNO, the Quality Manager and the Corporate Director of Patient Resource Management all acknowledged the facility had no evidence that the QAPI program assessed the discharge planning program for effectiveness and adequacy.

Based on staff interviews and committee meeting minutes it was determined the facility's QAPI program failed to address the issue of identifying and reducing medical errors.

See tag A-0263 for details related to this deficient practice.

Based on staff interviews and review of committee meeting minutes it was determined the facility failed to provide evidence it measures, analyzes and tracks quality indicators for discharge planning, contracted services and medical errors.

See tag A-0263 for details related to this deficient practice.

Based on staff interviews and committee meeting minutes it was determined the facility failed to use data to monitor the effectiveness of contracted services, discharge planning and medical errors as they relate to safety of services and quality of care.

See tag A-0263 for details related to this deficient practice.

Based on staff interviews and committee meeting minutes it was determined the facility failed to use data to identify opportunities for improvement or changes related to their contracted services, discharge planning process and medication errors.

See tag A-0263 for details related to this deficient practice.

Based on staff interviews and committee meeting minutes it was determined the facility failed to set priorities for its performance improvement activities that would affect health outcomes, patient safety and quality of care as related to contracted services, discharge planning and medical errors.

See tag A-0263 for details related to this deficient practice.

Based on staff interviews and committee meeting minutes it was determined the facility failed to provide evidence their performance improvement activities tracked medical errors, specifically medication errors.

See tag A-0263 for details related to this deficient practice.

Based on staff interviews and committee meeting minutes it was determined the facility failed to provide evidence their performance improvement activities analyze medical error causation.

See tag A-0263 for details related to this deficient practice.

Based on staff interviews and committee meeting minutes it was determined the facility failed to provide evidence their performance improvement activities incorporated preventive actions and mechanisms that would include feedback and learning throughout the hospital related to medical errors.

See tag A-0263 for details related to this deficient practice.

Based on staff interviews and committee meeting minutes it was determined the facility failed to provide evidence of actions aimed at performance improvement related to contracted services, discharge planning and medication errors.

See tag A-0263 for details related to this deficient practice.

Based on staff interviews and committee meeting minutes it was determined the facility failed to provide evidence they were measuring success related to performance improvement activities in contracted services, discharge planning, and medication errors.

See tag A-0263 for details related to this deficient practice.

Based on staff interviews and committee meeting minutes it was determined the facility failed to provide evidence it tracked performance to ensure improvements were sustained related to contracted services, discharge planning and medication errors.

See tag A-0263 for details related to this deficient practice.

Based on staff interviews and committee meeting minutes it was determined the facility's governing body failed to ensure an ongoing QAPI program that was implemented, maintained and evaluated with clear expectations in the area of patient safety, specifically as it relates to medical errors, contracted services and discharge planning.

See tag A-0263 for details related to this deficient practice.

Based on staff interviews and committee meeting minutes it was determined the facility failed to provide evidence an ongoing program for quality improvement was defined, implemented, and maintained as it relates to contracted services, discharge planning and medication errors.

See tag A-0263 for details related to this deficient practice.

Based on staff interviews and committee meeting minutes it was determined the facility failed to provide evidence they have an ongoing program that is clearly defined, implemented and maintained regarding patient safety, including the reduction of medical errors.


See tag A-0263 for details related to this deficient practice.

Based on staff interviews and committee meeting minutes it was determined the facility's quality assessment and performance improvement efforts failed to evaluate all actions.


See tag A-0263 for details related to this deficient practice.

Based on staff interviews and committee meeting minutes it was determined the facility's quality assessment and performance improvement efforts failed to evaluate the area of patient safety as it related to medical errors.

See tag A-0263 for details related to this deficient practice.

Based on staff interviews and committee meetings minutes the facility failed to provide evidence of clear expectations for safety as it relates to contracted services, discharge planning and medical errors.

See tag A-0263 for details related to this deficient practice.

Based on a review of clinical records, interviews with staff, and a medication event report it was determined the registered nurses (R.N.) acted in a manner which was in violation of the orders of the practitioner responsible for the patient's care, Federal and State laws, and accepted standards of practice when documenting and administering an intravenous medication for Patient #6.
The review of clinical record findings was:
The clinical record of Patient #6 was reviewed during a focused clinical record review predicated by a complaint investigation on 4/14/11. The clinical record contained evidence that Patient #6 was a 53 year old admitted to the hospital's Critical Care Unit (CCU) on 03/06/11 with a diagnosis of Bilateral Pneumonia and an Exacerbation of COPD (Chronic Obstructive Pulmonary Disease).
The record contained evidence that Patient #6's condition deteriorated and she required intubation and mechanical ventilator support shortly after her admission. Her condition was classified as "critical." She developed acute renal failure requiring hemodialysis treatments at the bedside while in CCU.
Registered Nurse #1 documented on 03/13/11 at 15:35 that Patient #6's heart rate was ranging from 140 to 200 beats per minute. The attending physician was at the bedside and was asked "if Cardizem or Metoprolol would be an option to which he states, "No it will bring down pressure too much." This same nurse documented on 03/13/11 at 16:10, "Rate continues at 140s to 160s B/P 80s/40s."
The MAR (Medication Administration Record) for the administration period of 03/13/11 07:30 thru 03/14/11 07:29 for Patient #6 documents that Registered Nurse #1 administered Cardizem 10 milligrams intravenously (IV) on 03/13/11 at 16:25.
The record of Patient #6 failed to contain evidence of a physician's order for the dose of Cardizem administered at 16:25. The record did contain clear evidence as described above, that while the physician was in the CCU to check on the patient at 15:35 he had in fact ordered that Cardizem not be given to Patient #6.
Registered Nurse #1 documented on 03/13/11 at 19:11 that a different physician was then attending Patient #6 and this physician was given a status report. This same nurse documented that on 03/13/11 at 19:11 she asked this physician if a Cardizem bolus would be appropriate if Patient #6 "goes into A-Fib with RVR" and "order received."
The record of Patient #6 contained a verbal order dated 03/13/11 that was not timed but was signed by Registered Nurse #1 for "Cardizem 10 mg. IV PRN A-Fib c RVR then call MD." This same order was authenticated with the ordering physician's electronic signature dated 04/04/11 (22 days after it was given).
The interview findings were:
An interview took place on 04/14/11 at 3:00 p.m. with the Nurse Manager of CCU. During the interview the Nurse Manager was made aware of the findings in the record of Patient #6 regarding the verbal order dated 03/13/11 taken by Registered Nurse #1, which failed to contain a time the order was received (see above). The Nurse Manager responded that Registered Nurse #1 is usually so diligent with paperwork that she was surprised at this finding. The Nurse Manager was then asked if she was aware of any medication error with Patient #6 on 03/13/11 involving the drug Cardizem. The Nurse Manager stated, "The nurse took it upon herself about the Cardizem" and "She was very upset and concerned about the patient's heart rate." At this point in the interview the Nurse Manager began to move about restlessly in her chair, appeared nervous, and moved her hands from her lap to her face then back again frequently as she talked. The Nurse Manager stated that the CCU Charge Nurse (R.N. #2) reported to her that she had concerns on 03/13/11 about Patient #6's heart rate being too high. The Nurse Manager stated that the CCU Charge Nurse reported she asked the doctor for an order for Cardizem and "he said no," but the nurse prepared a Cardizem drip, hung it at the bedside, but never started the infusion. The Nurse Manager stated her awareness of these details was a result of her investigation into the reported medication error.
At this point in the interview the CNO entered the room to provide the surveyor a document titled "Medication Event." The CNO was asked by the surveyor to participate in the remainder of the interview. The Medication Event report documents the patient's heart rate was elevated, the blood pressure was low, the attending physician was in the CCU to check the patient, the Charge Nurse (R.N. #2) asked the doctor if she could give some Cardizem to convert the patient, the doctor stated no because of the low blood pressure, and the Charge Nurse administered the Cardizem anyway. This same report documents the Charge Nurse stated she thought she would be covered under ACLS protocol. This document contained evidence the report was reviewed by the Nurse Manager and the CNO on 04/04/11. The CNO stated that she and the Quality Manager talked with the Charge Nurse about this event and the Charge Nurse told them she thought she would be covered under ACLS protocol. The CNO stated the ACLS protocols are only applicable to Code Blue situations and this patient was not in a Code Blue status at that time. Both the CNO and the Nurse Manager acknowledged there was no order for the Cardizem that was given at 16:25 on 03/13/11, the physician had actually given orders not to administer Cardizem on 03/13/11 at 15:35, that R.N. #1 charted that she administered the Cardizem dose in question when in fact the Charge Nurse (R.N. #2) was the nurse who administered the medication. The CNO stated she had interviewed R.N. #1 to ask her why she would document that she gave a medication that was actually given by another nurse, and the nurse stated it was because the nurse who had given the medication had been called away from the unit for a personal emergency and she just wanted to make sure it was documented in the patient's record. The CNO provided a copy of the formal report the facility sent to the Department of Health Professions regarding the actions of R.N. #1 and #2.
The survey team conducted a phone interview on 04/15/11 at 8:10 a.m. with R.N. #2 (the CCU Charge Nurse). During the interview the nurse was asked if she administered the dose of Cardizem to Patient #6 on 03/13/11 at 16:25 against the physician's directive to not do so and she replied, "Yes ma'am I did." The nurse stated she was very concerned about the patient's elevated heart rate and called the physician. The nurse stated the physician came right away to assess the patient and while he was present in the CCU she had requested he give approval for a dose of Cardizem. The nurse stated the physician said "no" he did not want Cardizem given due to his concern of dropping the patient's blood pressure too low. The nurse stated the physician left the CCU after informing her there were two physician's assistants (PA) covering. The nurse stated that approximately 45 minutes after the physician left the CCU, she continued to be concerned about the patient's elevated heart rate so she went ahead and gave the Cardizem. She stated she thought she would be covered under ACLS protocol. The nurse stated the Supervisor came into the CCU shortly after the medication had been given and she reported to the Supervisor what she had done. The nurse acknowledged that the dose of Cardizem documented in the record of Patient #6 as given by R.N. #1 on 03/13/11 at 16:25, was actually given by her (R.N. #2). She stated she was called away from the CCU for a personal emergency just after giving the Cardizem and did not document it in the record herself. The nurse stated that she now realizes that she had other options which included calling her Supervisor, calling the P.A.s on duty, or enacting the hospital's "Chain of Command Conflict Resolution" process.
R.N. #1 was not working during the survey period and an attempt to reach her by phone was unsuccessful therefore, R.N. #1 was not interviewed.

Based on a review of clinical records, medical staff bylaws, and interviews with staff, it was determined the facility failed to ensure that physician's orders included the required elements of date, time, signature or electronic authentication of verbal orders according to hospital requirements.
The findings were:
During a focused clinical record review predicated by a complaint investigation on 4/14/11, it was determined that out of 42 total orders reviewed, 3 failed to contain a doctor's signature or electronic authentication at all, 3 were not dated, 17 were not timed by the doctor, 14 were not authenticated within 72 hrs (per medical staff bylaws requirements).
The Medical Staff Quality Coordinator was interviewed on 04/13/11 at 11:05 a.m. She stated she was very aware of the issues the hospital has in regards to completed physician's orders as well as ensuring verbal orders are authenticated according to the medical staff bylaws required 72 hours. She stated she has been working on this issue with the physicians. She further stated that according to her own study, the current time frame for authentication of verbal orders is 7 to 10 days on average.

Based on a review of clinical records and interviews with staff, it was determined the hospital failed to provide discharge planning for 6 of 6 patients who were discharged or transferred directly from the hospital's CCU.
The findings were:
A focused clinical record review predicated by a complaint investigation took place on 4/14/11. The record review sample consisted of 6 patients that had received services in the hospital's CCU and were subsequently discharged directly from the CCU to their homes, or transferred to another facility. Of the 6 records reviewed, 3 patients had hospital stays ranging from 1 to 2 days; 3 patients had hospital stays ranging from 6 to 10 days. None of the 6 patient records reviewed contained evidence that the hospital's discharge planning services were provided.
An interview took place on 04/14/11 at 4:35 p.m. with the Corporate Director of Patient Resource Management which includes oversight of the discharge planning process. She stated the discharge planners would see a patient in the CCU if a need for that was "triggered" by the nursing assessment however, in the rest of the hospital the discharge planners "try to see 100 % of the patients." She further stated that the discharge planners usually wait for the patients to be transferred out of the CCU to another floor within the hospital before they would begin the discharge planning process.
The Corporate Director of Patient Resource Management, was reinterviewed on 04/15/11. She acknowledged the number of patients being discharged from the hospital's CCU had increased. She further acknowledged that since some patients being discharged from the CCU may have significant discharge planning needs, the discharge planning process needs to be revised to accommodate that potential need.

Based on a review of clinical records and interviews with staff it was determined the clinical records failed to include a discharge planning evaluation for 6 of 6 patients who were discharged or transferred directly from the hospital's CCU.
The findings were:
A focused clinical record review, predicated by a complaint investigation, took place on 4/14/11. The record review sample consisted of 6 patients that had received services in the hospital's CCU and were subsequently discharged directly from the CCU to their homes, or transferred to another facility. Of the 6 records reviewed 3 patients had hospital stays ranging from 1 to 2 days; 3 patients had hospital stays ranging from 6 to 10 days. None of the 6 patient records reviewed contained a discharge planning evaluation.
An interview took place on 04/14/11 at 4:35 p.m. with the Corporate Director of Patient Resource Management, whose job responsibilities include oversight of the discharge planning process. She stated the discharge planners participate in the multi-disciplinary team's daily "rounding" of patients in the CCU, however, a discharge planning evaluation is not completed and placed in the patient's clinical record.

Based on staff interviews and committee meeting minutes it was determined the facility failed to provide evidence of an ongoing reassessment of discharge plans.


See tag A-0263 for details related to this deficient practice.