HospitalInspections.org

Based on document review and interview the facility failed to ensure safe medication administration for one (1) patient (Tag A-0405) and the facility failed to ensure an incident report was filed for a medication error for one (1) patient (Tag A-0411).

The cumulative effects of the above resulted in the facility inability to provide nursing services in a safe manner.

Based on document review and interview the facility failed to ensure a safe medication administration for one (1) of ten (10) medical records(MR) reviewed (Patient # 10).

Findings include:

1. The hospital policy titled, " Medication Management Ordering, Dispensing, Distribution, Administration and Monitoring", no policy number, publication date 08/21/22, indicated if an order needs clarification, the prescriber should be contacted by the pharmacist, the pharmacist reviews every order individually and as part of the patient's complete profile, that team members checked the patient's cart, CareAdmin, CareMobile or Cerner for allergies prior to administering medications.
a. The pharmacist profile review covers the following:
i. Orders are entered correctly.
ii. Allergies.
iii. Therapeutic or duplicate medication orders
iv. Medication is appropriate the patient with regard to dose, diagnosis, current known lab values, age, weight, and sex.
v. Medication is appropriate to dose, frequency, and route of administration.
vi. Medication interaction.
vii. Medication is cost effective.
viii. Medication requiring order sets per required order set policy.
b. All team members who administer medications will do so in a safe and appropriate manner under the guidelines of the "Five Rights plus Two" of drug administration. Those "Seven Rights" include: right patient, right medication, right dose, right route, right time, right documentation, and right to refusal. Follow the patient identification policy for administering medication and check patient's chart, CareAdmin, CareMobile or Cerner for allergies prior to administering medications.


2. Review of patient # 10 medical record indicated the following:
a. An allergy to Percocet was listed on the navigator bar and in the ED Nursing Flowsheet under the allergies tab for P 10. P 10's allergy to Percocet was first documented on 6/24/2023 at 8:56 am with an allergy symptom of itching.
b. Neurosurgery history and physical dated 8/2/23 indicated P 10 has a medication allergy to Percocet.
c. Orders dated 8/2/23 at 6:40 pm indicated 2 (two) tablets Percocet (Oxycodone-acetaminophen) 10 mg( milligram) -325 mg to be given orally every 4 hours for severe pain and/ or 1 tablet Percocet 5 mg -325 mg to be given orally every 4 hours for moderate pain. MD 1 entered these orders into the EMR (Electronic Medical Record) using CPOE (Computerized Physician Order Entry).
d. Alert History dated 8/2/23 indicated MD 1 was alerted/understood/suppressed the allergy at 6:40 pm, PH 1 reviewed and verified these orders/alert at 6:52 pm. Alert history lacked documentation of communication between PH 1 and MD 1..
e. Percocet tablets listed on MAR( Medication Administration Record) administered for P 10 as follows: 2 tablets on 8/2/23 at 8:32 pm, 2 tablets on 8/3/23 at 12:19 am, 1 tablet on 8/3/23 at 3:51 am, 1 tablet on 8/3/23 at 7:56 am, 2 tablets on 8/3/23 at 8:55 pm, 2 tablets on 8/4/23 at 6:35 am, 2 tablets on 8/5/23 at 4:39 pm, 2 tablets on 8/6/23 at 4:01 am and 1 tablet on 8/6/23 at 1:21 pm. These medications were retrieved from the nursing unit's medication dispensing unit.
f. Nursing Narrative Event dated 8/6/23 at 8:41 indicated P 10's nurse called the attention of the Hospitalist doctor to the patient's documented Percocet allergy. That nurse revalidated the allergy with P 10. P 10 reported that Percocet gives him/her itching, shakiness and ear lobe redness. P 10's pain medication was changed to Norco.
g. Internal Medicine Hospitalist note dated 8/7/23 at 3:57 pm indicated P 10 reported that he/she started to go crazy last night and discovered that he was taking Percocet's which he/she is allergic to. Allergy reported to Percocet is itching. P 10's pain pill was changed to Norco and has been tolerated the medication well.


3. In interview on 8/24/23 at approximately 12:40 am with administrative staff member A 4 (Interim Pharmacy Director), confirmed the pharmacy gets an alert when a medication is ordered for a patient with an allergy, the pharmacist should follow up with the provider and/or patient for clarification of allergy and there was no documentation between the pharmacist that reviewed the medication and the doctor who ordered and/or patient to verify allergy when there should have been some kind of documentation for P 10.

4. In interview on 8/24/23 at approximately 1:00 pm with administrative staff member A 2 (Director of Quality & Patient Safety), confirmed that P 10's allergies to medication should have been reviewed before administering Percocet.

5. In interview on 9/26/23 at 10:51 am with N 1 (Registered Nurse), confirmed allergies were reviewed for the patient, did not confirm allergy with patient, gave the medication to P 10 because the patient had received the medication on previous shifts, the medication was acquired from the Pyxis located on the nursing unit, and Cerner did not alert to an allergy when the medication was scanned prior to administration.

6. In interview on 9/26/23 at 11:20 am with N 5 (Registered Nurse), confirmed P 10's allergy to Percocet was reviewed along with severity of allergy (mild itching), Cerner did not alert to an allergy when medication was scanned, gave the medication because the patient had received medication previously during admission.

7. In interview on 9/26/23 at 11:28 am with N 6 (Registered Nurses), confirmed the nurse did not recall an alert message from Cerner when medication was scanned and did not confirm with the patient the allergy to medication.

8. In interview on 9/26/23 at 11:55 with PH 1 (Pharmacist), confirmed he/she does not recall specifics, should have responded accordingly to patient allergy and should have documented accordingly if there was communication between MD 1, nursing staff and PH 1 in regards to P 10's allergy.

9. In interview on 9/26/23 at 12:53 pm with MD 1 (Medical Doctor), confirmed MD overrode P 10's Percocet allergy at the order entry stage with no reason listed in chart and MD 1 does not recall having a conversation with PH 1 related to P 10's allergy to Percocet.

Based on document review and interview the facility failed to ensure an incident report was filed for a medication error for one (1) of ten (10) medical records(MR) reviewed (Patient # 10).

Findings include:

1. Facility policy titled, "Adverse Event Management & Incident Reporting", no policy number, publication date 8/26/2022, indicated any patient safety event or near miss/ good catch should be documented in the web-based incident reporting system.

2. Review of patient # 10 's medical record indicated Nursing Narrative Event dated 8/6/23 at 8:41 indicated P 10's nurse called the attention of the Hospitalist doctor to the patient's documented Percocet allergy. That nurse revalidated the allergy with P 10. P 10 reported that Percocet gives him/her itching, shakiness and ear lobe redness. Eight nurses administered Percocet tablets (15 tablets total) to P 10 during his/her admission at H 1.

3. In interview on 8/24/23 at approximately 1:00 pm with administrative staff member A 2 (Director of Quality & Patient Safety), confirmed that P 10's allergies to medication should have been reviewed before administering Percocet and an incident should have been filed for the doses of Percocet that had been administered to P 10.

4. In interview on 10/2/23 at 10:30 am with N 8 (Registered Nurse), confirmed the medication error was discovered by having a discussion with the patient about his/her allergy and what medication they have received during the hospitalization, the Hospitalist was notified resulting in a switch in pain medication, no incident report was made for this event, nursing note made, charge nurse notified and pt offered Benadryl for itching but refused.

Based on document review and interview the facility failed to ensure patient safety for one (1) of ten (10) medical records(MR) reviewed (Patient # 10).

Findings include:

1. The hospital policy titled, " Medication Management Ordering, Dispensing, Distribution, Administration and Monitoring", no policy number, publication date 08/21/22, indicated if an order needs clarification, the prescriber should be contacted by the pharmacist, the pharmacist reviews every order individually and as part of the patient's complete profile.
a. The pharmacist profile review covers the following:
i. Orders are entered correctly.
ii. Allergies.
iii. Therapeutic or duplicate medication orders
iv. Medication is appropriate the patient with regard to dose, diagnosis, current known lab values, age, weight, and sex.
v. Medication is appropriate to dose, frequency, and route of administration.
vi. Medication interaction.
vii. Medication is cost effective.
viii. Medication requiring order sets per required order set policy

2. Review of patient # 10 medical record indicated the following:
a. An allergy to Percocet was listed on the navigator bar and in the ED Nursing Flowsheet under the allergies tab for P 10. P 10's allergy to Percocet was first documented on 6/24/2023 at 8:56 am with an allergy symptom of itching.
b. Neurosurgery history and physical dated 8/2/23 indicated P 10 has a medication allergy to Percocet.
c. Orders dated 8/2/23 at 6:40 pm indicated 2 (two) tablets Percocet (Oxycodone-acetaminophen) 10 mg( milligram) -325 mg to be given orally every 4 hours for severe pain and/ or 1 tablet Percocet 5 mg -325 mg to be given orally every 4 hours for moderate pain. MD 1 entered these orders into the EMR (Electronic Medical Record) using CPOE (Computerized Physician Order Entry).
d. Alert History dated 8/2/23 indicated MD 1 was alerted/understood/suppressed the allergy at 6:40 pm, PH 1 reviewed and verified these orders/alert at 6:52 pm. Alert history lacked documentation of communication between PH 1 and MD 1.

3. In interview on 8/24/23 at approximately 12:40 pm with administrative staff member A 4 (Interim Pharmacy Director), confirmed the pharmacy gets an alert when a medication is ordered for a patient with an allergy, the pharmacist should follow up with the provider and/or patient for clarification of allergy and there was no documentation between the pharmacist that reviewed the medication and the doctor who ordered and/or patient to verify allergy when there should have been some kind of documentation for P 10.


4. In interview on 9/26/23 at 11:55 am with PH 1 (Pharmacist), confirmed he/she does not recall specifics, should have responded accordingly to patient allergy and should have documented accordingly if there was communication between MD 1, nursing staff and PH 1 in regards to P 10's allergy.

5. In interview on 9/26/23 at 12:53 pm with MD 1 (Medical Doctor), confirmed MD overrode P 10's Percocet allergy at the order entry stage with no reason listed in chart and MD 1 does not recall having a conversation with PH 1 related to P 10's allergy to Percocet.

Based on document review and interview the facility failed to ensure surgical incision wound care teaching was provided for one (1) of ten (10) medical records(MR) reviewed (Patient # 10).

Findings include:

1. Facility policy titled, " Patient and Family Education", no policy number, publication date 8/01/2022, by not ensuring documentation of education in the medical record as appropriate:
a. Individual(s) taught.
b. Preferred method of learning
c. Barriers to learning.
d. Assessed needs, readiness to learn.
e. Education Provided
f. Teaching method utilized.
g. Patient/Family response to education (evaluation)

2. Review of patient # 10 's medical record lacked documentation of discharge education relating to dressing changes at it applied to P 10's surgical incision.

3. In interview on 6/23/23 at approximately at 5:00 pm with administrative staff members A 2 (Director of Quality and Patient Safety) and A 3 (Consultant of Risk & Regulation), confirmed that there should have been documentation on wound care in P 10's discharge teaching and the MR lacked documentation of this.