HospitalInspections.org

Based on record review, interview, medical staff rules and regulations, and policy and procedure review, it was determined that the governing body failed to require that the medical staff was accountable for the quality of care, when conscious sedation drugs were not ordered according to medical staff rules and regulations and Hospital policies and procedures in five (5) of six (6) Intensive Care Unit (ICU) patients for whom conscious sedation was ordered (Patients #1, #2, #3, #4, and #5).

Findings include:

The "Oro Valley Hospital "Medical Staff Rules and Regulations" revealed: "...d. Orders must include name of drug, dosage, route, and time...."

The "Oro Valley Hospital Medication Administration Policy" revealed: "...Medications are delivered safely and accurately by professional health care practitioners...d) All medication orders including verbal orders shall contain at least the following: ii) Name and strength of medication iii) Frequency of administration v) Route of administration...."

- Patient #1

Patient #1 presented to the Emergency Department (ED), and was admitted to the Hospital on 01-09-11. The "History of Present Illness" revealed: "The patient is a (an elderly) male with past medical history for ischemic cardiomyopathy, history of 3-vessel disease, congestive heart failure, diabetes, who presents to the emergency department with shortness of breath...While evaluating the patient in the emergency department, the patient went into code arrest...."

Patient #1 was admitted to the Intensive Care Unit (ICU), intubated, and placed on a ventilator. On 01-09-11 at 11:30 P.M., an order was written for: "Versed gtt (drip) titrate to effect."

The Interim ICU Director acknowledged, during interview conducted on 01-10-11 at 2:45 P.M., that the order written "to effect" was not definitive regarding the level of sedation, and was an incomplete order.

- Patient #2

Patient #2 was an elderly female, admitted to the Hospital on 01-06-11. The "History of Present Illness" revealed: "The patient is very spry (elderly) female, who got herself caught on her walker and fell onto a hard tile floor. She did bump her head but only complaint [sic] of pain in her left elbow and left hip. She was brought to the emergency room, found by x-ray to have a left hip fracture...."

On 01-09-11 at 4:35 A.M., an order was written to transfer the patient to ICU. On the same order set, an order was written which revealed: "Start midazolam (Versed) gtt (drip) 0.5 titrate to RASS (Ramsey Scale)-4."

The Chief Nursing Officer (CNO) stated, during interview conducted on 01-10-11 at 3:05 P.M., that the conscious sedation orders for Patients #1 and #2 were incomplete orders.

- Patient #3

Patient #3 was admitted to the Hospital on 01-01-11. The "History of Present Illness" "Assessment" revealed: "1. Acute cholecystitis with cholelithiasis 2. Diabetes mellitus type 2 on oral medicines, uncontrolled without complications. 3. Chronic low back pain. 4. Hypertension. 5. Hyperlipidemia. 6. Dementia. 7. Peripheral vascular disease."

The "Plan" revealed: "...place him on sliding scale insulin, hydrate him aggressively. Anticipate surgical intervention her per (surgeon's) discretion."
On 01-02-11 at 10:20 A.M., an order was written: "Initial vent settings per anes (anesthesiologist)." On 01-02-11 at 4:30 P.M., an order was written for: "Propofol gtt for sedation." There was no dosage, and no parameters for the level of sedation to be achieved and maintained.

- Patient #4

Patient #4 was admitted to the Hospital on 12-10-10, with complaints of "difficulty breathing and sore throat." The "History of Present Illness" revealed: "...On evaluation, CAT (Computerized Axial Tomography) was reviewed by both myself as well as Anesthesia and the emergency room physician. She had very very swollen and narrowed oropharynx and it was thought best to consult Otolaryngology for tracheostomy placement secondary to impending respiratory obstruction/failure."

Patient #4 was placed on a ventilator in the Intensive Care Unit (ICU), and on 12-11-10 at 1:45 A.M., an order revealed: "Propofol gtt (drip) titrate to sedation scale 4." The strength of the medication was not ordered as required by policy.

On 12-11-10 at 2:00 P.M. an order revealed: "begin to lighten sedation in AM @ 0800 (8:00 A.M.)." The name of the medication, strength of the medication, route of administration were not specified as required by Hospital policy.

- Patient #5

Patient #5 presented to the Hospital with shortness of breath, and was admitted on 12-26-10. Patient #5 had a history of Coronary Artery Disease, "with at least 2 prior myocardial infarctions." The "Impression" revealed: "Acute pulmonary edema and congestive heart failure...." The "Plan" revealed: "Admit to the intensive care unit with full ventilatory support...."

Orders written for Patient #5 on 12-26 (no year documented) revealed: "OK to use Versed gtt." There was no strength, dosage, or route ordered.

The Interim Chief Quality Officer acknowledged, during interview conducted on 01-08-11, that the conscious sedation orders for patients #1, #2, #3, #4, and #5 were incomplete orders per Hospital policy.