HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure nursing staff were trained and available to provide safe and effective care for patient's health care needs.

Failure to provide trained staff to meet patient needs risks deterioration of the patient's health status and delays in treatment.

Findings included:

The hospital failed to ensure that staff members followed standards of practice and hospital policy and procedure for patient identification prior to administration of medications.

The hospital failed to ensure staff members followed its procedure and recognized standards of care for duplicate drug therapy.

The hospital failed to ensure staff members followed its policy for safe medication administration.

The hospital failed to ensure staff members completed and documented assessments and reassessments after each as need medication intervention for alcohol withdrawal treatment.

Due to the scope and severity of deficiencies cited under 42 CFR 482.23, the Condition of Participation for Nursing Services was NOT MET.

Cross Reference: Tags A0405
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Item #1- Patient Identification

Based on observation, interview, and document review, the hospital failed to ensure staff members followed its procedure for identification of patients prior to medication administration, as demonstrated by 2 of 5 patients observed (Patients #304, #305).

Failure to follow the hospital's patient identification process prior to medication administration places patients at risk for medication errors and patient harm.

Findings included:

1. Document review of the hospital policy and procedure titled, "Medication Administration - General Guidelines," PolicyStat ID number 11667812, last approved 06/22, showed that patients shall be identified before medication is administered utilizing the five rights (right patient, right dose, right route, right time, and right medication) and two patient identifiers (name and date of birth). Other identifiers may be used including date of admission, patient identification number, and patient identification sticker.

2. On 01/24/23 at 8:45 AM, Investigator #3 and the House Supervisor (Staff #303) observed the nursing staff administer morning medications on the "Meadows" inpatient unit. The observation showed the following:

a. A Registered Nurse (Staff #307) addressed the patient (Patient #304) by their first name. Staff #304 then administered the medications to the patient without using two approved identifiers.

b. A Registered Nurse (Staff #307) addressed a patient (Patient #305) at the medication window by their first name. Staff #304 then handed the medication to the patient without using two approved identifiers.

3. Following the morning medication pass, Investigator #3 interviewed the nurse (Staff #307) about what was observed. Staff #307 stated that they (staff) knew their patients and did not always ask them for their full name and date of birth when administering medications. The nurse relayed that patients often remove their hospital identification band which precluded them from using the barcode scanner.

Item #2 - Duplicate Drug Therapy

Based on record review, interview, and review of hospital policy and procedures, hospital staff failed to follow its procedure and recognized standards of care for duplicate drug therapy for 3 of 3 patient records reviewed (Patient #304, #306, #307).

Failure to follow the hospital's medication administration and patient assessment processes places patients at risk for medication errors and patient harm.

Findings included:

1. Document review of the hospital policy and procedure titled, "Medication Administration - General Guidelines," PolicyStat ID number 11667812, last approved 06/22, showed that medications shall be administered in accordance with orders of the prescribing provider. If medication orders seem to be unrelated to the patient's current condition, the provider is to be contacted for clarification prior to administration of the medication.

2. On 01/24/23 at 3:15 PM, Investigator #3 reviewed the medical record for Patient #306 who was admitted on 01/18/23 for treatment of symptoms of psychosis. Investigator #3 reviewed the physician medication orders and the medication administration reports and observed:

a. On 01/18/23, Patient #306 received duplicate medication therapy for agitation including:

-Haloperidol 5 mg by mouth at 8:05 PM
-Lorazepam 2 mg by mouth at 8:06 PM

The physician's medication order did not instruct nursing staff on the duplicate medication sequencing or how to administer based on patient symptoms. Investigator #3 found no evidence that hospital staff clarified the physician orders.

b. On 01/19/23, Patient #306 received duplicate medication therapy for agitation including:

-Haloperidol 5 mg by mouth at 3:43 AM
-Lorazepam 2 mg by mouth at 3:43 AM

-Haloperidol 5 mg by mouth at 9:27 AM
-Lorazepam 2 mg by mouth at 9:27 AM

-Haloperidol 5 mg by mouth at 2:25 PM
-Lorazepam 2 mg by mouth at 2:25 PM

-Haloperidol 5 mg by mouth at 10:22 PM
-Lorazepam 2 mg by mouth at 10:22 PM

The physician's medication order did not instruct nursing staff on the duplicate medication sequencing or how to administer based on patient symptoms. Investigator #3 found no evidence that hospital staff clarified the physician orders.

c. On 01/20/23, Patient #306 received duplicate medication therapy for agitation including:

-Haloperidol 5 mg by mouth at 10:28 PM
-Lorazepam 2 mg by mouth at 10:28 PM

The physician's medication order did not instruct nursing staff on the duplicate medication sequencing or how to administer based on patient symptoms. Investigator #3 found no evidence that hospital staff clarified the physician orders.

d. On 01/24/23, Patient #306 received duplicate medication therapy for agitation including:

-Haloperidol 5 mg by mouth at 5:05 AM
-Lorazepam 2 mg by mouth at 5:05 AM

The physician's medication order did not instruct nursing staff on the duplicate medication sequencing or how to administer based on patient symptoms. Investigator #3 found no evidence that hospital staff clarified the physician orders.

e. On 01/25/23, Patient #306 received duplicate medication therapy for agitation including:

-Haloperidol 5 mg by mouth at 9:13 AM
-Lorazepam 2 mg by mouth at 9:14 AM

The physician's medication order did not instruct nursing staff on the duplicate medication sequencing or how to administer based on patient symptoms. Investigator #3 found no evidence that hospital staff clarified the physician orders.

3. On 01/24/23 at 3:15 PM, Investigator #3 reviewed the medical record for Patient #307 who was admitted on 01/22/23 for treatment of acute psychotic disorder. Investigator #3 reviewed the physician medication orders and the medication administration reports and observed:

a. On 01/23/23, Patient #306 received duplicate medication therapy for agitation including:

-Haloperidol 5 mg by mouth at 6:38 AM
-Lorazepam 2 mg by mouth at 6:39 AM

-Haloperidol 5 mg by mouth at 10:51 AM
-Lorazepam 2 mg by mouth at 10:50 AM

The physician's medication order did not instruct nursing staff on the duplicate medication sequencing or how to administer based on patient symptoms. Investigator #3 found no evidence that hospital staff clarified the physician orders.

4. Investigator #3 found similar duplicate medication therapy administration for Patient # 304 on 01/21/23.

5. On 01/30/23 at 1:30 PM, Investigator #3 interviewed the Chief Medical Officer (CMO) (Staff #308) about duplicate drug therapy. Staff #308 stated that he prefers less "prn" (as needed) medications are utilized in the facility. The Investigator reviewed the above referenced incidents of duplicate drug therapy administration with the CMO. Staff #308 acknowledged medication orders should be clarified if similar indications are used.

Item #3 - Medication Administration outside of Provider Orders

Based on record review, interview, and review of hospital policy and procedures, the hospital failed to ensure staff followed its policy for safe medication administration for 2 of 2 patient records reviewed (Patient #306, #307).

Failure to follow the hospital's medication administration and patient assessment processes places patients at risk for medication errors and patient harm.

Findings included:

1. Document review of the hospital policy and procedure titled, "Medication Administration - General Guidelines," PolicyStat ID number 11667812, last approved 06/22, showed that medications shall be administered in accordance with orders of the prescribing provider.

2. On 01/24/23 at 3:15 PM, Investigator #3 reviewed the medical record for Patient #306 who was admitted on 01/18/23 for treatment of symptoms of psychosis. Investigator #3 reviewed the provider medication orders and the medication administration report and found the following:

a. A provider wrote an order for the patient to receive trazodone (an antidepressant medication) 50 mg by mouth at bedtime as needed for insomnia. The provider's medication orders stated the medication may be repeated (given again) one hour after the initial dose of medication is given if the initial dose is not effective.

b. On 01/23/23 at 9:37 PM, a nurse administered 50 mg of trazodone to Patient #306 for insomnia.

c. On 01/23/23 at 10:16 PM, a nurse administered a second additional dose of 50 mg of trazodone which was 21 minutes too early before the minimal time between medication doses as stated in the provider's order. Investigator #3 found no evidence that the hospital staff notified the provider prior to administering the medication outside of the stated medication order instructions.

d. A provider wrote an order for the patient to receive haloperidol 5 mg by mouth as needed for psychotic agitation. The provider's medication order also stated the medication was not to exceed three doses in a twenty-four-hour period.

e. A provider wrote an order for the patient to receive diphenhydramine 50 mg by mouth for dystonia prevention whenever haloperidol is given (linked medications). The provider's medication order also stated the medication was not to exceed three doses in a twenty-four-hour period.

f. A provider wrote an order for the patient to receive lorazepam 2 mg by mouth for agitation. The provider's medication order also stated the medication was not to exceed three doses in a twenty-four-hour period.

g. On 01/19/23, Patient #306 received the following as needed medications:

-Haloperidol 5 mg by mouth at 3:43 AM, 9:27 AM, 2:25 PM and 10:22 PM

-Diphenhydramine 50 mg by mouth at 3:43 AM, 9:26 AM, 2:25 PM, and 10:22 PM.

-Lorazepam 2 mg by mouth at 3:43 AM, 9:27 AM, 2:25 PM, and 10:22 PM

The investigator noted the patient received three different medications 4 times in 18 hours and 39 minutes which is outside the stated parameters of the medication order instructions. Investigator #3 found no evidence that the hospital staff notified the provider prior to administering the medication outside of the stated medication order instructions.

3. At the time of the review, Investigator #3 interviewed the House Supervisor (Staff #303) who confirmed the findings that staff had administer medications outside of the provider orders.

Item #4 - CIWA Assessment and Reassessment

Based on record review, interview, and review of hospital policy and procedures, the hospital failed to ensure staff members completed and documented assessments and reassessments after each "as needed" (PRN) medication intervention for alcohol withdrawal as evidenced by 5 of 5 medical records reviewed (Patient #308, #310, #311, #312, and #313).

Failure to assess and reassess patients after medication administration as part of an alcohol withdrawal protocol risks inconsistent, inadequate, or delayed relief of symptoms including anxiety, agitation, tremors, and sensorium.

Findings included:

1. Document review of the hospital policy titled, "CIWA-AR and COWS," PolicyStat ID number 12152810, last approved 09/22, showed the purpose of the policy was to provide guidelines for early recognition and appropriate interventions based on a symptom triggered assessment of adult patients at risk for experiencing substance (alcohol) withdrawal.

Each item on the scale for CIWA-AR (Clinical Institute Withdrawal Assessment of Alcohol -Revised) is scored separately. A sum of the scores for each category provides a value that correlates with the severity index and intervention type and dose of medication. Medication will be administered based on the system triggered score.

Document review of the hospital policy titled, "Medication Administration - General Guidelines," PolicyStat ID number 1167812, last approved 06/22, showed that medications should be administered in accordance with the orders of the prescribing provider. If the dose seems excessive considering the patient's age, condition, and other factors, the provider is contacted for clarification prior to the administration of the medication.

Document review of the hospital form titled, "Clinical Institute Withdrawal Assessment (CIWA)," form number (CIWA) SPR-FSW-014-05, last updated 08/23/22, showed under procedures that prophylactic medication should be started for any patient with a total CIWA-AR score of 8 or greater. Document vital signs and CIWA-AR assessment scores. "The CIWA-AR scale is the most sensitive tool for assessment of the patient experiencing alcohol withdrawal. Nursing assessment is vitally important. Early intervention for CIWA-AR score of 8 or greater provides the best means to prevent the progression of withdrawal."

Document review of the alcohol withdrawal protocol medication orders showed that lorazepam (a medication used for anxiety) 2 mg by mouth is to be given every two hours as needed for alcohol detoxication. If CIWA score is greater than 8 or less than or equal to 15. Give until CIWA score is less or equal to 8.

Document review of the alcohol withdrawal protocol medication orders showed that lorazepam (a medication used for anxiety) 2 mg by mouth is to be given every hour as needed for alcohol detoxication. If CIWA score is greater than 15 or diastolic blood pressure greater than 110 mm Hg. Give until CIWA score is less or equal to 15 or diastolic blood pressure less than 110 mm Hg.

2. On 01/24/23 at 10:51 AM, Investigator #3 and Nursing Supervisor (Staff #303) reviewed the medical record of Patient #310 who was admitted for treatment of alcohol dependence. The review showed:

a. On 01/24/23 at 10:11 PM, Patient #310 was assessed and evaluated to have a CIWA score of 9 and received appropriate medication. The patient was not assessed until 01/25/23 at 1:34 AM (1 hour and 23 minutes late beyond the required reassessment time of 2 hours). The patient was reassessed with a score of 8 and was given lorazepam 2 mg by mouth which is outside of the provider orders (a score greater than 8 is required for medication to be given).

b. On 01/25/23 at 9:06 AM, the patient received a CIWA score of 9 and was appropriately medicated. The patient was not reassessed until 01/25/23 at 12:07 PM (1 hour and 1 minute late beyond the required reassessment time of 2 hours).

c. On 01/25/23 at 1:58 PM, the patient received a CIWA score of 12 and was appropriately medicated but was reassessed late (1 hour and 47 minutes).

d. On 01/25/23 at 9:26 PM, the patient received a CIWA score of 10 and was appropriately medicated. The patient was not reassessed within 2 hours as required by the protocol nor was assessed at 2:00 AM as required by provider orders (routine CIWA assessments every 6 hours).

e. On 01/26/23 at 8:15 AM, the patient received a CIWA score of 9 and was appropriately medicated. The patient was not reassessed within 2 hours as required by the protocol.

f. On 01/26/23 at 2:04 PM, the patient received a CIWA score of 11 and was appropriately medicated. The patient was not reassessed within 2 hours as required by the protocol.

g. On 01/26/23 at 8:48 PM, the patient received a CIWA score of 8 and was given lorazepam 2 mg by mouth which is outside of the provider orders (a score greater than 8 is required for medication to be given). The patient was not assessed at 2:00 AM as required by provider orders (routine CIWA assessments every 6 hours).

h. On 01/27/23 at 8:14 AM, the patient received a CIWA score of 3 and was given lorazepam 2 mg by mouth which is outside of the provider orders (a score greater than 8 is required for medication to be given).

3. On 01/25/23 at 12:45 PM, Investigator #3 reviewed the medical record of Patient #311 who was admitted for treatment of alcohol dependence. The review showed:

a. On 01/21/23 at 10:32 PM, Patient #311 was assessed and evaluated to have a CIWA score of 9 and received appropriate medication. The patient was not reassessed within 2 hours as required by the protocol. Next, the patient was not assessed at 2:00 AM as required by provider orders (routine CIWA assessments every 6 hours).

b. On 01/22/23, the patient was not assessed at 8:00 AM as required by provider orders (routine CIWA assessments every 6 hours). Eventually, the patient was assessed at 10:34 AM, (12 hours and 2 minutes after the last assessment) and received a CIWA score of 6.

c. On 01/22/23 at 3:21 PM, the patient was assessed (1 hour and 21 minutes late) and received a CIWA score of 5 and was given lorazepam 2 mg by mouth which is outside of the provider orders (a score greater than 8 is required for medication to be given).

d. On 01/22/23 at 8:49 PM, the patient was assessed and received a CIWA score of 8 and was given lorazepam 2 mg by mouth which is outside of the provider orders (a score greater than 8 is required for medication to be given).

e. On 01/23/23 at 3:05 AM, the patient received a CIWA score of 9 and was appropriately medicated. The patient was not reassessed within 2 hours as required by protocol.

f. On 01/23/23 at 8:56 AM, the patient received a CIWA score of 9 and was appropriately medicated. The patient was not reassessed within 2 hours as required by protocol.

g. On 01/23/23 at 3:38 PM, the patient was assessed (1 hour and 33 minutes late) and received a CIWA score of 9 and was appropriately medicated. The patient was not reassessed within 2 hours as required by protocol.

h. On 01/23/23 at 8:18 PM, the patient was assessed and received a CIWA score of 8 and was given lorazepam 2 mg by mouth which is outside of the provider orders (a score greater than 8 is required for medication to be given).

i. On 01/24/23 at 1:30 AM, the patient was assessed and received a CIWA score of 8 and was given lorazepam 2 mg by mouth which is outside of the provider orders (a score greater than 8 is required for medication to be given).

j. On 01/24/23, the patient was not assessed at 8:00 AM as required by provider orders (routine CIWA assessments every 6 hours). Eventually, the patient was assessed at 9:52 AM, (1 hours and 52 minutes late) and received a CIWA score of 1.

k. On 01/24/23 at 5:59 PM, the patient was assessed (1 hour and 40 minutes late) and received a CIWA score of 10 and was appropriately medicated.

l. On 01/24/23 at 9:18 PM, the patient was assessed (1 hour and 16 minutes late) and received a CIWA score of 10 and was appropriately medicated. The patient was not assessed within 2 hours as required by protocol.

m. On 01/25/23, the patient was not assessed at 2:00 AM as required by provider orders (routine CIWA assessments every 6 hours).

n. On 01/25/23 at 10:11 AM (2 hours and 11 minutes late), the patient was assessed and received a CIWA score of 8 and was given lorazepam 2 mg by mouth which is outside of the provider orders (a score greater than 8 is required for medication to be given).

o. On 01/25/23 at 2:44 PM and at 5:31 PM, the patient was assessed and received a CIWA score of 9 and no medication was given although indicated by provider orders.

4. On 01/26/23 at 5:00 PM, Investigator #3 reviewed the medical record of Patient #308 who was admitted for treatment of alcohol dependence. The review showed:

a. Staff failed to perform 4 reassessments after administering medications for elevated CIWA scores .

b. On 08/07/23 at 1:34 AM, the patient was assessed and received a CIWA score of 8 and was given lorazepam 2 mg by mouth which was outside of the provider orders (a score greater than 8 is required for medication to be given).

c. On 08/07/23 at 4:04 PM, the patient was given lorazepam 2 mg by mouth without a documented CIWA score recorded.

5. On 01/27/23 at 10:00 AM, Investigator #3 reviewed the medical record of Patient #312 who was admitted for treatment of alcohol dependence. The review showed:

a. Staff failed to perform 12 reassessments after administering medications for elevated CIWA scores .

b. Staff failed to perform 4 required scheduled CIWA assessments.

c. Staff performed required scheduled CIWA assessments late on 2 occasions (ranging from 1 hour and 31 minutes to 3 hours and 8 minutes).

d. Staff administered medications on 3 occasions where CIWA scores were 8 or below and did not indicate a need.

6. On 01/30/23 at 9:00 AM, Investigator #3 reviewed the medical record of Patient #313 who was admitted for treatment of alcohol dependence. The review showed:

a. Staff failed to perform 17 reassessments after administering medications for elevated CIWA scores.

b. Staff failed to perform 1 required scheduled CIWA assessment.

c. Staff performed required scheduled CIWA assessments late on 3 occasions.

d. Staff did not administer medications on 2 occasions where CIWA scores were greater than 8 (Score of 17 and 9 respectively).

e. Staff administered medications on 1 occasion where CIWA scores were 8 or below and did not indicate a need.

7. On 01/30/23 between 9:00 AM and 11:00 AM, Investigator #3 interviewed the Infection Preventionist (Staff #301) (assisted with medical records review) and the House Supervisor (Staff #303) about the required CIWA assessments and reassessments. Staff #301 and #303 acknowledged the findings and stated that there had been a large turnover of nursing staff and that many of the staff were new to the facility.