HospitalInspections.org

Based on medical record reviews, review of facility documentation, review of facility policies, observations, and interviews for one of ten patients who had a physician's order for a guided right knee needle biopsy, to be performed in Special's Radiology Department, (Patient #33), the facility failed to ensure that the communication form was accurate and/or that Patient # 33 was sent for the correct procedure as ordered by the physician. The finding includes:
Patient #33 was admitted to the hospital on 4/14/15 with bilateral lower leg cellulitis, right greater than left. He/she had a past medical history that included paranoid schizophrenia. A physician order dated 4/15/15 directed a guided right knee needle aspiration to be performed in the Special's Radiology Department.
Patient #32 (Patient #33's roommate) was admitted to the facility on 4/14/15 with a diagnosis of rule out chronic obstructive pulmonary disease versus pulmonary embolism. A physician order dated 4/15/15 directed a Pulmonary Perfusion Scan be performed in the Nuclear Medicine Department.
A Misadministration Report dated 4/15/15 identified that Patient #33 was sent to Nuclear Medicine (instead of the Special's Radiology Department) for a Ventilation Perfusion Scan (VQ Scan) and received 45 millicuries of the radioactive isotopeTc99m in error. Interview with Radiology Technician (RT) #3 on 8/4/15 at 1:33 PM noted that he/she requested that the nursing unit send Patient #32 to the Nuclear Medicine Department and the unit sent Patient #33 instead. Interview with Director #1 on 7/22/15 at 9:20 AM and/or 10:20 AM identified that the Unit Secretary usually worked in the intensive care unit, documented that Patient #33 was to go to the Nuclear Medicine Department, instead of the Special's Radiology Department on the "ticket to ride " (communication form), and that the nurse was ultimately responsible to verify that the form was correct. Although RN #4 was unavailable for an interview due to extended time off, interview with Director #3 on 8/5/15 at 8:23 AM noted that he/she interviewed RN #4. According to Director # 3, RN #4 was in another patient's room when Patient #33 was sent to the Nuclear Medicine Department and believed that RN #4 had not checked the communication form (ticket to ride). She further identified that when speaking to RT# 3, it was identified that he had not checked the physician's order. Interview with Director #1 on 7/22/15 at 9:20 AM identified that the nurse was ultimately responsible to verify that the form was correct.
The facility registered nurse (RN) job description indicated that an essential function included, demonstrating the skills and judgement necessary to implement the medical plan of care. The job description further identified that as an essential function and in order to provide quality care to assigned patients, the verification of patient identity is conducted following hospital procedure. Although the hand- off communication policy identified that a "ticket to ride" form is completed when a patient is placed in the temporary care of a diagnostic treatment and includes treatment and services, the policy did not identify the person(s) responsible for completing and/or verifying the accuracy of the form.

Based on medical record reviews, review of facility documentation, review of facility policies, and interviews for one of ten patients who had a guided right knee needle aspiration ordered, (Patient #33), the facility failed to ensure that the patient was free of any unnecessary radioactive isotope. The finding includes:
Patient #33 was admitted to the hospital on 4/14/15 with bilateral lower leg cellulitis, right greater than left. He/she had a past medical history of paranoid schizophrenia. A physician order dated 4/15/15 directed a guided right knee needle aspiration. The Misadministration Report for 4/15/15 identified that Patient #33 was sent to Nuclear Medicine (instead of the Special's Radiology Department) for a Ventilation Perfusion Scan (VQ Scan) in error. The report further indicated that RT #3 administered 45 millicuries of the radioactive isotopeTc99m to Patient #33 on 4/15/15. Interview with RT #3 on 8/4/15 at 1:33 PM noted that he/she requested that the nursing unit send Patient #32 to the Nuclear Medicine Department and the unit sent Patient #33 instead. He/she indicated that he/she had already administered the aerosolized Tc99m to Patient #33 before he/she became aware of the error. The Misadministration Report for 4/15/15 identified that in the worst case scenario, Patient #33 received 8.1 rad to the bladder wall and 0.3 rad to the total body. The facility job description for Nuclear Medicine technologist identified performing nuclear medicine procedures as ordered as an essential function. An interview on 8/4/15 at 1:33 PM with RT#3 identified that he/she RT#3 further indicated that he/she believed that P#33 was intellectually challenged, he verified the patient by name, date of birth, and checked the identification band against the printed label on the patient's medical record, he/she failed to check the physician's order (requisition). The patient gave RT#3 the right name, however, RT# 3 identified that the mistake was made because he/she looked at the patient label and not the requisition, which is the order. According to facility policy, "ask the patient their name and date of birth, review the wristband, and compare it to the patient's Meditech requistion." The facility job description for a Nuclear Medicine Technologist identified that he/she "administers contrast agents and/or radiopharmaceuticals according to site-specific protocols", it further identified that such a position is "under the general supervision of a radiologist and/or Director of Radiology Services."

Based on medical record reviews, review of facility documentation, review of facility policies, and interviews for one patient (Pt#33) who had the wrong procedure initiated in Nuclear Medicine, the facility failed to ensure that the patient's record accurately reflected the administration of a radioactive isotope in error. The finding includes:
Patient #33 was admitted to the hospital on 4/14/15 with bilateral lower leg cellulitis, right greater than left. A physician order dated 4/15/15 directed a guided right knee needle aspiration be performed in the Special's Radiology Department.
The Misadministration Report for 4/15/15 and dated 4/30/15 (5 days later)identified that Patient #33 was sent to Nuclear Medicine (instead of the Special's Radiology Department) for a Ventilation Perfusion Scan (VQ Scan) and received 45 millicuries of the radioactive isotopeTc99m in error. Interview with RT #3 on 8/4/15 at 1:33 PM noted that after he/she realized that he/she had initiated the VQ Scan on the wrong patient, he/she notified the nursing unit of the error and that the wrong patient had been sent to the Nuclear Medicine Department. Although, a physician progress note dated 4/15/15 at 5:49 PM identified that the physician discussed the patient's last admission with the patient's family member, the record lacked documentation of the administration of 45 millicuries of the radioactive isotopeTc99m in error. Review of nursing narratives and/or procedure reports dated 4/15/15 also lacked documentation that the wrong procedure had been performed on the patient. The policy and procedure for internal occurrence reporting directed to document only relevant data pertaining to the event in the medical record and do not note that an occurrence report had been completed.

The Condition of Participation for Nuclear Medicine Services has not been met.
Based on medical record reviews, review of facility documentation, review of facility policies, and interviews for one of ten patients who had a physician's order for a guided right knee needle aspiration to be performed in the Special's Radiology Department (Patient #33), the facility failed to ensure that the patient was free of any unnecessary radioactive isotope. The finding includes:
Patient #33 was admitted to the hospital on 4/14/15 with bilateral lower leg cellulitis, right greater than left. A physician order dated 4/15/15 directed a guided right knee needle aspiration be performed in the Special's Radiology Department.
Patient #32 (Patient #33 ' s roommate) was admitted to the facility on 4/14/15 with the diagnosis of rule out chronic obstructive pulmonary disease versus a pulmonary embolism. A physician order dated 4/15/15 directed a Pulmonary Perfusion Scan be performed in the Nuclear Medicine Department.
The Misadministration Report dated 4/15/15 identified that Patient #33 was sent to Nuclear Medicine (instead of the Special's Radiology Department) for a Ventilation Perfusion Scan (VQ Scan) and received 45 millicuries of the radioactive isotopeTc99m in error. Interview with RT #3 on 8/4/15 at 1:33 PM noted that he/she requested that the nursing unit send Patient #32 to the Nuclear Medicine Department and the unit sent Patient #33 instead. RT#3 further indicated that he/she believed that P#33 was intellectually challenged, he verified the patient by name, date of birth, and checked the identification band against the printed label on the patient's medical record, he/she failed to check the physician's order (requisition). The patient gave RT#3 the right name, however, RT# 3 identified that the mistake was made because he/she looked at the patient label and not the requisition, which is the order. RT #3 noted that when he/she did check the requisition/order, the requisition/order was for Patient #32. According to facility policy, "ask the patient their name and date of birth, review the wristband, and compare it to the patient's Meditech requistion."