HospitalInspections.org

Based on review of hospital policy/procedure, medical record and staff interviews, it was determined that the hospital failed to ensure that an order for restraints for 1 of 1 patient ( patient # 1) was written per hospital policy and procedure.

Findings include:

Review of hospital policy titled "Restraint and Seclusion" revealed: "...all orders must be in writing and include reason for use (application criteria), type of restraint used and time limits of order...."

Review of medical record for patient # 1 revealed: "...2/14/2014 at 1030 PM wrist restraints per protocol, read back telephone order (RBTO) Physician # 9/ RN # 13...."

The DON confirmed in an interview conducted on 9/2/2014 that the order for restraints for patient # 1 was not written correctly as per the hospital policy/procedure.

The Clinical Educator confirmed in an interview conducted on 9/3/2014 confirmed that the order for restraints for patient # 1 was not written correctly as per the hospital policy/procedure.

Based on review of the hospital's Medical Staff Rules and Regulations, hospital policy/procedure, medical record, credential file and interview, it was determined that the hospital failed to require that a Physician authorized the order for restraints, that the order was complete and the physician followed the hospital restraint policy for 1 of 1( patient # 1).

Findings include:

Review of Rules and Regulations the Medical Staff revealed: "...The Medical Staff has developed written policies on the proper use of restraint and seclusion in the Hospital...The Medical Staff ensures that the policies meet all requisite standards of the Arizona Department of Health, the Center for Medicare and Medicaid Services, and the Joint Commission...."

Review of the hospital policy/procedure titled "Restraint and Seclusion" revealed: "...all orders must be in writing and include reason for use (application criteria), type of restraint used and time limits of order...."

Review of credential file for Physician # 9 indicated the Medical Staff Orientation and Guide; which includes an outline for restraints, was signed on 7/16/2013.

Review of the medical record for patient # 1 revealed: "...2/14/14 at 1030 PM hours wrist restraint per protocol-read back telephone order Physician # 9/RN # 13...."

The Director of Nursing and the Clinical Practice Educator confirmed in an interview on 9/3/2014 that the restraint order did not contain all the components for an order, as required in the Restraint policy/procedure.

Based on review of hospital policy/procedure, medical record, and staff interviews, it was determined that the hospital failed to provide restraint and seclusion education to staff caring for a patient in restraints.

Findings include:

Review of the hospital policy/procedure titled "Restraints and Seclusion" effective June 2011 and revised March, 2014, revealed: "...an education program is provided annually. Only those members of the staff who have completed the training program may apply and care for patients in restraints...an educational program provides staff with strategies and alternatives to meet the patient's needs. This program allows the staff within their scope of practice to demonstrate competence in: Behavioral assessment, preventive strategies, alternative interventions, proper application of restraints, assessment and monitoring and care of patients in restraints, including supporting documentation, and Basic Life Support and basic first aid techniques...."

Review of the medical record for patient # 1 revealed: "...2/14/14 at 1030 PM hours wrist restraint per protocol - read back telephone order (RBTO) Physician # 9/RN # 13...."

The Director of Nursing confirmed in an interview conducted on 9/5/2014 that RN # 13 provided nursing care to patient # 1 on 2/14/2014 from 1910 hours to 2/15/2014 at 0045 hours.

The Director of Perioperative Services confirmed in an interview conducted on 9/3/2014 that no restraint training is provided to the pre-operative, intra-operative or post-anesthesia care unit (PACU) staff. Additionally, the Director confirmed that RN # 13 is assigned to PACU.

The Director of Nursing and the Clinical Practice Educator confirmed in an interview on 9/3/2014 that the restraint order did not contain all the components for an order, as required in the Restraint policy/procedure.

Based on review of Medical Staff Rules and Regulations, other documents, medical records, and staff interview it was determined the medical staff failed to ensure a complete order was written for sedation and pain for 2 of 2 patients' (Patient's #1 and #10).

(A0353) hospital failed to ensure that the medical staff complied with the Medical Staff Rules and Regulations requiring all medication orders will contain the required elements of the name of the drug, dosage, frequency of administration, and route of administration. Medication orders must follow the approved policy and procedures. Titration and taper orders are specific parameters for Titration and tapering.

The cumulative effects of this systemic deficient practice resulted in the failure of the hospital to be in compliance with 42 CFR 482 Conditions of Coverage.

Based on review of Medical Staff Rules and Regulations, other documents, medical records, and staff interviews, it was determined the hospital failed to ensure that the medical staff complied with the Medical Staff Rules and Regulations requiring all medication orders will contain the required elements of the name of the drug, dosage, frequency of administration, and route of administration. Medication orders must follow the approved policy and procedures. Titration and taper orders are specific parameters for Titration and tapering as evidenced by:

failure to ensure the medical staff write a complete order for continuous intravenous medication for sedation and pain for 2 of 2 patients' (Patient's #1 and #10).

Findings include:

Review of the Medical Staff Rules and Regulations requires: "...All medication orders will contain the required elements of the name of the drug, dosage, frequency of administration, and route of administration. Medication orders must follow the approved policy and procedures. Titration and taper orders are specific parameters for Titration and tapering...."

Review of facility document titled "Medication Administration and Documentation in the Electronic Environment" requires: "...medication name, dose, route, and frequency of each medication will be verified...Contact the prescribe to clarify any unclear, questionable, or illegible orders...Document clarified medication orders...."

Patient 1
Patient # 1 had cervical fusion on 2/14/2014. The patient was transferred post operatively to Intensive Care, remained intubated, and sedated with intravenous (IV) fentanyl and IV propofol.

Review of post anesthesia care unit anesthesia orders, date and time illegible, indicated a hand written order for fentanyl gtt (drip) 50/mcg/hr titrate for pain...SBP greater than 100; propofol gtt...keep SBP (systolic blood pressure) greater than 100. Part of both orders were illegible.

Review of physician # 9 orders dated 2/14/2014 at 1830 hours indicated fentanyl gtt 100 mcg (micrograms) titrate to pt (patient) comfort and propofol gtt titrate to keep SBP greater than 100 and Ramsey 3-4.

Patient 10
On 08/18/14, Patient #10 was admitted to the hospital with cervical spondylotic myelopathy from stenosis. The patient underwent a C4-C7 anterior cervical discectomy and fusion with anterior plating. Post operatively, the patient was sent to ICU intubated and sedated for a "slow extubation secondary to concern of airway swelling."

Patient #10's post anesthesia care unit notes (PACU) dated 08/18/14 at 1637 hours revealed: propofol drip titrate sedation ...illegible. Fentanyl drip (illegible.)

Patient #10's computer physician order entry (CPOE) ordered by Physician #5 revealed: propofol/Diprivan 100 mls (milliliters) @ 0 mls/hour total dose; PRN reason sedation, start date 08/18/14, Drug class General Anesthetics, 100ml (1 vial) propofol 10 Mg(milligram)/ml.

The Director of Nursing, Pharmacist, the Clinical Educator, and the ICU nurse confirmed during an interview conducted 09/03/14, the patient's PACU titration orders were illegible and incomplete for patient #'s 1 and 10.
Additionally the DON confirmed during an interview on 09/04/14, that the hospital has not developed a policy/procedure/protocol for continuous intravenous titrated medications.

Based on review of hospital policy/procedure, medical records, nursing personnel records and staff interviews, it was determined that the hospital failed to ensure that medication orders were complete, legible and administered within the nursing scope of practice.


(A0405) the hospital failed to ensure that the nursing staff administered and monitored continuous IV sedation and IV pain medications using a complete physician order.

The cumulative effects of these deficient practices and findings under the following Nursing Services, resulted in the failure of the hospital to be in compliance with 42 CFR 482 Conditions of Coverage.

Based on review of hospital policy and procedure, medical record, and staff interview it was determined the hospital nursing staff failed to ensure that the patient was assessed for a post-fall follow up according to hospital policy.

Findings include:

Hospital policy and procedure titled "Fall Prevention" revealed: "...all patient's...shall be deemed as high risk for potential falls...Post Fall Follow-Up c. fall assessment and actions include...iv. Neurological status. Pain location and rating.... "

Medical record review identified Patient #26 sustained a fall following a left total knee arthroplasty. The patient required an open reduction internal fixation of the left hip.

The Director of Nursing confirmed during an interview conducted 09/03/14 at 1300 hours, that the nursing staff failed to document the patient's neurological status and pain location and rating per hospital policy.

Based on review of Medical Staff Rules and Regulations, hospital policy and procedure, other documents, medical record review, personnel files and staff interview, it was determined the hospital nursing staff failed to properly document and administer continuous intravenous (IV) sedation and pain medications, as evidenced by failing to obtain an appropriate and complete order from a physician for 2 of 2 patients (Patient's # 1 and 10).

Findings include:

Review of the Medical Staff Rules and Regulations of the requires: " ...Order clarity: The practitioner's orders must be written clearly, legibly, and completely...Orders illegible or improperly written will not be carried out until rewritten or understood by the person responsible for the following orders...orders...not clear...may require that the Hospital Staff inquire as to their correctness...."

Review of the hospital policy and procedure titled "Medication Administration and Documentation in the Electronic Environment" revealed: "...All medication orders will be verified by a pharmacist...Contact the prescriber to clarify any unclear order, questionable, or illegible orders...at a minimum...medication name, dose, route, and frequency of each medication will be verified...."

Review of the Arizona State Board of Nursing rules, updated 7/25/2014, R4-19-402 Standards Related to Registered Nurse Scope of Practice requires: "...administers prescribed...medications; clarifies health care provided orders when needed...."

Patient 1
Review of the medical record for Patient # 1 indicated the patient had a cervical fusion on 2/14/2014. The patient was transferred post operatively to Intensive Care, remained intubated, and sedated with intravenous (IV) fentanyl and IV propofol.

Review of post anesthesia care unit anesthesia orders identified the date and time as illegible, and indicated a hand written order: "... fentanyl gtt (drip)50/mcg/hr titrate for pain...SBP greater than 100; propofol gtt...keep SBP (systolic blood pressure) greater than 100..." Part of both orders were illegible.

Review of physician #9 orders dated 2/14/2014 at 1830 hours indicated: "...fentanyl gtt 100 mcg (micrograms) titrate to pt (patient) comfort and propofol gtt titrate to keep SBP greater than 100 and Ramsey 3-4...."

Review of nursing note by RN # 13 revealed: "...1910 pt in the ICU. propofol gtt at 50 meg/kg/min or 39.0 cc/hr. for sedation. Ramsey 3-4. Fentanyl 100 meq/hr or 10 cc/hr. for pain...."

2/15/2014 at 0045 hours, RN # 18 documented: "..fentanyl gtt infusing at 100 mcg/hr, propofol (propofol) gtt at 50 mcg/kg/min..." Additional review of the MAR and the nursing notes for 2/15/2014 indicated that the Ramsey scale, the fentanyl and propofol rates are not documented.

Patient 10
Review of the medical record for Patient #10 identified the patient had an anterior cervical discectomy for cervical stenosis. After recovery the patient was admitted to the hospital ' s intensive care unit with a propofol drip.

Patient #10's post anesthesia care unit notes (PACU) dated 08/18/14 at 1637 hours revealed: "...propofol drip titrate sedation...(illegible); fentanyl drip..." (illegible.)

Patient #10's computer physician order entry (CPOE) ordered by Physician #5 revealed: "...Propofol/Diprivan 100 mls (milliliters) @ 0 mls/hour total dose; PRN reason sedation, start date 08/18/14, Drug class General Anesthetics, 100ml (1 vial) propofol 10 Mg(milligram)/ml...."

Medication Administration Record (MAR) dated 08/18/14 at 2003 hours revealed: "... propofol at 29.4 mls/hr..." Administered by RN # 26. RN # 26 documented blood pressure (B/P) as "112/63."

Nursing Notes dated 08/18/14 at 2052 hours documented by RN # 26 revealed: "... Patient sedated on propofol drip as ordered. Will continue to monitor. No signs or symptoms of pain or discomfort...."

Nursing Notes dated 08/18/14 at 2150 hours documented by RN # 26 Nurse revealed: "...propofol drip decreased to 30 mcg/kg/min (micrograms/kilograms/minute) from 40 mcg/kg/min..." There was no documentation of patient sedation assessment.

Medication Administration Record (MAR) dated 08/19/14 at 0026 hours revealed: "...propofol at 50 mls/hr., blood pressure (B/P) 107/60..." There was no documentation of patient sedation assessment.

Nursing Notes dated 08/19/14 at 0250 hours documented by RN # 26 revealed: "... Systolic B/P under 100mmHg (millimeters of mercury), propofol decreased...." There is no documentation of new medication rate.

Medication Administration Record (MAR) dated 08/19/14 at 0539 hours revealed: "...propofol at 18 mls/hr., B/P 102/58...."

Nursing Notes dated 08/19/14 at 0617 hours documented by RN #26 revealed: "... Patient awake, attempting to communicate with wife. Sedation increased due to restlessness and increased B/P and heart rate. Patient denies any pain or discomfort...."

The Director of Nursing, Pharmacist, the Clinical Educator and the ICU nurse confirmed during an interview conducted 09/03/14 that the hospital does not have a policy or protocol for IV sedation or IV pain.

The Director of Nursing confirmed in an interview conducted on 9/3/2014 that the agency RN # 26 titrated the sedation medication by increasing and decreasing the rate without specific orders/parameters.

Review of personnel file for (agency) RN # 26 revealed a current Arizona RN license, current ACLS and BLS certification, and ICU and sedation drip competencies.

Review of the personnel file for RN #18 revealed a current Arizona RN license and current ACLS and BLS certification. However; there was no documentation of ICU or sedation drip competencies.

The Director of Nursing confirmed in an interview on 9/3/2014 that the hospital employed one ICU RN. (employee #18)

The Director of Human Resources confirmed the above RN competencies



.

Based on review of hospital policy and procedure, medical record review, and staff interview it was determined the administrator failed to require Medical Staff write complete and legible propofol and fentanyl intravenous drip orders in the medical record for 2 of 2 patients. (patient's # 1 and 10)

Findings include:

Hospital policy and procedure titled "Medication Administration and Documentation in the Electronic Environment" revealed: " ...All medication orders will be verified by a pharmacist ...Contact the prescribe to clarify any unclear order, questionable, or illegible orders.... "

Patient 1
Review of post anesthesia care unit anesthesia orders for patient # 1 identified the date and time as illegible. The order revealed a hand written order: "...fentanyl gtt (drip) 50/mcg/hr titrate for pain...SBP greater than 100; propofol gtt...keep SBP (systolic blood pressure) greater than 100..." Part of both orders were illegible.

Review of physician #9 orders dated 2/14/2014 at 1830 hours indicated: "...fentanyl gtt 100 mcg (micrograms) titrate to pt (patient) comfort and propofol gtt titrate to keep SBP greater than 100 and Ramsey 3-4...."

Patient 10
Patient #10's post anesthesia care unit notes (PACU) dated 08/18/14 at 1637 hours revealed: "...propofol drip titrate sedation ...illegible. Fentanyl drip (illegible.)...." Order signed by physician # 2...."

The Director of Nursing, Pharmacist, the Clinical Educator and the ICU nurse confirmed during an interview conducted 09/03/14, that the patient's PACU titration orders were illegible.

Based on Medical Staff Rules and Regulations, hospital policy, medical record review, and staff interview it was determined the administator failed to require the hospital pharmacy staff failed to properly verify the completeness of physician orders as evidenced by:

(A0500) pharmacy staff failed to verify completeness of orders for fentanyl and propofol intravenous (IV) drips, obtain clarification for written/ illegilbe physician orders, and ensure that the order contain a start dose, maximum dose, tiration dosage and increments for 2 of 2 patients. (patients # 1 and 10).

The cumulative effects of these deficient practices and findings under the Pharmaceutical Services, resulted in the failure of the hospital to be in compliance with 42 CFR 482 Conditions of Coverage.

Based on Medical Staff Rules and Regulations, hospital policy, medical record review, personnel files and staff interview, it was determined the administrator failed to require hospital pharmacy staff failed to verify completeness of orders for fentanyl and propofol intravenous (IV) drips, obtain clarification for written/ illegilbe physician orders, and ensure that the order contain a start dose, maximum dose, tiration dosage and increments for 2 of 2 patients. (patients # 1 and 10).

Findings include:

Review of the Medical Staff Rules and Regulations requires: " ...Order clarity: The practitioner's orders must be written clearly, legibly, and completely ...Orders illegible or improperly written will not be carried out until rewritten or understood by the person responsible for the following orders ...orders ...not clear ...may require that the Hospital Staff inquire as to their correctness ...."

Review of hospital policy and procedure titled "Medication Administration and Documentation in the Electronic Environment" revealed: "...All medication orders will be verified by a pharmacist ...Contact the prescriber to clarify any unclear order, questionable, or illegible orders ...at a minimum...medication name, dose, route, and frequency of each medication will be verified...."

Review of post anesthesia care unit anesthesia orders for patient # 1, date and time illegible, indicated a hand written order for fentanyl gtt (drip) 50/mcg/hr titrate for pain...SBP greater than 100; propofol gtt...keep SBP (systolic blood pressure) greater than 100..". Part of both orders were illegible.

Review of physician # 9 orders dated 2/14/2014 at 1830 hours indicated: "...fentanyl gtt 100 mcg (micrograms) titrate to pt (patient) comfort and propofol gtt titrate to keep SBP greater than 100 and Ramsey 3-4....'

Patient #10's computer physician order entry (CPOE) ordered by Physician #5 revealed: "...propofol/Diprivan 100 mls (milliliters) @ 0 mls/hour total dose; PRN reason sedation, start date 08/18/14, Drug class General Anesthetics, 100ml (1 vial) Propofol 10 Mg(milligram)/ml...."

Pharmacist confirmed during an interview conducted 09/05/14 at 0845 hours that all orders are verified and reviewed for appropriateness, including dosage and parameters. The pharmacist confirmed physician orders for the continuous intravenous propofol and fentanyl drips were incomplete, illegible and did not contain a start dose, maximum dose or titration dosage and increments.

The Director of Nursing, Pharmacist, the Clinical Educator and RN # 18 confirmed during an interview conducted 09/03/14 that the patient's PACU titration orders were illegible and incomplete for patient #'s 1 and 10.






Pharmacist (employee #29) confirmed during an interview conducted 09/05/14 at 0845 hours that all orders are verified and reviewed for appropriateness, including dosage and parameters. The pharmacist confirmed physician orders continuous intravenous propofol and fentanyl were incomplete, illegible and did not contain a start dose, maximum dose or titration dosage and increments.