HospitalInspections.org

Based on interviews and facility document reviews, the governing body failed to ensure that a thorough screening was conducted of potential nurses with a questionable drug and/or criminal history.


The governing body failed to ensure that the Emergency Department prevented controlled substances from being available to staff without pharmacy or physician knowledge, thus increasing the possibility of abuse which transpired (see A 145).


The governing body failed to ensure that the quality assessment and performance improvement program included audits of patients' medical records for evidence of nursing assessment of pain medication effectiveness. This deficient practice potentially exposed patients to inadequate pain control by nurses (see A 297.)


The cumulative effect of the failures resulted in the noncompliance with the Condition of Participation.

Based on interviews, incident reports and facility documents, the facility failed to prevent a patient from being administered an undetermined amount of medication that was (1) not ordered by a physician, and (2) not authorized for intravenous (IV) administration by a nurse. The failure resulted in harm to the patient.


The findings are:


A. The Incident Report received by the state Department of Health (the licensing authority) from the hospital on 12/15/14 revealed the following: "Based on the assessment by the nurse relieving [Nurse #1], we [hospital administrative staff] are operating under the belief that [Patient #1] was given medications not ordered including Ketamine."


B. Review of a 12/04/14 email communication from the Chief Nursing Officer of the hospital to the state Board of Nursing revealed the following: "Ketamine was positive on [Patient #1]. [Patient #1] did not have Ketamine ordered and it is a violation of our policy to administer IV ketamine." The email communication by the Chief Nursing Officer also noted that Nurse #1 "used ultrasound guided IV insertion device for which he was not credentialed to use per [the Clinical Manager of Emergency Services]."


C. The Incident Report received by the state Department of Health contained the following additional information: " [Patient #1] was discovered unmonitored (both EKG and pulse oximetry removed), with oxygen removed, hypotensive and poorly ventilating. This required [Patient #1] to be rescued from adverse decline and admitted to the Critical Care Unit. Dr. [name of physician] had been asked for a Ketamine order by (Nurse #1]. Dr. [name of physician] declined to order the Ketamine."


D. Review of an 11/26/14 email communication from the Chief Nursing Officer of the hospital to the Board of Nursing of the state from which Nurse #1 had obtained a multistate nursing license revealed the following statement: "We believe [Nurse #1] inflicted harm on a patient [Patient #1] requiring critical care admission for the patient in additional [sic] to failure to meet standard of care on other patients."

Based on interviews, incident reports and facility documents, the facility failed to limit access to controlled medications. This failed action made controlled substances available to staff without pharmacy or physician knowledge thus increasing the possibility of abuse which transpired.


The findings are:


A. "[Patient #1] was discovered unmonitored (both EKG and pulse oximetry removed), with oxygen removed, hypotensive and poorly ventilating. This required [Patient #1] to be rescued from adverse decline and admitted to the Critical Care Unit. Dr. [name of physician] had been asked for a Ketamine order by [Nurse #1]. Dr. [name of physician] declined to order the Ketamine. In addition, it is a violation of our hospital policy for Registered Nurses to administer Ketamine."


B. Review of an email from the Chief Nursing Officer (CNO) to the state Board of Nursing, a copy of which was submitted to the surveyors, revealed an acknowledgement by the CNO that "Ketamine was positive on [Patient #1]" although "[Patient #1] did not have Ketamine ordered," and that "[Nurse #1] used ultrasound guided IV insertion device for which [Nurse #1] was not credentialed to use per [Clinical Manager of Emergency Services].


C. Review of an 11/26/14 email communication from the Chief Nursing Officer of the hospital to the Board of Nursing of the state from which Nurse #1 had obtained a multistate nursing license revealed the following statement: "We believe [Nurse #1] inflicted harm on a patient requiring critical care admission for the patient in additional [sic] to failure to meet standard of care on other patients."


D. The Incident Report received by the state Department of Health (State Agency) from the hospital on 12/15/14 described the occurrences that immediately preceded and precipitated the harm inflicted on Patient #1:


1. "[Nurse #1] was unaccounted from unit on 11/24/2014 at 0420 when RN [name of registered nurse] noticed [Nurse #1] had multiple orders for discharge and admits not cared for." Another nurse found Nurse #1 in an Emergency Department bathroom, unconscious, at 4:35 am, with a needle, attached to a syringe, on the floor nearby. Blood was observed on his right antecubital area. According to the Incident Report narrative of Clinical Supervisor #1, who discovered Nurse #1 in the bathroom, as well as the Incident Report narrative of Nursing Administrative Supervisor #1, present in the clothing of Nurse #1 were an empty 2 mg vial of lorazepam (a sedative) and an empty vial of 500 mg of ketamine (an anesthetic). The Incident Report further stated, "As of this time 1000 mg of Ketamine was withdrawn from Pyxis without orders, Haldol [an antipsychotic] 10 mg no order placed, 5 mg of Ativan [lorazepam] not ordered."


E. On 12/17/14 at 2:30 pm during interview, the Pharmacy Director acknowledged that the facility pharmacy and nursing staff did not audit specific, low-activity controlled substances after each 12-hour shift or daily, but rather on a weekly basis.

Based on interviews and electronic medication record review, the facility failed to audit pain medication effectiveness and include it in the quality assessment and performance improvement program. This deficient practice potentially resulted in patients not receiving pain medication sufficient to control their level of pain.


The findings are:


A. On 12/17/14 at 3:00 pm, during interview, the Corporate Compliance Officer confirmed that the performance improvement process at the facility did not include audits of documentation for pain medication effectiveness.


B. On 12/17/14 at 1:30 pm, the survey team reviewed Emergency Department (ED) electronic medical records of patients receiving pain medication during the month of November, 2014, with the Clinical Manager of Emergency Services. Review of 5 of 16 (Patients #1, 2, 3, 7, and 8) sampled records revealed no evidence of a follow-up assessment as to the effectiveness of the pain medication. At the time of the review, the Clinical Manager of Emergency Services confirmed the absence of such evidence.

Based on staff interviews, medical chart reviews, and facility document reviews, the director of the nursing service failed to ensure that the personal drug abuse issues of Nurse #1, as evidenced by the contracting agency's documents supplied to the hospital, were considered in the nursing duty assigned to Nurse #1. This failure exposed a patient to administration by a nurse of a controlled anesthetic unauthorized by a physician and thereby, potential lethal harm (see A 398.)


The facility also failed to document follow-up assessment of the effect of administered pain medications in 5 of 16 sampled electronic patient records in the emergency department (see A 405.) This failure limited the facility's ability to manage patient's pain in the ED.


The cumulative effect of the failures resulted in noncompliance with the Condition of Participation.

Based on staff interviews, chart reviews, and facility document reviews, the facility (1) failed to respond to audible and observable indications of frustration by Nurse #1 while Nurse #1 was on duty in the Emergency Department (ED), and (2) failed to ensure that the personal drug abuse history of Nurse #1, a traveling registered nurse, were considered in the nursing duty to which Nurse #1 was assigned. These failures were contributing causative factors in the exposure of a patient to administration of a controlled sedative unauthorized by a physician and thereby, lethal harm.


The findings are:


A. Review of an email by a nurse in the ED to the Clinical Manager of Emergency Services revealed the following first-person account by the nurse, who was already at work (having begun a work shift at 3:00 pm) on 11/23/14 when Nurse #1 arrived at approximately 7:00 pm:

1. "The first thing I noticed about [Nurse #1] was that he was quieter than normal and was very disgruntled about his assignment. . . . The patient in room 10 had been brought in per [Nurse #1], for possible benzo[diazepine] over dose [sic]. . . . [Nurse #1] was attempting to start an IV and was obviously frustrated. [Nurse #1] kept saying, 'just hold her, just hold her.' I helped temporarily restrain the patient, but the IV attempts were unsuccessful. This angered [Nurse #1] and he left the room. . . . I left the room and reported that [Nurse #1] was being really abrupt and seemed very angry and frustrated to the charge nurse. . . ."


2. "Later in the shift I was passing by room ten and there was more commotion. I went in and [Nurse #1] was trying to stick the patient again in an attempt to get blood for lab work. I asked if he needed help. He did not respond. The patient was screaming. [Nurse #1] turned to me and said 'We have to cath[eterize] her.' I went to get a cath kit and asked [Nurse #1] if he wanted me to just cath the patient. The husband of the patient was in the room and assisted me with holding. It was then I noticed a wealed hand print on the patients [sic] left inner thigh. I inquired about this to [Nurse #1] and the husband. James replied with a shrug. I placed the catheter and left the room. I reported the hand print to the charge nurse. I also reported that I felt like [Nurse #1] was being a little rough with the patient and that he was acting oddly."


3. "Approx[imately] [11:00 pm] [Nurse #1] was at the pixus [Pyxis, a medication dispenser] pulling meds. He said something to the affect [sic], 'it's [expletive] like this that makes me want to clock out and go home.' I told [Nurse #1] to calm down that we would help him and to not take things so personal. Later in the shift [Nurse #1] came over to the charge nurse and [me] and said, 'you know what I like best about this hospital is that I can't understand you. I can understand stand [sic] everyone else, but not you and I like that.' This was very obscure and random commentary. A few min[utes] later [Nurse #1] was sitting at his work station starring [sic] into space, when interrupted he became angry and told me he was fine."


B. The Incident Report received by the state Department of Health (State Agency) from the hospital on 12/15/14 revealed the following:


1. "[Nurse #1] was unaccounted from unit on 11/24/2014 at 0420 when RN [name of registered nurse] noticed [Nurse #1] had multiple orders for discharge and admits not cared for." Another nurse found Nurse #1 in an ED bathroom, unconscious, at 4:35 am, with a needle, attached to a syringe, on the floor nearby. Blood was observed on his right antecubital area. According to the Incident Report narrative of Clinical Supervisor #1, who discovered Nurse #1 in the bathroom, as well as the Incident Report narrative of Nursing Administrative Supervisor #1, present in the clothing of Nurse #1 were an empty 2 mg vial of lorazepam (a sedative) and an empty vial of 500 mg of ketamine (an anesthetic). The Incident Report further stated, "As of this time 1000 mg of Ketamine was withdrawn from Pyxis without orders, Haldol [an antipsychotic] 10 mg no order placed, 5 mg of Ativan [lorazepam] not ordered."


2. Patient #1 "was discovered unmonitored (both EKG and pulse oximetry removed), with oxygen removed, hypotensive and poorly ventilating. This required [Patient #1] to be rescued from adverse decline and admitted to the Critical Care Unit. Dr. [name of physician] had been asked for a Ketamine order by [Nurse #1]. Dr. [name of physician] declined to order the Ketamine. In addition, it is a violation of our hospital policy for Registered Nurses to administer Ketamine."


C. Review of an email from the Chief Nursing Officer (CNO) to the state Board of Nursing, a copy of which was submitted to the surveyors, revealed an acknowledgement by the CNO that "Ketamine was positive on [Patient #1]" although "[Patient #1] did not have Ketamine ordered," and that "[Nurse #1] used ultrasound guided IV insertion device for which [Nurse #1] was not credentialed to use per [Clinical Manager of Emergency Services]."


D. Blood and urine specimens from Nurse #1 and Patient #1 were sent to the lab to be tested for ketamine and other controlled substances. The lab results dated 11/24/14 that Nurse #1 was positive for benzodiazepines, opiates, tricyclic antidepressants and cannabinoid (marijuana) in his urine specimen and positive for ketamine in the blood specimen.


E. On 12/17/14 at 2:00 pm, during interview, the Human Resources (HR) representative acknowledged the following regarding the contents of the packet supplied by the employment agency that contracted Nurse #1:


1. The packet of 80 some pages was not completely reviewed by HR before hire.

2. The packet revealed that Nurse #1 received an action of "Censure" by a Division of Professional Registration of another state while employed in 1995 at a hospital in that state. The documentation indicated that he had provided care to patients while two Schedule IV controlled substances, Xanax and Dalmane, were in his system. The report cited evidence of Nurse #1's impaired condition, and that "it became apparent to [Nurse #1] that taking these medications pursuant to his physician's prescription left him unable to provide competent patient care."


F. On 12/16/14 at 1:30 during interview, the Clinical Manager of Emergency Services reported that on 11/24/14, he received a call shortly after 4:00 am informing him of the incident regarding Nurse #1. He reported that each person involved was instructed to write a summary of the events for the shift starting on 11/23/14 at 7:00 PM to 7:00 am on 11/24/14. He reported that after reviewing staff summaries, Pyxis reports, and medical records he concluded that some medication was removed from Pyxis that was neither administered nor ordered. He reported that Nurse #1 had failed or neglected some of his nursing duties in providing care for his patients, such as not taking vital signs for some patients and not completing an assessment on one patient. Nurse #2 also reported that Nurse #1 "had a number of discharges and admits without care."

Based on interviews and medical record review, the facility failed to document follow-up assessment of the effect of administered pain medications in 5 of 16 electronic patient records, Patient's #2. 3, 7, 8, 13, who were seen in the emergency department.


The facility pharmacy processes also failed to prevent Nurse #1 from obtaining and administering a controlled medication, without a physician order, to Patient #1 and self. This deficient practice exposed patients to potentially ineffective pain management and lethal harm.


The findings are:


A. On 12/17/14 at 2 pm during interview, the Clinical Manager of Emergency Services confirmed that 5 of 16 electronic medication records did not contain follow-up pain medication efficacy. At the time of the review, the Clinical Manager of Emergency Services confirmed the absence of such evidence.


B. On 12/17/14 at 3:00 pm during interview, the Corporate Compliance Officer confirmed that the performance improvement process at the facility did not include audits of documentation of pain medication effectiveness by the nurses.


C. The Incident Report received by the state Department of Health (the licensing authority) from the hospital on 12/15/14 revealed the following:


1. "[Nurse #1] was unaccounted from unit on 11/24/2014 at 0420 when RN [name of registered nurse] noticed [Nurse #1] had multiple orders for discharge and admits not cared for." Another nurse found Nurse #1 in an Emergency Department (ED) bathroom, unconscious, at 4:35 am, with a needle, attached to a syringe, on the floor nearby. Blood was observed on his right antecubital area. According to the Incident Report narrative of Clinical Supervisor #1, who discovered Nurse #1 in the bathroom, as well as the Incident Report narrative of Nursing Administrative Supervisor #1, present in the clothing of Nurse #1 were an empty 2 mg vial of lorazepam (a sedative) and an empty vial of 500 mg of ketamine (an anesthetic). The Incident Report further stated, "As of this time 1000 mg of Ketamine was withdrawn from Pyxis without orders, Haldol [an antipsychotic] 10 mg no order placed, 5 mg of Ativan [lorazepam] not ordered."


2. Patient #1 "was discovered unmonitored (both EKG and pulse oximetry removed), with oxygen removed, hypotensive and poorly ventilating. This required [Patient #1] to be rescued from adverse decline and admitted to the Critical Care Unit. Dr. [name of physician] had been asked for a Ketamine order by [Nurse #1]. Dr. [name of physician] declined to order the Ketamine. In addition, it is a violation of our hospital policy for Registered Nurses to administer Ketamine."


D. Review of an email from the Chief Nursing Officer (CNO) to the state Board of Nursing, a copy of which was submitted to the surveyors, revealed an acknowledgement by the CNO that "Ketamine was positive on [Patient #1]" although "[Patient #1] did not have Ketamine ordered,"


E. On 12/16/14 at 10:35 am during interview, the facility Pharmacy Manager explained the Pyxis (medication dispenser) and the procedure by which nurses access medication in the ED. She stated that reconciliation of prescribed medication (medication prescribed for each patient via a standing order or a response to a specific request) is to be done at the end of each shift, and if the count is off it gets reported to the ED Supervisor on duty and the pharmacy. She stated that the ED also completes a weekly reconciliation and inventory count of medication on Sundays, and any discrepancy identified at that time is investigated by the pharmacy and the Clinical Manager of Emergency Services. She acknowledged that that "the Pyxis system currently in place is not perfect in identifying medication diversion immediately."

Based on staff interviews, chart reviews, and facility document reviews, the facility failed to prevent the unauthorized administration of a sedative by a traveling nurse, Nurse #1. This failure exposed an emergency room patient and others to potential lethal harm (see A 500).


The facility failed to control access to a controlled medication in the emergency room by Nurse #1 and audit controlled substances daily (see A 503). Nurse #1 diverted unprescribed, controlled medications and administered those medications to himself and Patient #1. This failure exposed Patient #1 to unauthorized anesthetic administration and its potential lethal effects.


The cumulative effect of the failures resulted in noncompliance with the Condition of Participation.


.

Based on staff interviews, chart reviews, and facility document reviews, the facility failed to prevent the unauthorized administration of a sedative by a traveling nurse, Nurse #1. This failure exposed an emergency room patient and others to potential lethal harm.


The findings are:


A. The Incident Report received by the state Department of Health (the licensing authority) from the hospital on 12/15/14 revealed the following:


1. "[Nurse #1] was unaccounted from unit on 11/24/2014 at 0420 when RN [name of registered nurse] noticed [Nurse #1] had multiple orders for discharge and admits not cared for." Another nurse found Nurse #1 in an Emergency Department (ED) bathroom, unconscious, at 4:35 am, with a needle, attached to a syringe, on the floor nearby. Blood was observed on his right antecubital area. According to the Incident Report narrative of Clinical Supervisor #1, who discovered Nurse #1 in the bathroom, as well as the Incident Report narrative of Nursing Administrative Supervisor #1, present in the clothing of Nurse #1 were an empty 2 mg vial of lorazepam (a sedative) and an empty vial of 500 mg of ketamine (an anesthetic). The Incident Report further stated, "As of this time 1000 mg of Ketamine was withdrawn from Pyxis without orders, Haldol [an antipsychotic] 10 mg no order placed, 5 mg of Ativan [lorazepam] not ordered."


2. "[Patient #1] was discovered unmonitored (both EKG and pulse oximetry removed), with oxygen removed, hypotensive and poorly ventilating. This required [Patient #1] to be rescued from adverse decline and admitted to the Critical Care Unit. Dr. [name of physician] had been asked for a Ketamine order by [Nurse #1]. Dr. [name of physician] declined to order the Ketamine. In addition, it is a violation of our hospital policy for Registered Nurses to administer Ketamine."


C. Review of an email from the Chief Nursing Officer (CNO) to the state Board of Nursing, a copy of which was submitted to the surveyors, revealed an acknowledgement by the CNO that "Ketamine was positive on [Patient #1]" although "[Patient #1] did not have Ketamine ordered."


D. On 12/17/14 at 10:15 am during interview, the Pharmacy Informatics specialist explained that the hospital utilized a medication dispenser, known as Pyxis, in the ED. He described a scenario in which a nurse could obtain a controlled substance from a Pyxis (of which there are several in the ED) for indiscriminate use without discovery by nursing or pharmacy staff until the end of the week, and another scenario in which discovery might never occur.


The two processes are as follows:


1. A nurse in the ED can "pull" from the Pyxis 1 vial of ketamine (or any controlled substance) that is currently prescribed to be administered to a given patient at a given time. The nurse can obtain as many vials as available, but the Pyxis will record that only 1 vial has been removed from Pyxis, if that is entered by the nurse. The discrepancy will not come to the attention of the nursing staff -- and therefore the pharmacy -- unless (1) another nurse later needs to administer a dose of that same medication for some patient, or (2) the pharmacy, in its reconciliation at the end of the week, makes the discovery.


2. A nurse in the ED can "pull" from the Pyxis 1 vital of ketamine (or any controlled substance) that is available. The nurse can then identify in Pyxis for the record that 1 vial of ketamine has been removed from Pyxis, but pocket the vial without documenting on any MAR that it has been administered to a patient. The absence of a record of its administration on any MAR will not be discovered, according to the hospital Pharmacy Informatics specialist, until "maybe never."


E. On 12/16/14 at 10:35 am during interview, the facility Pharmacy Manager stated that reconciliation of prescribed medication (medication prescribed for each patient via a standing order or a response to a specific request) is to be done at the end of each shift, and if the count is off it gets reported to the ED Supervisor on duty and the pharmacy. She stated that the ED also completes a weekly reconciliation and inventory count of medication on Sundays, and any discrepancy identified at that time is investigated by the pharmacy and ED Manager. She acknowledged that "the Pyxis system currently in place is not perfect in identifying medication diversion immediately."


The Pharmacy Informatics specialist reported on 12/17/14 at 10:15 am that some different controls can be added to the Pyxis, such as having two nurses sign for each withdrawal of medication and limiting the amount of medication in each compartment irrespective of the size of the compartment, but that such controls had not been implemented.

Based on staff interviews, chart reviews, and facility document reviews, the facility failed to control access to a controlled medication in the emergency room by Nurse #1 and audit controlled medications daily. This failure exposed patients to unauthorized medication administration to Patient #1 and its potential lethal effects.


The findings are:


A. On 12/17/14 at 10:15 am during interview, the Pharmacy Informatics specialist explained that the hospital utilized a medication-dispensing device, known as Pyxis, in the Emergency Department (ED). He described a scenario in which a nurse could obtain a controlled substance from the Pyxis in the ED for indiscriminate use without discovery by nursing or pharmacy staff until the end of the week, and another scenario in which discovery might never occur.

The two processes are as follows:


1. A nurse in the ED can "pull" from the Pyxis 1 vial of ketamine (or any controlled substance) that is currently prescribed to be administered to a given patient at a given time. The nurse can obtain as many vials as available, but the Pyxis will record that only 1 vial has been removed from Pyxis, if that is entered by the nurse. The discrepancy will not come to the attention of the nursing staff -- and therefore the pharmacy -- unless (1) another nurse later needs to administer a dose of that same medication for some patient, or (2) the pharmacy, in its reconciliation at the end of the week, makes the discovery.


2. A nurse in the ED can "pull" from the Pyxis 1 vital of ketamine (or any controlled substance) that is available. The nurse can then identify in Pyxis for the record that 1 vial of ketamine has been removed from Pyxis, but pocket the vial without documenting on any MAR that it has been administered to a patient. The absence of a record of its administration on any MAR will not be discovered, according to the hospital Pharmacy Informatics specialist, until "maybe never."


B. The Pharmacy Director and the Pharmacy Informatics specialist stated in the interview on 12/17/14 that there is no daily reconciliation count of Pyxis; a shift reconciliation of prescribed medication is done at the end of each shift. The Pharmacy Informatics specialist reported that some different controls can be added to the Pyxis, such as having two nurses sign for each withdrawal of medication and limiting the amount of medication in each compartment irrespective of the size of the compartment, but that such controls had not been implemented.


C. The Incident Report received by the state Department of Health (State Agency) from the hospital on 12/15/14 revealed the following:


1. "[Nurse #1] was unaccounted from unit on 11/24/2014 at 0420 when RN [name of registered nurse] noticed [Nurse #1] had multiple orders for discharge and admits not cared for." Another nurse found Nurse #1 in an ED bathroom, unconscious, at 4:35 am, with a needle, attached to a syringe, on the floor nearby. Blood was observed on his right antecubital area. According to the Incident Report narrative of Clinical Supervisor #1, who discovered Nurse #1 in the bathroom, as well as the Incident Report narrative of Nursing Administrative Supervisor #1, present in the clothing of Nurse #1 were an empty 2 mg vial of lorazepam (a sedative) and an empty vial of 500 mg of ketamine (an anesthetic). The Incident Report further stated, "As of this time 1000 mg of Ketamine was withdrawn from Pyxis without orders, Haldol [an antipsychotic] 10 mg no order placed, 5 mg of Ativan [lorazepam] not ordered."


2. "[Patient #1] was discovered unmonitored (both EKG and pulse oximetry removed), with oxygen removed, hypotensive and poorly ventilating. This required [Patient #1] to be rescued from adverse decline and admitted to the Critical Care Unit. Dr. [name of physician] had been asked for a Ketamine order by (Nurse #1]. Dr. [name of physician] declined to order the Ketamine. In addition, it is a violation of our hospital policy for Registered Nurses to administer Ketamine."


D. Review of an email from the Chief Nursing Officer (CNO) to the state Board of Nursing, a copy of which was submitted to the surveyors, revealed an acknowledgement by the CNO that "Ketamine was positive on [Patient #1]" although "[Patient #1] did not have Ketamine ordered."


E. On 12/17/14 at 2:30 pm during interview, the Pharmacy Director acknowledged that the facility pharmacy and nursing staff did not audit specific, low-activity controlled substances after each 12-hour shift or daily, but rather on a weekly basis.