HospitalInspections.org

Based on a review of facility policy, review of medical record (MR), and interview with staff (EMP), it was determined that the facility failed to notify a family member or representative of patient's choice of his or her admission to the hospital for seven of ten medical records reviewed (MR7, MR9, MR10, MR11, MR12, MR13, MR15).

Findings include:

Review on April 26, 2017, of facility policy, "Rights and Responsibilities-Patients," dated August 1, 2016, revealed, "... 25. Patients have the right to have a family member or representative and/or physician of their choice promptly notified of their admission to the hospital."

Review on April 25, 2017, of MR7, MR9, MR10, MR11, MR12, MR13, and MR15, revealed no documented evidence that patients' family members or representatives were notifed of patients' admission to hospital.

Interview on April 25, 2017, with EMP1 at 12:57 PM confirmed MR7, MR9, MR10, MR11, MR12, MR13, and MR15 had no documented evidence of family members or representatives being notified of admission to the hospital.

Based on review of facility documents, policies and procedures and medical records (MR), and interview with staff (EMP), it was determined the facility failed to follow its own established policy by not seeking physician clarification for a medication order in one of six medical records reviewed (MR31).

Findings include:

Review on April 25, 2017, of facility document, dated April 13, 2017, revealed "Description of event [age of patient and gender] presented to St. Luke's University Hospital on March 17, 2017, ... On admission patient stated [gender] was on Prograf [an immunosuppressant] 20 mg in the morning and 10 mg in the evening. This medication and dosage was subsequently reconciled, ordered, profiled, dispensed, and administered through the morning of March 20, 2017. Nephrology was consulted on March 20, 2017, for elevated BUN (38) and Creatinine (1.84). Upon consultation it was identified the wrong dose of Prograf was reconciled on admission. Actual dose is 2 mg in the morning and 1 mg in the evening ... Causes considered: Human ... Internal Medicine and Nursing staff ... questioned dosing with patient who was adamant dosing was 20 mg and 10 mg ... Process: Medication Reconciliation Patient gave dosage for Prograf as 20 mg and 10 mg ... Prescribing When physician ordered the medication from the medication reconciliation a 'high dose' warning was received. Again dose was clarified with patient and alert was bypassed ... Profiling when pharmacy attempted to profile medication they too received a "high dose" warning Again dose was clarified with patient ..."

Review on April 25, 2017, of policy "Medication Orders and Patient Profile", dated August 2016, revealed "... Procedure ... The pharmacist will review all orders ... Orders will be checked for ... correct dosage ... If there is any problem (such as clarity ...), the nurse and physician must be notified before the drug is dispensed. It is the Pharmacist's responsibility to clarify any issues with the medication order directly with the Physician ... Documentation of discussion of patient's drug therapy is to be written on the pharmacy copy of the Physician's Order Sheet or documented in the comment field in the computer."

Review of MR31 on April 25 and 26, 2017, revealed Prograf was administered to the patient on March 18, 2017, at 3:11 AM (10 mg), at 9:04 AM (20 mg), and at 9:51 PM (10 mg), and on March 19, 2017, at 8:01 AM (20 mg) and 9:22 PM (10 mg), and March 20, 2017, at 8:44 AM (20 mg).

A request was made to EMP3 on April 26, 2017, for pharmacy documentation that the pharmacist clarified the Prograf medication order with the prescribing physician. None was provided.

Interview with EMP3 on April 26, 2017, at 10:15 AM, confirmed the pharmacist did not clarify the medication order with the physician as required by facility policy. EMP3 also confirmed there was no documented evidence that the pharmacist clarified the medication order with the prescribing physician.