HospitalInspections.org

Based on records reviewed and interviews the hospital failed to provide clear and unambiguous language in the ventricular assist device (a VAD is a mechanical pump that assists blood from the lower chambers of the heart to the rest of the body. A VAD is used in people who have weakened hearts or heart failure) order set as part of the Hospital's response plan to an identified improvement opportunity.

According to the Oxford Languages Dictionary, and/or is defined as either or both of two stated possibilities.

The Surveyor reviewed the Admission/Transfer order set for the Patient with a VAD. In response to an anticoagulation issue. The Hospital added "INR Target 2-3, Please contact the MD (physician) and/or HF (Heart Failure) attending for any supra-therapeutic (an elevated level above the target level) INR." to the revised order set.

The Surveyor interviewed the Interim Director of Patient Safety at 7:20 A.M. on 4/22/21. The Interim Director of Patient Safety said she believed the order set meant for both the MD and the Heart Failure Attending to be notified of a supra-therapeutic INR.

The Surveyor interviewed Registered Nurse (RN) #1 at 1:00 P.M. on 4/22/21. RN #1 said that she would interpret that order to mean either the MD or the Heart Failure Attending was to be notified of a supra-therapeutic INR.

The Surveyor interviewed Pharmacist #1 at 2:30 P.M. on 4/22/21. Pharmacist #1 said that she would interpret that order to mean both the MD and the Heart Failure Attending were to be notified of a supra therapeutic INR.

Only notifying the MD would not address the improvement opportunity identified by the Hospital's internal investigation as a critical feature to prevent a like occurrence.