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Based on interview and record review, the hospital failed to ensure the ordering physicians had clear, non-conflicting and completed the pain medication orders with ranges for two of 40 sampled patients (Patients 6 and 7), creating the risk for inconsistent pharmacological pain intervention practices by the RNs providing care to the patients in the hospital.

Findings:

Review of the hospital's Rules and Regulations of the Medical Staff dated 1/22 showed an ambiguous order will be clarified before it is carried out. The clarified order will be documented by the practitioner.

During the Complaint Validation survey from 3/1-3/3/22, the following concerns were identified:

* Patient 6's physician had ordered hydromorphone with a dosing range which was conflicted with the PRN timing intervals on how often the pain medication could be given. Cross reference to A405, example #3.a.

* Patient 7's physician had ordered hydromorphone on a dosing range with failure to specify how subsequent doses should be administered after the initial dosing. Cross reference to A405, example #3.b.

On 3/2/22 at 1357 hours, an interview and concurrent facility document review was conducted with the Manager of Pharmacy Operations and Medication Safety Pharmacist.

Review of the hospital's protocol titled Guideline: PRN Analgesics - Order of Use and Opioid Range Orders approved on 9/20 showed the document is meant to provide guidance if the prescriber's pain medication order did not give specific instructions for the "order of use" of multiple PRN pain medications or implementation of range orders.

When the above concerns were shared regarding the dosing ranges of pain medications, the Manager stated the routine audits were not conducted to ensure the MDs and RNs were in compliance with the hospital's protocol for the PRN analgesics with ranges.

At 1610 hours, the above concerns were shared with the CNO who stated the dosing range could be ambiguous and unclear. The CNO stated the physicians needed the PRN pain medication orders with ranges to be clear and complete.

Based on interview and record review, the hospital failed to ensure the consents for the Conditions of Admissions were completed for three sampled patients (Patients 1, 5, and 32) and the Notice of Patient's Rights (EMTALA sign) was posted in an area visible to all patients entering the ED for treatment and examination. These failures posed the increased risk for the patients not to be informed of their rights as the patients receiving care in the hospital.

Findings:

1. On 3/2/22 at 0950 hours, an interview and concurrent medical record review for Patient 32 was initiated with RN 7, Director of ED/CCU, and RT 1. Patient 32 was admitted to the hospital on 2/23/22.

Review of the H&P examination dated 2/23/22, showed Patient 32 had a history of COVID 19 infection in January 2022 and was admitted in the hospital on 2/9 to 2/17/22, for COVID pneumonia. Patient 32 was readmitted for pneumonia and acute respiratory failure with hypoxia and was out of the isolation.

Review of the COA dated 2/23/22 at 1510 hours, showed, "obtained verbal" for the Signature of the Patient/Legal Representative and one signature for the hospital representative. When asked who gave the verbal consent, the Director of ED/CCU and RN 7 stated they did not know.

On 3/3/22 at 1105 hours, an interview and concurrent record review was conducted with the Registration Patient Access Supervisor. When asked about the process of obtaining the consent for the COA, the Registration Patient Access Supervisor stated the verbal consent was obtained when the patient was in isolation for COVID 19 due to PUI or unable to sign due to medical condition. The consent also needed a witness either by the primary RN or the clinical staff who evaluated the patient if the RN was not available. The Registration Patient Access Supervisor stated Patient 32 was at the COVID 19 cohort area and was a PUI at the time when the patient was at the ED. The Registration Patient Access Supervisor stated the registration staff were not to go inside the isolation rooms and they obtained the consent via the intercom or call the patient's personal phone. The Registration Patient Access Supervisor verified the witness to the verbal consent was missing.

2. On 3/2/22 at 0840 hours, during the tour of the ED with the Director of ED/CCU, Executive Director of Nursing Services, the EMTALA sign was not observed noticeable and visible at the ED lobby. The Director of ED/CCU was asked where the EMTALA sign was posted. The Director of the ED/CCU showed the EMTALA sign posted in the small hallway on the wall across the public restroom at the left side of the ED lobby. However, the sign could not be noticed when standing in the lobby of the ED. The Director of ED/CCU was asked where the patients waited to be examined or treated. The Director of ED/CCU stated the patients either wait in the lobby after triaged or if not, the patients could go inside the ED straight to the treatment room for traige and stay in the treatment room if the ED was not busy. When asked if the sign specifying the rights of the individual for the treatment in the ED and the women in labor could be seen or notice by all individuals who entered the ED and waiting for examination and treatment, the Director of ED/CCU stated the patients registered at the registration area and were led to the Business Services counter. The Business Services was asked how the individuals entering the ED would be notified of the patient rights. The Business Services stated the patients were provided a patient information booklet after the patients were seen or examined by the physician.


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3. Review of the hospital's P&P titled Conditions of Admission (COA) approved on 3/12/20, showed in the event a patient is unable to sign his or her name due to a medical or physical condition, the Patient Access Representative will notate on the signature line"patent is unable to sign due to condition/illness." The Patient Access Representative and the ED Patient Access staff member or clinician will witness and sign under "Hospital Representative" line as witness to the patient's condition or illness.

On 3/2/22 at 0838 hours, an interview and concurrent review of Patients 1 and 5's medical records was initiated with the Director of Mother Baby, and the Clinical Safety Data Coordinator RN. Patient 1 delivered Patient 5 via C-section on 2/26/22.

Review of item #5 on Patient 1's COA signed 2/27/22 at 0800 hours, showed if the patient delivered an infant while being a patient of the hospital, the undersigned agreed that the COA applied to the infant. However, the area to initial the specific acknowledgement by the patient was left blank. Further review of the COA showed the area for the "Signature of Patient/Legal Representative" had the statement "Verbal Consent" written on the signature line. The area to sign for the "Hospital Representative" showed only one signed signature.

On 3/2/22 at 1104 hours, on interview and concurrent review of Patients 1 and 5's medical records was conducted with the Director of Patient Access and the Clinical Safety Data Coordinator RN. When asked, the Director stated there was no P&P regarding the workflow process on when and how to receive a verbal consent when a patient was not able to sign. However, the Director stated the usual procedure was to only obtain a verbal consent when the patient was a PUI or in isolation precautions.

The above concerns were shared with the Director of Patient Access and the Clinical Safety Data Coordinator RN. The Director stated the COA was incomplete and all the necessary initials and signatures should have been done on Patients 1 and 5's COA.

Based on interview and record review, the hospital failed the patient's information on the rights was provided for one sampled patient (Patient 16) as evidenced by:

1. The IM form was not provided to the patient within two calendar days of admission to the hospital as per the hospital's P&P.

2. The IM form did not identify the individual who gave the verbal acknowledgement of the IM form.

This failure had the potential for the patient being unaware of their rights as a Medicare recipient including the rights to appeal their discharge.

Findings:

Review of the hospital's P&P titled Important Message from Medicare About Your Rights dated 7/5/19, showed in part:

Purpose:
- To ensure that all Medicare patients are aware of their rights as a Medicare recipient.
- Provide a copy of the Important Message from Medicare about Your Rights (IM) upon admission to a unit.

Policy:
- Provide patient with "The Important Message from Medicate" within two calendar days following the beneficiary's admission to the hospital.
- Should the patient or representative not be able to sign, reasonable attempts will be made to follow up and get signatures.
- Family member will be contacted when patient is unable to sign. Notice will be read to them and noted as such as well as sent a copy by certified mail.
- Patient or patient representative to sign, date and time they receive this notice.

Review of the hospital's document titled An Important Message from Medicare About Your Rights dated 4/1/20, showed in part:

- Please sign and date here to show you received this notice and understand your rights
- Additional Information: If signed by other than the patient, indicate name, relationship and phone number.

On 3/1/22, review of Patient 16's medical record was conducted. Patient 16 was admitted to the hospital on 2/17/22, with altered mental status.

The H&P examination dated 2/17/22, showed, "Neurological: Patient keeps eyes closed, nonverbal, not able to follow commands or answer any questions."

The medical record showed the patient's preferred language was Spanish, and the patient needed an interpreter.

a. At 1134 hours, medical record review for Patient 16 and concurrent interview was conducted with the Care Management Assistant. The medical record showed the IM form was completed on 2/26/22, nine days after admission to the hospital.

The Care Management Assistant acknowledged the findings.

b. On 3/3/22 at 1114 hours, review of Patient 16's medical record and concurrent interview was conducted with the Patient Access Supervisor.

Review of Patient 16's IM form showed in part, "Verbal Acknowledgement...02/26/22...1033 AM..."

However, there was no documentation showing whether the verbal acknowledgement was by the patient or by a Representative.

The Registration Patient Access Supervisor acknowledged the findings.

Based on interview and record review, the facility failed to ensure the following:

1. Patient 15 received a copy of the Blood Transfusion Consent Form and the Paul Gann Blood Act "A Patient's Guide to Blood Transfusion."

2. Patient 34 who was a limited English speaking patient received the information regarding his care in the language that he understood prior to signing the English language consent form.

These failures had the potential for the staff to provide the treatments to the patients without their informed consents.

Findings:

1. The hospital's P&P Transfusion of Blood and Blood Components dated 2/9/22, showed in part:

- Informed Consent must be given to the patient by a physician prior to Blood Transfusion and include Possible Risks, Benefits and Alternatives to receipt of blood and an opportunity to ask questions.

- Registered Nurses: Confirm patient has been provided State of California information sheet on Blood Transfusion and Blood Transfusion Consent has been signed.

On 3/1/22 at 1041 hours, a medical record review for Patient 15 and concurrent interview was conducted with RN 5 and Director 6W. The medical record showed Patient 15 was admitted for the facility on 2/23/22, with diagnoses of rectal bleeding. Patient 15 received two unit of blood on 2/26/22.

When asked about the completed Blood Transfusion Consent, the double-sided hard copy was provided for review. Review of the Blood Transfusion Consent (a double-sided form with "A Patient's Guide to Blood Transfusion" printed on the back) showed Patient 15 had not been provided with a copy of the consent.

Director 6W acknowledged the findings.

2. On 3/2/22, at 0915 hours, during a tour of the Medical/Surgical/Telemetry unit, RN 4 stated there were two patients on the unit requiring an interpreter, one of them was Patient 34.

Medical Record review for Patient 34 and concurrent interview was conducted with the Director of Med/Surg/Tele and RN 4.

The medical record showed Patient 34 was admitted to the hospital on 2/28/22, for a dialysis access problem.

The medical record showed the English language consent dated 2/28/22, for a non-tunneled dialysis catheter placement signed by the patient. The consent showed the following:

- Patient 34 signed the consent at 1432 hours.
- A physician signed the Physician Surgeon Documentation of Informed Consent Discussion at 1433 hours.
- A witness signed the Interpreter's Statement at 2145 hours.
- The Interpreter Name and Identification Code was left blank.
- The patient's primary language was Japanese.

* There was no documentation showing an interpreter had been used. There was no documentation showing interpreter services were offered and that the patient declined.

* There was no documentation showing the patient's family member had been used for interpreting at the patient's request.

The Director of Med/Surg/Tele acknowledged the findings.

Based on observation and interview, the hospital failed to ensure the privacy of the patients in the ED quick triage area when a computer screen with sensitive patient information was left unattended and open. This failure had the potential for the patients' sensitive and confidential health information to be left unmonitored in a high traffic area of the ED.

Findings:

On 3/1/22 at 1419 hours, a tour of the ED was conducted with the Director of ED and Quality and Improvement Performance RN.

The quick triage area closest to the ambulance bay had an area with multiple large screen monitors and smaller computer work stations. A computer screen on a work station had sensitive patient information left open and unattended. When asked, the Director stated the screen should have been turned off when the user was done with charting.

The above finding was acknowledged by the Director of ED.

Based on observation, interview, and record review, the hospital failed to ensure the patients received care in a safe environment as evidenced by:

1. The Preventative Maintenance was not done for various patient care equipment on the Medical/Surgical/Telemetry units.

2. The fire pull station was blocked with the vitals sign machine.

These failures had the potential to create an unsafe environment for the patients receiving care in the hospital.

Findings:

The facility's P&P Medical Equipment Management Program dated 9/30/20, was reviewed and showed in part:

Preventative Maintenance (PM) Plan:

- The Bio Med is responsible for establishing appropriate PM intervals based upon manufacturer's recommendation.

PM Process:

- Ensuring preventive maintenance is performed on equipment that is consistent with maintenance strategies to minimize clinical and physical risks.

- Incomplete maintenance due to any justifiable reason such as: "Unable to Locate" or "Continually In Use" is subject to a 30 day follow-up and completion period.

Unable to Locate Equipment:

- When equipment is not located for the PM, each Responsible Clinical Department Director or Manager will receive written notification from the Bio Med with a list of equipment that could not be located for the scheduled preventative maintenance due.

a. On 3/2/22 at 0915 hours, a tour of the 6th floor Medical/Surgical/Telemetry (M/S/T) unit was conducted with the Patient Safety and Director of Med/Surg/Tele.

During the tour, the following patient care equipment was observed with a PM sticker indicating the PM was overdue:

- One enteral feeding pump had the PM due on 11/2021.

- One mobile stand-on scale had the PM due on 9/2021.

- One Stryker air mattress pump had the PM due on 9/2021.

At 1013 hours, the Bio Med Engineer and Bio Med Services were interviewed and confirmed the findings.

b. On 3/2/22 at 1106 hours, a tour of the 5th floor Medical/Surgical/Telemetry (M/S/T) unit was conducted with the Patient Safety and Director of Med/Surg/Tele.

During the tour, two enteral feeding pumps had the PM due on 11/2021.

During a concurrent interview, the Director of Med/Surg/Tele acknowledged the findings.


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2. The facility document titled Fire Response and Extinguisher Use dated 9/23/21, was reviewed and showed in part: General fire safety reminders ....Nothing in front of fire pull stations and extinguishers.

On 3/1/22 at 1019 hours, an initial tour of 8 West, Medical/Oncology unit was conducted with the Director of Social Work and RN 10. During the initial tour, a fire pull station was observed in the corridor with a vital sign machine in front of it and one computer on each side of the vitals sign machine. Above the vitals sign machine, in front of the fire pull station was a signage in red stating fire pull station, do not block.

The Director of Social Work stated the machine should not be in front of the pull station. The Director stated she would have a clinical staff member from the Medical Oncology unit speak regarding this observation.

An observation and interview was conducted with RN 10. RN 10 acknowledged the vitals sign machine was in front of the pull station and the sign stating no blocking the fire pull station. RN 10 stated the access to a fire pull station could not be blocked by any equipment or anything placed in front of it. RN 10 stated in case of a fire, the staff needed clear access to the pull station to alert anyone of a possible fire. RN 10 stated it was a safety issue and a fire department rule.

The Director of Social Work and RN 10 verified the above findings.

Based on interview and record review, the nursing staff failed to ensure one of 40 sampled patients' (Patient 6) pain was managed as per the hospital's P&P. This failure had the potentail to cause Patient 6 to have continued pain.

Findings:

Review of the hospital's P&P titled Pain Management approved on 3/18/19, showed the assessment of pain includes the patient's self reported pain level, physical or behavioral symptoms of pain, vital signs, conditions known to cause pain for this patient and the patient's history of pain and interventions used to alleviate the pain. Based on the assessment, the RN will formulate a plan of care to alleviate the patient's pain. Non-medical forms of treatment may be utilized. If non-medical measures do not adequately alleviate the patient's pain, the RN may utilize pain medication ordered by the patient's MD. The numeric and faces pain scale shows mild pain is 1 to 3, moderate pain is 4 to 6, and severe pain is 7 to 10.

On 3/2/22 at 0939 hours, an interview and concurrent medical record review was conducted with the Director of ED, RN 3, and the Clinical Safety Data Coordinator RN. Patient 6 arrived at the hospital's ED on 3/1/22, with a chief complaint of abdominal pain and bloody output.

Review of Patient 6's Patient Care Timeline showed the following:

* On 3/1/22 at 0219 hours, Patient 6's pain was assessed to be at a level of 7 on a 0-10 pain scale (with 0 = no pain and 10=worst pain). The pain location was the bilateral flank and the pain was constant and aching in quality.

* At 0300 hours, Patient 6's pain was still assessed to be at a level of 7 and the pain quality had changed to become aching and sharp.

* At 0400 hours, Patient 6's pain was still assessed to be at a level of 7 and the pain quality had changed to become aching, sharp, and throbbing.

* At 0500 hours, Patient 6's pain was still assessed to be at a level of 7 and the pain quality had changed to become aching, sharp, and burning.

* At 0600 hours, Patient 6's pain was still assessed to be at a level of 7 and the pain quality had changed to aching and sharp.

* At 0700 hours, Patient 6's pain was still assessed to be at a level of 7 and the pain quality had changed to sharp.

However, further review of the medical record failed to show documentation of any pharmacological or non-pharmacological interventions for the pain management in the ED for Patient 6. No PRN pain medications were ordered for Patient 6.

The Director of ED, RN 3 and the Clinical Safety Data Coordinator RN were informed and acknowledged the above findings.

Based on observation, interview, and record review, the facility failed to ensure the hospital's P&Ps were implemented as evidenced by:

1. For Patient 15, the hospital failed to show documentation of the vital signs completed hourly during the administration of blood.

2. The facility failed to ensure clean linens and clean mop heads were stored properly stored in the GI Lab unit.

3. The facility failed to remove an expired supply from the supply room in the Interventional Radiology unit.

4. For Patient 32, the hospital failed to show a documentation of the zeroing and leveling (ensures only the actual pressures from the patient will be measured by the transducer to provide accurate data) of the arterial line transducer (sensor capable of converting the pressure acting on it into electrical signals) performed after the insertion of the arterial line.

These failures had the potential to result in substandard healthcare outcomes to the patients in the hospital.

Findings:

1. Review of the hospital's P&P titled Transfusion of Blood and Blood Components dated 2/9/22, showed in part:

- Document the following in the EHR during blood transfusion:
- Vital Signs,
1. Pretransfusion
2. At 15 minutes
3. Hourly
4. Upon completion.

On 3/1/22 at 1041 hours, a medical record review for Patient 15 and concurrent interview was conducted with RN 5. The medical record showed Patient 15 was admitted for the facility on 2/23/22, with diagnoses of rectal bleeding. Patient 15 received two unit of blood on 2/26/21. The first unit of blood was started at 1307 hours and ended at 1622 hours. The second unit of blood was started at 1622 hours and ended at 1930 hours.

RN 5 stated the vitals signs should be done at pretransfusion, 15 minutes, hourly, and upon completion of the blood transfusion.

However, there was no documentation on the Blood Administration Flowsheet showing the vitals signs were done hourly during the transfusion of the first unit of blood at 1422 and 1522 hours.

In addition, there was no documentation on the Blood Administration Flowsheet showing the vitals signs were done hourly during the transfusion of the second unit of blood at 1737 and 1837 hours.

On 3/3/22 at 1139 hours, the Patient Safety confirmed there was no documentation in Patient 15's medical record showing the vital signs were done hourly on 2/26/22, during the administration of the first or the second units of blood.


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2. The facility's P&P titled Environmental Services Soiled and Clean linen services dated 11/12/19, showed the soiled linen and clean linen is collected, transported and distributed in the appropriate manner following standard precautions and infection prevention guidelines ....the organization shall receive store and distribute clean ...and dirty linen ...using methods that meet the regulatory standards of the state federal and accrediting agencies.

On 3/1/22 at 1310 hours, an initial tour of the GI Lab unit of the hospital was conducted with the Director of Social Work and the Manager of GI Lab. During the initial tour of the GI lab, the clean towels and clean mop heads were observed stored in a cupboard located in the soiled utility room.

A subsequent interview was conducted with the GI Lab Manager. The GI Lab Manager stated the observed towels and mop heads in the soiled utility room cupboard were clean and not soiled. The GI Lab Manager stated the soiled utility room were for dirty items, not clean ones. The GI Lab manager verified the soiled utility room was not the appropriate place to store clean linens, like towels and clean mop heads. The GI Lab Manager stated the clean towels and clean mop heads had a storage place in the EVS storage room. The GI Lab Manager stated the expectation was for the clean towels and mop heads to be stored in the EVS storage room, not the soiled utility room. The GI Lab Manager stated the clean linens and mop heads should not be stored in the soiled room due to possible cross contamination and infection control concerns.

The GI Lab Manager verified the above findings.

3. The facility's document titled Supply Expirations Check Process dated 6/11/21, was reviewed and showed in part, older inventory will be rotated to the front using the FIFO method, first in first out ... Expired supplies will be immediately disposed of or donated.

On 3/1/22 at 1336 hours, an initial tour of the Interventional Radiology unit of the hospital was conducted with the Director of Social Work and the Interventional Radiology Charge Nurse. During the tour, an expired supply was observed in a blue storage bin located in the supply room.

A subsequent interview was conducted with the Interventional Radiology Charge Nurse. The Interventional Radiology Charge Nurse stated the observed supply item, a box of bandage was dated 3/2021. The Interventional Radiology Charge Nurse stated the box of bandage had expired and should have been removed from the stock and not available for use.

The Interventional Radiology Charge Nurse stated the expectation for the nursing staff was to check for expired items in the supply room on a quarterly basis. The Interventional Radiology Charge Nurse stated an expired item like this expired bandage could be degraded and not work as well as it should be if it was not expired.

The Interventional Radiology Charge Nurse verified the above findings.


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4. Review of the hospital's P&P titled Hemodynamic Monitoring revised on 2/1/22, showed the leveling and zeroing of an arterial line (cannula placed into an artery to measure the pressure in the artery) transducer must be performed and documented post insertion of the line.

Review of Patient 32's Critical Care Medicine Progress Notes on 2/28/22 at 1633 hours, showed an arterial line was inserted in the right femoral artery (blood vessel supplying blood to the lower part of the body) of the patient.

Review of Patient 32's Flowsheets on 2/28/22 at 1600 hours, showed an arterial line was placed in the patient's right femoral artery.

On 3/3/22 at 0855 hours, a concurrent observation and interview was conducted with RN 9. A transducer clamped on a pole was observed on the left side of Patient 32's bed. RN 9 acknowledged Patient 32 had an arterial line to continuously monitor the patient's blood pressure. RN 9 explained the arterial line transducer was zeroed and leveled every four hours, or the transducer was leveled after repositioning Patient 32.

On 3/3/22 at 1011 hours, a concurrent interview and medical record review was conducted with RN 8. RN 8 was asked to show the documentation for Patient 32's arterial line. RN 8 showed a documentation of the patient's arterial line in the right femoral artery placed on 2/28/22 at 1600 hours. RN 8 was asked to show a documentation of zeroing and leveling was performed for the arterial line transducer after the line was inserted in Patient 32's right femoral artery. RN 8 acknowledged there was no documentation of the zeroing and leveling when the arterial line transducer performed after the line was inserted in the patient's right femoral artery on 2/28/22 at 1600 hours.

Based on observation, interview, and record review, the nursing staff failed to ensure the physicians' orders were followed for three sampled patients (6, 7, and 32) as evidence by:

1. The Fentanyl drip was not administered as per the physician's order for Patient 32.

2. The Nimbex drip was not administered as per the physician's order for Patient 32.

3. The pain medications were not administered as ordered or per the hospital's protocol for Patients 6 and 7.

These failures posed the increased risk of substandard health outcomes to the patients in the hospital.

Findings:

On 3/2/22 at 0955 hours, observation, interview, and concurrent medical record was conducted with RN 7, the Director ED/CCU, RT 1, the Executive Director Nursing Services. Patient A was admitted to the hospital on 2/23/22, and transferred to CCU on 2/27/22, and was intubated at 1319 hours.

Patient A was observed to be orally intubated, asleep, with multiple IV drip medications infusing. RN 7 stated Patient A was receiving Fentanyl (narcotic pain medication) and Nimbex (medication to induce paralysis) drips.

Review of the H&P examination dated 2/23/22, showed Patient A was admitted to the hospital for pneumonia, acute respiratory failure, and history of COVID 19 virus infection.

1. Review of the physician's order for Fentanyl drip dated 2/27/22 at 1426 hours, showed the order for Fentanyl 20 mcg/ml in sodium chloride 0.9 % 100 ml, infusion dose 50 - 250 mcg/hr to start on 2/27/22 at 1445 hours, titration goal was analgesia, initial dose 25 mcg/hr, increase or decrease rate by 25 mcg/hr every 15 minutes; and to titrate drug per order as tolerated and titration may vary based on patient's critical condition.

RN 7 was asked what the reason for the Fentanyl drip administration for Patient 32. RN 7 stated the Fentanyl drip was administered for the relief of the patient's pain. RN 7 was asked what pain scale the RNs used for pain assessment. RN 7 stated the RNs used CPOT for pain scale assessment.

Review of the Fentanyl drip titration for pain using CPOT showed the following on 2/27/22:

- at 1545 hours, the RASS score was - (minus) 4 (deep sedation: No response to voice, but any movement to physical stimulation) and CPOT was 0.
- at 1553 hours, the Fentanyl drip was initiated at 25 mcg/hr.
- at 1600 hours, the CPOT was 0.
- at 1645 hours, the Fentanyl drip rate was increased to 50 mcg/hr.
- at 1646 hours, the RASS score was -4.
- at 1700 hours, the CPOT was 0 and the patient was turned to a prone position.
- at 1800 hours, the RASS score was -5 (unarousable: No response to voice or physical stimulation), and the CPOT was 0.
- at 1851 hours, the Fentanyl drip rate was increased to 75 mcg/hr.
- at 1900 hours, the RASS score was -5 and the CPOT was 0;
- at 1935 hours, the Fentanyl drip rate was increased to 100 mcg/hr.
- at 2000 hours, the RASS score was -5 and the CPOT was 0.
- at 2030 hours, the Fentanyl drip rate was increased to 125 mcg/hr.
- at 2050 hours, the Fentanyl drip rate was increased to 150 mcg/hr
- at 2100 hours, the RASS score was -5 and the CPOT was 0.
- at 2200 hours, the RASS score was -5, CPOT was 0, and Fentanyl drip rate was increased to 200 mcg/hr.
- at 2240 hours, the CPOT was 0.

RN 7 was asked what the patient's pain level goal to be at. RN 7 stated the goal was for the patient to have 0 pain level and RASS of minus 2 (light sedation). However, the patient's pain scale was 0 when the Fentanyl drip was started at 50 mcg/hr and the RASS was -5. RN 7 was asked why the Fentanyl drip was started when the patient's CPOT assessment was 0. RN 7 stated per the RNs note, the patient was hypertensive.

On 3/3/22 at 1000 hours, interview and medical record review was conducted with CIs 1, 2, the Pharmacy Director, Supervisor Pharmacist, Director ED/CCU and RN 8. When asked what the analgesia level meant on the physician order. The Pharmacy Director and Supervisor Pharmacy could not answer. CI 2 stated the analgesia level was reflected on the EMR story book of Patient 32 that showed the CPOT of 2 to 3 and RASS of -4 to -5. RN 8 stated he did not know what the story book in the EMR was. RN 8 stated the analgesia goal was the CPOT of 2 to 3. However, the RN administered the Fentanyl drip with the CPOT of 0 (no pain). RN 8 stated if the physician was using Fentanyl for sedation, the physician could modify the order. However, the physician had ordered the Fentanyl drip for analgesia (for pain).

2. Review of the hospital's P&P titled Neuromuscular Blocking Agents and Use of Peripheral Nerve Stimulator to Monitor Effectiveness effective date 9/20 showed in part:

The TOF measures the level of neuromuscular blockade. Four consecutive electrical stimulation are delivered along the path of the ulnar or posterior tibia nerves and the motor response is measured in order to assess the effectiveness of the current neuromuscular blockade dose. Electrodes are placed apart and in correct position to directly stimulate the nerve, not the muscle. If four equal muscle contractions occur, this indicated there was no effective neuromuscular blockade.

* Dosing: Adjust continuous infusions according to TOF.

1. 0/4 twitches: 100% neuromuscular blockage. Before assuming 100 % blockade perform the following interventions: hold the neuromuscular blocking agent and recheck the TOF in 20 minutes.

2. 1/4 twitches: 90% neuromuscular blockade. Recommend titration: decrease rate by 0.2 mcg/kg/min every 15 minutes until ordered goal of TOF is met. Always follow physician instruction regarding titration of neuromuscular blockade.

3. 2/4 twitches: 80- 90 % neuromuscular blockade. Do not adjust the infusion rate.

* Monitoring: the goal response is two motor responses in response to four consecutive stimuli. When using a continuous drip IV infusion monitor the TOF as follows:
- Obtain baseline TOF prior to starting.
- Every hour after the infusion started and as needed.
- 15 minutes after adjustment of the infusion.

The goal is to use the lowest dose of neuromuscular blocking agent to achieve the identified patient goal. This will prevent excessive drug accumulation and reduce the potential for residual muscle weakness after discontinuation of the blockade.

On 3/2/22 at 0955 hours, interview and concurrent medical record was conducted with RN 7, the Director ED/CCU, RT 1, and the Executive Director Nursing Services.

Review of the physician's order dated 2/27/22 at 1445 hours, showed Nimbex drip 2 mg/ml in 50 ml infusion, goal of 2/4 (two twitches out of four) TOF, initial dose 3 mcg/kg/min, increase or decrease rate by 1 mcg/kg/min every 15 minutes; and titrate drug per order as tolerated and titration may vary based on the patient's critical condition.

Review of the Nimbex drip infusion and the TOF assessment using power level of 10 (nerve stimulator) for Patient 32 on 2/27/22, showed the following:

- at 1610 hours, per the RN's note, the physician was informed Patient 32's TOF was 0. The Nimbex drip was started at 3 mcg/kg/min. However, the physician's ordered the TOF goal of 2/4.
- at 1700 hours, the TOF was 0/4.
- at 1815 hours, the TOF was 0/4.
- at 1900 hours. the TOF was 0/4.
- at 1935 hours, the TOF was 0/4.
- at 2000 hours, the TOF was 0/4.
- at 2100 hours, the TOF was 0/4.
- at 2130 hours, the TOF was 0/4.
- at 2200 hours, the TOF was 0/4 and the Nimbex drip rate was decreased to 2 mcg/kg/min.
- at 2300 hours, the TOF was 0/4 and the Nimbex drip rate was decreased to 1 mcg/kg/min.

RN 7 was asked for the reason to administer the Nimbex at 3 mcg/kg/min with the TOF of 0/4 when the physician's ordered to the TOF goal of 2/4. RN 7 stated the patient could be asynchronous or having high pressure (more than 30) with the artificial respirator or the patient was hypertensive. RT 1 was asked for the peak pressures of Patient 32. RT 1 stated the peak pressures were 30 and less and the patient was not breathing above the ventilator set RR of 30 breaths per minute.

On 3/3/22 at 1100 hours, interview and concurrent medical review was conducted with RN 8 with the Director of ED/CCU, CIs 1, 2, the Pharmacy Director, and Supervisor Pharmacist. RN 8 was asked why the Nimbex drip was administered at 3 mcg/kg/min with TOF 0/4, and the physician's order was the TOF goal of 2/4. RN 8 stated it could be the patient was asynchronous or having high pressuring with the artificial respirator.

The Director of ED/CCU acknowledge the findings.


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3. Review of the hospital's P&P titled Pain Management approved 3/18/19, showed the Critical-Care Pain Observation Tool (CPOT) is used to assess for pain in the critical care patient following observations of facial expression, body movements, muscle tension, compliance with the ventilator or vocalization on extubated patients. If indicators are present the RN may assume pain is present. Total scores range from 0-8 (based on a scale of 0-2 for four items), with the higher score possibly indicating higher levels of pain but still assuming pain is present since the patient cannot verbalize or self-report.

3.a. On 3/2/22 at 0939 hours, an interview and concurrent review of Patient 6's medical record was conducted with the Director of ED, RN 3, and the Clinical Safety Data Coordinator. Patient 6 was brought to the ED on 3/1/22, for a chief complaint of abdominal pain and bloody output.

Review of Patient 6's MAR showed Patient 6 was prescribed to have hydromorphone (opioid pain medication), however, the order and its instructions were conflicting. For example, the physician ordered hydromorphone with a range of 0.4 to 0.8 mg injection every two hours as needed for a CPOT >2. The administration instructions showed to administer the initial dose using the lowest dose in the range first. However the dosing schedule was conflicted with the instructions as it showed the lowest dose may be repeated one time if pain uncontrolled within 15 minutes, then to use the next highest dose in the range every three hours as needed. If no dose was given in three hours, then the RN would go back to the lowest dose for the subsequent dose.

Further review of Patient 6's MAR and the Pain/Comfort flowsheet showed the following concerns:

* On 3/1/22 at 2135 hours, Patient 6's CPOT was 5. However, the initial dose of 0.2 mg of hydromorphone IVP was not given as per the order instructions. Instead, Patient 6 received 0.5 mg of hydromorphone IVP.

* Two hours later at 2325 hours, Patient 6's CPOT was 8. However, Patient 6 received 0.4 mg of hydromorphone IVP.

RN 3 acknowledged Patient 6 did not to receive hydromorphone as prescribed for pain management.

3.b. On 3/2/22 at 1308 hours, an interview and concurrent review of Patient 7's medical record was conducted with the Director of 4 East, 7 & 8 West, and the Clinical Safety Data Coordinator RN. Patient 7 was admitted to the hospital on 2/19/22, with a current history of cancer and presenting with abdominal pain.

Review of Patient 7's MAR showed the physician ordered hydromorphone 0.2 to 0.6 mg every two hours as needed for moderate to severe pain. The administration instructions showed the first dose must be the lowest dose, titrate to the effective dose by repeating the lowest dose every 30 minutes as needed for pain. The RN was not to exceed the maximum dose ordered per interval. However, further review of the order failed to show how to determine dosing of the subsequent doses.

Review of Patient 7's MAR showed the physician also ordered morphine (opioid pain medication) IVP 2-4 mg for severe pain. Unlike the hydromorphone order, there was no additional administration instructions. However, there was a link to the hospital's protocol titled Guideline: PRN Analgesics - Order of Use and Opioid Range Orders.

Review of the Guideline: PRN Analgesics - Order of Use and Opioid Range Orders approved 9/20 showed the document is meant to provide guidance if the prescriber's pain medication order does not give specific instructions for the "order of use" of multiple PRN pain medications or implementation of range orders. The document showed the following:

* For opioids ordered for moderate or severe pain, titrate to the effective dose by repeating the lowest dose every 30 minutes as needed for pain.

* Start with the lowest dose for the first dose unless the patient has recently received a higher dose of the medication in an inpatient area or at home.

* Assess the patient for symptom relief when the drug reaches its peak effect. Give subsequent doses based on the documented effectiveness of previous doses as well as the patient's level of sedation and respiratory status. Total dose during the interval may not exceed maximum prescribed dose.

Review of Patient 7's MAR and the Pain/Comfort flowsheet showed the following concerns:

* On 2/25/22 at 2204 hours, Patient 7 had severe pain. The RN administered 0.6 mg of hydromorphone IV to the patient instead of the initial dose order of 0.2 mg.

* On 3/1/22 at 1250 hours, Patient 7 was administered morphine 4 mg with no pain assessment. The RN failed to follow the hospital protocol and gave 4 mg IVP of morphine instead of the lowest initial dose 2 mg. Further review of the record showed Patient 7's pain was not reassessed.

* At 0359 hours, Patient 7 had severe pain; however, the patient received a lesser dose of 0.3 mg of hydromorphone IVP from the administration instructions.

* At 0413 hours (approximately 14 minutes after receiving hydromorphone IV), the RN administered 3 mg of morphine IV to Patient 7. The RN administered the opioid medication before the required 30 minutes as per the hospital's protocol.

The Director acknowledged the above concerns.

Based on interview and record review, the hospital failed to ensure one of 40 sample patients(Patient 8) received the instructions on a new prescription medication, creating the risk for the patient to not have full understanding of the discharge instructions for a safe recovery.

Findings:

On 3/2/22 at 1357 hours, an interview and concurrent review of Patient 8's medical record was conducted with the Director of 4 East, 7&8 West, and the Clinical Safety Data Coordinator RN. Patient 8 was admitted to the hospital on 2/28/22, and had a TURP performed.

Review of the After Visit Summary dated 3/1/22, showed Patient 8 was prescribed a new medication, oxybutynin (reduces muscle spasms in the bladder and the urinary tract). However, further review of the document and medical record failed to show the new medication, including its indication for use and side effects was discussed with Patient 8 prior to discharge.

The Director acknowledged the above concern and stated oxybutynin was a new medication for the patient.