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46120

Based on observation, interview and record review, the facility failed to ensure that the Condition of Participation for Nursing Services was met as evidenced by:

1. Failure to ensure nursing staff would adhere to facility's policy and procedures of checking one (1) of 1 crash cart (a moveable storage device with a locking mechanism that store emergency drugs and supplies) at a nursing unit at least daily when the nursing unit was in use. The facility failed to check the nursing unit crash cart for 8 days out of 15 days between 5/1/2023 through 5/18/2023 when the nursing unit was occupied with patients. (Cross refer A-398).

2. Failure to prepare and administer the correct medication as ordered for one (1) of 26 sampled patients (Patient 1) when:

a. Registered Nurse 2 (RN 2) did not verify the correct drug (Narcan-treatment to reverse overdose of sedative [sleeping medication]) was removed from the facility's automated medication dispensing device. RN 2 removed Hydralazine (medication to treat high blood pressure) instead. (Cross refer A-405)

b. RN 1 did not verify the correct drug was being administered prior to preparation and injection of the medication to Patient 1. (Cross refer A-405).

The cumulative effect of these systemic problems resulted in the facility inability to ensure the Condition of Participation for Nursing Services was met.

Based on observation, interview, and record review, the facility failed to ensure nursing staff would adhere to facility's policy and procedures of checking one (1) of 1 crash cart (a moveable storage device with a locking mechanism that store emergency drugs and supplies) at a nursing unit at least daily when the nursing unit was in use. The facility failed to check the nursing unit crash cart for 8 days out of 15 days between 5/1/2023 through 5/18/2023 when the nursing unit was occupied with patients.

This deficient practice had the potential of failure to ensure emergency drugs and supplies were kept readily available for patient needs.

Findings:

On 5/18/2023, at 1:35 PM, during an observation in the 2 G nursing unit with a pharmacist (Pharm 1) and the Director of Patient Safety and Risk Management (PSRM), Pharm 1 stated 2 G nursing unit was an overflow for adult intensive care unit (area where patients who were acute ill and requiring critical medical care). A list of patients was posted on a board located in the nursing station, and the patient rooms were occupied. One (1) crash cart was observed near the nursing station. The Crash (Emergency) Cart Checklist (dated 5/14/2023 to 5/20/2023) in a binder was concurrently reviewed with Pharm 1 and PSRM. The Crash Cart Checklist indicated the columns (indicate items that need to be present in the crash cart. Example: full oxygen tank) corresponding to 5/15/2023, 5/17/2023, and 5/17/2023 were not filled out (blank).

On 5/18/2023 at 1:40 PM, during an interview, Resource Nurse, stated the 2 G nursing unit was in use and had patients, on 5/17/23.

A review of the Crash (Emergency) Cart Checklists, dated 5/1/2023 through 5/18/2023, indicated eleven (11) out eighteen (18) dates were either crossed off or blank (5/1/2023, 5/3/2023, 5/5/2023, 5/6/2023, 5/7/2023, 5/10/2023, 5/12/2023, 5/13/2023, 5/15/2023, 5/17/2023, & 5/18/2023.

On 5/19/2023 at 10:21 AM, during an interview, the interim Manager of Regulatory Accreditation (MRA) stated the 2 G nursing unit was closed (not in use or occupied) on 5/1/2023, 5/7/2023, and 5/12/2023. MRA confirmed the crash cart in the nursing unit should have been inspected daily (on 5/3/2023, 5/5/2023, 5/6/2023, 5/10/2023, 5/13/2023, 5/15/2023, 5/17/2023, & 5/18/2023) when the unit was in use (unit occupied with patients).

A review of the facility policy and procedures, Crash Cart and Emergency Drug Maintenance, dated 5/22, indicated " ... It is the responsibility of the clinical supervisor/relief charge nurse or his/her designee to check the exterior of the cart/box daily (or within the first four (4) hours of reopening of a closed unit/department) to ensure integrity and readiness of the cart/box and its contents ..."

Based on interview and record review the facility failed to prepare and administer the correct medication as ordered for one (1) of 26 sampled patients (Patient 1). Patient 1, recovering from anesthesia (use of medicines to prevent pain during surgery), had an order for Narcan (treatment to reverse overdose of sedative [sleeping medication]) on. The facility failed as evidenced by:

1. Registered Nurse 2 (RN 2) did not verify the correct drug (Narcan) was removed from the facility's automated medication dispensing device. RN 2 removed Hydralazine (medication to treat high blood pressure) instead.

2. RN 1 did not verify the correct drug was being administered prior to injection of the medication to Patient 1.

The deficient practice resulted to Patient 1 having a code blue (an emergency code system initiated in a hospital when a patient has gone into cardiac or respiratory arrest requiring resuscitation and activation of a hospital-wide alert)

On 5/17/2023 at 2:53 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Chief Medical Officer, Chief Nursing Executive, Chief Operating Officer, Director Patient Safety and Risk Management, Manager Regulatory Accreditation, President and Chief Executive Officer regarding facility's failure to safely prepare and administer medication for Patient 1.

On 5/19/2023 at 2:29 p.m., the IJ was removed after the facility submitted an acceptable IJ removal plan (interventions to correct the deficient practices). During an onsite visit, the surveyors verified the implementations of the IJ removal plan. The IJ was removed in the presence of the facility's Chief Medical Officer, Chief Nursing Executive, Chief Operating Officer, Director Patient Safety and Risk Management, Manager Regulatory Accreditation, President and Chief Executive Officer.

The acceptable IJ removal plan was as follows:

1. On 5/17/2023 just-in-time education regarding 5 Rights of Medication Administration (right patient, right medication, right time right dose, right route, and right documentation) including hand-off provided to all staff responsible for medication administration

2. On 5/17/2023, the process was immediately modified for medication administration in an emergency situation, where the RN retrieving medication (RN 1) from the Omnicell will visually show (e.g., vial with syringe) and verbally communicate the 5 Rights of Medication Administration (a standard for safe medication practices performed by health care professionals involving identification of the right patient, right drug, right time, right dose and right route of administration) to the RN administering the medication (RN 2). Also, post emergency, the verification by the two RNs is now documented on "Emergency Medication Administration," sheet and scanned into the patient's medical record.

3. On 5/17/2023 at 1800 (6:00 p.m.), laminated signage of the 5 Rights of Medication Administration was posted by all Omnicell locations.

4. On 5/17/2023 all present staff educated regarding Omnicell prompts, alarms and the need to immediately respond to prompts and alerts. Unit leaders provided talking points for the subsequent staff huddles regarding 5 Rights of Medication Administration, and Omnicell alarms and prompts.

5. On 5/18/2023, Unit Director or designee started observation of medication administration process to ensure follow through on the five (5) rights of medication administration for 5 randomly selected patients. The facility will continue, per week per unit, observations of medication administration process to ensure nursing staff follow the five (5) rights of medication administration.

6. On 5/18/2023 at 10 a.m., the facility laminated signs of 5 Rights of Medication Administration were updated to include, "DO NOT IGNORE OMNICELL PROMPTS/ ALARMS"

7. On 5/18/2023 17:00 (5 p.m.), the audible volume was increased on all Omnicell in the units (nursing care areas)

8. On 5/18/2023, the process for every NULL Transaction review (e.g., the alarm that occurs when RN walks away from Omnicell during Medication transaction) reported daily, the Pharmacy will contact the Nurse Manager of the respective unit each morning by 10 a.m. to address with staff who did not respond to the alarm when it occurred, utilizing just culture algorithm.

Findings:

A record review of Patient 1's Team Triage Note from the Emergency department (ED) and Patient 1's History and Physical dated 2/14/2023 at 8:50 a.m., Patient 1 arrived in the ED on 2/13/2023 from home after dialysis, for generalized weakness and fatigue. Patient 1 had previously had right great toe amputation with first partial ray resection on 1/6/2023 at facility but reported it was not healing well.

A record review of Patient 1 Procedure Note dated 2/18/2023 at 12:37 p.m., Patient 1 went to the Operating Room (OR) for right foot excisional debridement (removal of infected tissue)) and application of skin allograft (skin applied from a skin/tissue bank donor).

A record review of Patient 1 Rapid Response Team (RRT) activation (A hospital-wide alert where a team of healthcare providers are summoned to the bedside of a patient with signs of imminent clinical deterioration to immediately assess and treat the patient with a goal of preventing escalation to code blue, cardiac arrest or death) and response note dated 2/18/2023 at 17:46 (5:46 p.m.), it is noted that on 2/18/2023 at 13:02 (1:02 p.m.,) Patient 1 had return of spontaneous circulation (ROSC) with vitals as follows: heart rated (HR) 122 beats per minute (normal HR 60 to 100 beats per minute), blood pressure (BP) 108/40 millimeters of mercury (mm Hg) (normal BP 90/60 mmHg to 120/80 mmHg), Oxygen saturation (SpO2, a measurement of how much oxygen blood) at 97 % (percent) (normal SpO2 at 95 % to 100 % on room air). and Patient 1 was intubated (a breathing tube inserted in the mouth to throat and lung for breathing) at 13:08 (1:08 p.m.), transferred to ICU at 1320 (1:20 p.m.) on 2/18/2023.

During an interview and concurrent medical record review, on 5/16/2023 at 11:29 a.m., with Director of Surgical Services (DSS 1) DSS 1 stated, the procedure was successful and lasted 16 minutes. Patient 1 was extubated and transferred to Post Anesthesia Care Unit (PACU-after surgery recovery unit), transported by OR RN 3(RN 3). Patient 1 arrived in the PACU on 2/18/2023 at 12:45 p.m., admitted by PACU RN (RN 1) with the first set of vital signs (a measurement of the body's most basic functions using a patient's body temperature, pulse or heart rate, respiratory rate and blood pressure which medical professionals routinely monitor to detect or monitor medical problems) documented as follows: Blood Pressure (BP): 41/26 mmHg, HR 61 beat per minute, RR 3 breath per minute (normal breathing 12 to 20 breath per minute, SpO2: 8 2% (normal level at 90 % to 100 %) on simple mask (6 L with oral airway.

1. During an interview, on 5/17/2023 at 1:33 p.m., RN 1 stated she received Patient 1 from OR, transported by RN 3, who was due to give RN 1 report however Patient 1 was not waking up from anesthesia (a combination of medication that sometimes bring on a sleep-like state, used to prevent pain during surgery and other invasive procedures). RN 1 and RN 3 were attempting to wake patient and open Patient 1's airway via a "Jaw thrust maneuver," (a treatment procedure used for suspected upper airway obstruction in obtunded or unresponsive patients) without success. RN 1 and RN 3 initiated advanced cardiovascular life support ([ACLS] a set of guidelines used by medical professionals for to treat emergent life-threatening conditions) protocol by bagging Patient 1, notifying the Medical Doctor 1 (MD 1) of the vital signs and non-responsiveness of Patient 1 as well as the RRT activation on 2/18/2023 at 12:48 p.m.

During an interview with Intensive Care Unit Manager (ICUM 1), and concurrent electronic medical record review on 5/18/2023 at 4:02 p.m., Resuscitation Report Text (RRT), dated 2/18/2023 at 12:55 (12:55 p.m.) indicated Patient 1 was in PACU, and vital signs were as follows: HR at 60 beats per minute, RR was 16 respiration per minute, BP: 44/29 mmHg (normal BP 90/60 mmHg to 120/80 mmHg) and SpO2: 91% with a bag valve mask or AMBU bag (a handheld tool used to provide respiratory support to patients) via oral airway. The record indicated, on 2/18/2023 at 12:57 p.m., code blue (an emergency code system initiated in a hospital when a patient has gone into cardiac or respiratory arrest requiring resuscitation and activation of a hospital-wide alert) was called after Hydralazine was administered.

During an interview, on 5/17/2023 at 1:33 p.m., RN 1 stated MD 1 left and came back with medication. MD 1 gave Patient medication for blood pressure. RN 1 stated suggesting giving Patient 1 Narcan (a brand name for Naloxone, a medication given to rapidly reverse or reduce the effects of opioids) as Patient 1 was still unresponsive. MD 1 gave verbal orders to administer Narcan 0.2 milligram (mg, unit of measurement) intravenous push (IVP, medication injected into the vein). RN 1 then asked another PACU RN staff member (RN 2) to pull and prepare the Narcan 0.2 mg IVP. RN 1 was actively preparing to administer Albumin Human (a liquid preparation of albumin derived from large pools of human plasma used to treat low blood volume) intravenous solution as ordered. RN 1 stated the medication (Hydralazine) was prepared by RN 2 who also handed RN 1 the medication vial and syringe. RN 1 stated medication (Hydralazine) was administered.

2. During an interview, on 5/17/2023 at 1:33 p.m., RN 1 stated, RRT was at bedside when MD 1 asked RN 1 how much Narcan was given. RN 1 looked at the medication vial and noted the medication was Hydralazine. RN 1 notified MD 1 and RRT. RN 1 stated MD 1 verified with RN 1 that medication administered was Hydralazine 20 mg IVP instead of Narcan 0.2 mg IVP as ordered.

During an interview, on 5/17/2023 at 1:33 p.m., RN 1 stated they were not sure of the exact time of the medication administration as Hydralazine was administered during an emergency. RN 1 stated the medication (Hydralazine) was pulled from the Omnicell and prepared by RN 2 and then handed to RN 1 to administer.

During an interview, on 5/17/2023 at 12:11 p.m., Manager Regulatory Accreditation (MRA 1), MRA 1 stated none of the registered nurses (RNs) checked the medication vial or scanned the medication vial and Patient 1's armband.

A record review of facility's policy and procedure for Patient Care Services Manual: Medication Administration, reviewed 4/2021, indicated a nurse removes medication from the automated medication dispensing mechanism, scans the patient's barcode on the armband to open the medication administration window, verifying the right of medication. The policy and procedure indicated after verification of the medication and the patient; patient teaching was done. The nurses again verify the rights of medication administration (right patient, right medication, right time right dose, right route, and right documentation).

Based on observations, interviews, and record reviews, the facility failed to ensure safe handling of patients' personal medications brought to the hospital for ten (10) out of twenty-four (24) bags containing Patients' personal medications that included Patient 13 and Patient 14. Patient 13 and Patient 14's personal medications were unsealed, without a list of content, and/or signatures (required as per policy), and were not return to Patient 13 and Patient 14's personal medications upon discharged.

This deficient practice had the potential for patient personal medications brought to the hospital being tampered and or lost.

Findings:

On 5/17/2023 at 11:50 AM, during an observation in the pharmacy department with the Director of Pharmacy (DOP) and the Director of Patient Safety and Risk Management (PSRM), the facility's narcotic room had a long countertop one the left side of the room. The narcotic room's long countertop had two blue bins filled with gray plastic bags.

On 5/17/2023 at 11:50 AM, during an interview, DOP stated those gray plastic bags were tamper-proof plastic bags containing Patients' personal medication (including Patient 13 and Patient 14) received from nursing units. DOP stated nurses would drop off patients' personal medications (including Patient 13 and Patient 14) and pharmacist would verify and log the contents.

On 5/17/2023 at 12 PM, DOP counted and confirmed there were 24 bags containing patient personal medications (including Patient 13 and Patient 14) in the blue bins. DOP confirmed ten (10) out of twenty-four (24) bags were unsealed, without the medication names listed, and or signatures on the outside. DOP stated two (2) of 10 bags belongs to Patients 13 and 14.

On 5/17/2023 at 2 PM during an interview, the interim manager of Regulatory Accreditation (MRA) stated confirmed both patients (13 & 14) had been discharged. At 3:14 PM, MRA stated there were no record that both patients (Patient 13 and Patient 14) or their family had been contacted regarding their personal medication that were left behind.

A review of the facility policy and procedures, Patient's personal medications brought to the hospital, dated 6/22), indicated " ...All medications brought to the hospital by the patient are to be sent home or stored in the pharmacy. These medications are kept in a tamper proof security bag with patient's name label and contents listed ... The medications will be placed in the tamper proof security bag ... with the names of the medications listed on the outside ... As the bag is sealed, the patient and the nurse will sign and date on the bag to verify the bags contents ... When a patient is to be discharged, the sealed medication bag shall be obtained from the pharmacy by the nursing staff ... Upon verifying the appropriate documentation on the sealed bag, ... The bag will not be received or picked up and the charge nurse will be informed if signatures are missing, medication names are not listed on the front of the bag, or the bags are not properly sealed. The bag will be recorded ... and stored in the pharmacy ..."

Based on interview and record review, the facility failed to evaluate and document one (1) of three (3) sampled patients (Patient 1) during sedation/anesthesia administration every five minutes according to facility's policy and procedure. Patient 1's last recorded assessment in the operating room was, on 2/18/2023, at 12:35 p.m., and Patient 1's sedation was stopped on 2/18/2023, at 12:46 p.m. (11 minutes).

The deficient practice resulted in Patient 1 arriving in the Post Anesthesia Care Unit (PACU) not arousable with low blood pressure (BP) and low respiratory rate (RR), on 2/18/2023, at 12:45 p.m. and Patient 1 had to receive Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure when the heart stop beating), on 2/18/2023, at 12:55 p.m.

Findings:

A review of Patient 1's Team Triage Note from the Emergency department (ED) and Patient 1's History and Physical, dated 2/14/2023, at 8:50 a.m., indicated Patient 1 arrived in the ED on 2/13/2023 from home after dialysis, for generalized weakness and fatigue. Patient 1 previously had right great toe amputation with first partial ray resection (a procedure used to help salvage the foot and maintain bipedal ambulation) on 1/6/2023 at facility but reported it was not healing well.

A review of Patient 1's Procedure Note, dated 2/18/2023 at 12:37 p.m., indicated Patient 1 went to the Operating Room (OR) for right foot excisional debridement (removal of infected tissue) and application of skin allograft (skin applied from a skin/tissue bank donor).

A review of Patient 1's Flow Sheet record (nursing documentation record) completed by RN 1 (PACU RN), dated 2/18/2023 at 12:45 p.m. indicated Patient 1 was received from the operating room (OR). RN 1 documented Patient 1 was unarousable (difficult to awake up) and O2 (Oxygen) saturation (the amount of oxygen in the body) was 82 % (percentage out zero [0] % to 100 %) (normal level 90 % to 100 %). Patient 1 was on 10 liter (L, unit of measurement for oxygen) O2 with heart rate (HR) 61 beats per minute (bpm, normal level 60 to 100 beats per minute), BP) 41/26 millimeter of mercury (mmHg, unit of measurement) (normal BP level between 90/60 mmHg to 120/80 mmHg), and RR was 3 breaths per minute (normal level 12 to 20 breaths per minute).

A record review of Patient 1's NHF (Nasal High Flow) Anesthesia Record completed by MD 1, dated 2/18/23, at 12:46 p.m. indicated Patient 1's anesthesia was stopped, and Patient 1 was transferred to PACU. Patient 1 had a face mask at 6 L O2 when report was given to PACU nurse. Patient 1's BP was 108/58 millimeter of mercury (mmHg, normal level between 90/60 mmHg to 120/80 mmHg), heart rate (HR) 69 beats per minute (bpm, normal level 60 to 100 beats per minute), O2 saturation at 96 %, and respiratory rate (RR) 16 breaths per minute (normal level 12 to 20 breaths per minute). The record indicated Patient 1's post operative (after surgery) status was awake and stable. Patient 1's transport to PACU was uneventful. No documentation noted from 2/18/2023 after 12:35 p.m. until 12:46 p.m. while Patient 1 was still under anesthesia care (11 minutes).

A record review of Patient 1's Anesthesia Documentation Record, dated 2/18/2023 at 12:55 p.m., indicated under Critical Event/Rapid Response Team (RRT) Progress Note, completed by Medical Doctor 1 (MD 1) indicated, Patient 1 transferred to PACU, Patient 1 had "Hypotension (low blood pressure) on arrival was treated with Ephedrine (medication used to increase BP) 15 milligram (mg, unit of measurement) times (x) two (2)". RN made error and gave 20 mg of Hydralazine (medication to low blood pressure) instead of Narcan (medication to reverse sedation)". ... " Patient was pulseless (no heartbeat) and code blue called, chest compression, and epinephrine 1 mg x 2 doses give return of spontaneous circulation (ROSC) obtained ... Patient intubated and transferred to intensive care unit (ICU, area where patient require critical medical care) in stable condition."

A review of Patient 1's Cardiopulmonary Resuscitation Report (CPR, emergency life-saving procedure when the heart stop beating), dated 2/18/2023 at 12:55 p.m. indicated condition of Patient 1's status post (S/P) anesthesia was, "Not awaking," and chest compressions was started at 12:57 p.m. Patient 1 was intubated at 1:09 p.m.

A review of Patient 1's Anesthesia Documentation record, dated 2/18/2023 at 12:55 p.m., indicated under Post anesthesia Evaluation, completed by MD 1, Patient 1's anesthesia end time on 2/18/23 was 12:46 p.m. Patient 1's vital signs (V/S, clinical measurement that indicate body's most basic function that includes Temperature, BP, RR, HR, and O2 saturation) on 2/18 23 at 1:45 p.m., included respiratory endotracheal tube (ETT, tube inserted thru the mouth into the throat to the lung to assist with breathing), ventilator (machine that act to help with breathing), blood BP 120/46 mmHg, HR 115 bpm. Patient 1 was sedated. The record also indicated, "RRT/Code Blue called in PACU; Patient resuscitated and transferred to ICU. Discharge from anesthesia care."

On 5/18/2023 at 2:10 p.m., during a concurrent interview with MD 1, Chief Medical Officer (CMO), Manager of Regulatory Accreditation (MRA) and record review of Patient 1's NHF (Nasal High Flow) Anesthesia Record, MD 1, CMO, and MRA reviewed and verified Patient 1's NHF Anesthesia Record, dated 2/18/23, completed by MD 1 which indicated Patient 1 was intubated (tube inserted thru the mouth into the throat to the lung to assist with breathing) on 2/18/2023 at 11:58 a.m. Patient 1's surgery was started, on 2/18/2023 at 12:11 p.m., ended at 12:27 p.m. (procedure was 16 minutes), and at 12:34 p.m. Patient 1 was suctioned and was extubated (tube for breathing was removed). On 2/18/2023 at 12:35 p.m., Patient 1 was placed on a face mask with 6 L. MD 1 stated Patient 1 was stable and was spontaneously breathing (able to breath by self) on face mask with 6 L of oxygen and saturated at 99%. MD 1 indicated Patient 1 was transported by MD I and Circulation Registered Nurse (RN) to PACU.

On 5/18/2023 at 2:10 p.m., during a concurrent interview with MD 1, CMO, MRA and record review of Patient 1's NHF Anesthesia Record, MD 1, CMO, and MRA reviewed and verified Patient 1's NHF Anesthesia Record completed by MD 1, dated 2/18/23, which indicated that at 12:46 p.m. Patient 1's anesthesia was stopped, and Patient 1 was transferred to PACU. Patient 1 had a face mask at 6 L when report was given to PACU nurse. Patient 1's BP was 108/58 mmHg, HR 69, O2 saturation at 96 %, and RR 16 breaths per minute. The record indicated Patient 1's post operative (after surgery) status was awake and stable. Patient 1's transport to PACU was uneventful.

A review of the facility's policy and procedure (P&P) titled, "Procedural Sedation, Management of Acute Care," dated 6/27/2018, indicated under Post procedure Recovery and Discharge, was included, "Monitoring of physiological statue during sedation/anesthesia administration to include blood pressure, pulse, respiration, oxygen saturation, end tidal carbon dioxide (CO2, how effectively CO2 is removed from the body and evaluation of Sedation Scales indicated by Richmond Agitation Sedation Scale (RASS, a score patient's sedation level, zero (0) alert and calm to minus 5 (unarousable). The documentation policy was, "Every 5 minutes." The policy and procedure indicated general anesthesia was, "A drug induced loss of consciousness during which patients are not arousable even by painful stimulation note reflex withdrawal may occur patients may experience a partial or complete loss of protective reflexes and the ability to independently maintain ventilatory function is often impaired." The policy and procedure indicated Patients often require assistance in maintaining a patent airway and positive pressure ventilation may be required," because of depressed spontaneous ventilation or drug induced depression of neuromuscular (nerve and muscle) function, and cardiovascular (heart and blood vessel) function may be impaired.