HospitalInspections.org

Based on interview, medical records, and the facility's Policies, the facility failed to ensure Patients right to care when:

a.) A 3-year-old infant did not receive the physician ordered Intravenous Fluids and Respiratory breathing treatments, placing the patient at risk of worsening condition and death.
b.) The facility's Pharmacist did not provide a physician ordered consult to assist in the sedation of a patient, possibly resulting in the patient being over-sedated and experiencing seizure-like symptoms.

Findings include:

a.) Review of Patient#2's medical record reflected a 3-year-old, admitted on 10/1/20, with a diagnosis of Rhinovirus.

Review of Patient #2's physician's orders dated 10/1/20, reflected, Albuterol 1 vial via nebulizer q3hrs + CPT (Chest physiotherapy treatment helps break up excess mucus in kids) pre and post.
Pulmicort 1 vial via nebulizer BID + CPT pre and post.

Review of Patient #2's electronic administration records reflected the breathing treatments and the IVFs had not been initiated during the admission.

On 5/11/21, during a telephone conversation, Patient #2's mother stated, "I asked the nurse when my baby was going to get the breathing treatment? She said the respiratory was in a code ...I waited 5 hours, I finally had to take my baby home to get the breathing treatment."

Review of the facility provided Patient's Rights and Responsibilities Policy dated (4/17/18) reflected, "POLICY:
It is the policy of The Hospitals of Providence Memorial Campus to respect the patient's rightsto treatment and service subject to the hosp ital's capability, mission, and applicable regulations Conditions of Participation 42 CFR 482.13."

During an interview, on the afternoon of 5/18/21, in the facility board room, Staff #1, Respiratory Director stated, "When the Respiratory therapist starts their shift, they get a list of what treatments are ordered." When asked how the Respiratory therapist gets informed of new admits during the shift, Staff #1 stated, "The nursing staff will call the Therapist, the therapist doesn't have the computer with them, they can't keep looking at the computer to check for orders."

During an interview, on the afternoon of 5/18/21, in the facility board room, Staff #5, DON stated, "Respiratory should be getting orders like nursing does; it should be flashing until they fill the order. Nursing only calls them for STAT orders ..."

b.) Review of Patient #3's medical records reflected a 97-year-old female admitted on with a diagnosis of Covid 19.

Review of Patient #3's physician's progress note, dated 8/10/2020 at 4:49 pm reflected, "Patient continues to have issues requiring sedatives and pain killers. I have initiated a consult with pharmacy to help coordinate with consult liaison for medication management to help patient with anxiety related issues ...Plan: Continue mechanical ventilation ...feeding by NG tube ..."

Review of Patient #3's Physician's orders dated 8/12/20 reflected, "Haldol 2 mg IM (Intramuscular Injection) BID for agitation."

Review of Patient #3's Electronic Medication Administration Record reflected Haldol 5mg (milligram) IM (Intramuscular injection) was given on:
8/12/20 at 2:54 pm and 8:33 pm.
8/13/20 at 8:20 am, 3:25 pm, and 10:05 pm.

Review of Patient #3's Progress note dated 08/27/2020 reflected,
"CHIEF COMPLAINT: "seizure like activity"
SUBJECTIVE: code RRT was called this am around 09:45 due to seizure like activity. Per nurse she was working with PT and had low saturations was placed back in bed and increased oxygen demand was noted. she was placed on 4L from 3 Liters where she maintained above 92%. Soon after RN noticed shaking of arms and rolling of eyes. she gave Ativan for seizure like activity, most consistent with extrapyramidal reaction from Haldol. Family at bedside stated she became more hypoxic. Shakiness in bed noted not to resemble seizures. Pt remains awake, responsive, interactive with noted trembling of arms. will order labs at this time and reconsult dr. will be transfer to ICU for close observation of increase o2 demand and r/o seizures."

During an interview, on the afternoon of 5/18/21, Staff #3, MD, Pharmacy director was unable to determine why pharmacy did not provide a consultation for the agitation. When asked if Haldol is a medication used for agitation due to being on a ventilator, Staff #3 stated, "It's given for severe agitation ...Haldol is a strong medication and a patient can have TDK (Tardive Dyskinesia, a neurological disorder presenting with tremors and repetitive motions) symptoms."

Review of Patient#3's Nursing notes reflects the patient experienced "seizure like activity." The Haldol was discontinued and the patient was transferred to the ICU. Further record review did not reflect Patient #3 as having displayed agitated behavior.