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Based on interview and record review, the facility failed to develop a current individualized nursing care plan that included treatment goals, patient tolerance level to the medication, individualized infusion rates, interventions, possible side effects, and patient needs/preferences for 3 of 5 sampled patients (Patients 5, 6, and 7) receiving intravenous immune globulin (IVIG, blood product containing antibodies extracted from human plasma, to treat autoimmune diseases).

Findings:

IVIG is a blood product manufactured from large pools of human plasma. Tolerance and infusion rates differ from one patient to another. Slower infusion rates diminish rate-related symptoms such as headaches, chills, blood pressure alterations, etc. Some patients require pretreatment with antihistamines (medication to treat itching), anti-inflammatories or corticosteroids (steroids to treat rashes, inflammation) particularly if they have a history of reaction. The manufacturer's warning indicates thrombosis (blood clots) may occur with IVIG products. Risk factors may include advanced age, prolonged immobilization, history of venous or arterial thrombosis, cardiovascular (relating to heart and blood vessels) risk factors, etc. (Full Prescribing Information for Immune Globulin, 9/2013.)

Patient 5 was an elderly patient who had been receiving IVIG 15 grams every 4 weeks at the hospital infusion center for hypogammaglobulinemia (a primary immune deficiency disease).

On 1/8/14 at 10 a.m., a review of Patient 5's medical record reflected there was no individualized nursing care plan for the IVIG use that included the treatment goals, patient drug tolerance level, individualized infusion rates, potential risk factors, and patient needs/preferences.

Patient 6 was an elderly patient who had been receiving IVIG 102 grams (a high dose) for idiopathic thrombocytopenic purpura (an auto-immune disease) from the infusion center. Due to kidney problems, he had a physician order to pre-hydrate with normal saline prior to the IVIG infusion. He also had a history of deep vein thrombosis (blood clot that forms in the vein) and pulmonary embolism (sudden blockage of an artery in the lung).

On 1/8/14 at 10:30 a.m., a review of Patient 6's medical record reflected no current individualized nursing care plan developed for the IVIG use that included patient treatment goals, drug tolerance level, IVIG infusion rates, pretreatment requirements, concomitant medical conditions that would be affected by IVIG, and possible reactions.

Patient 7 was an elderly patient who had been receiving IVIG 30 grams on a monthly basis at the infusion center for hypogammaglobulinemia. On 1/18/14 at 11:05 a.m., a review of his medical record showed there was no current individualized care plan developed for the IVIG therapy.

On 1/8/14 at 11:25 a.m., the infusion center manager stated there should be an individualized nursing care plan addressing treatment goals, tolerance level, infusion rates, and individual needs for each patient receiving IVIG. After reviewing the patients' medical records, the manager verified there were no current care plans developed for Patients 5, 6, and 7.

The hospital policy and procedures on "Interdisciplinary Patient Care Plan Guidelines," dated 9/2011, indicated:

"1. An individualized INTER DISCIPLINARY care plan will be developed for each patient within 24 hours of admission... The plan of care is based on patient needs identified by the patient's assessment, reassessment and results of diagnostic testing.
2. An individualized, patient-specific care plan with goals and interventions will be initiated for each patient in coordination with the patient's medical plan of care and individual patient/family needs..."

Based on observation, interview, and record review, the facility staff failed to administer medications in accordance with the physician's orders for 2 of 5 patients (Patients 3 and 11) observed during medication passes.

Findings:

1. On 1/7/14 at 10:55 a.m. at the infusion center with registered nurse (RN) A, Patient 3 was observed in a patient chair receiving an infusion of an intravenous (IV, through the vein) immune globulin 10% (IVIG, blood product containing antibodies extracted from human plasma, to treat autoimmune diseases) via an infusion pump (a delivery device). At the same time, Patient 3 was also receiving a hydration infusion from a 1-liter bag of D5/NS (5% dextrose in normal saline; a solution for hydration) on a separate IV line.

A review of Patient 3's medical record on 1/7/14 indicated the patient was to receive, per physician order, normal saline (0.9% sodium chloride, a salt solution for hydration), not D5/NS, concurrently with his IVIG for hydration.

On 1/7/14 at 11:25 a.m., RN A stated he had administered the wrong IV hydration solution, as it was supposed to be normal saline, not D5/NS. A review of the medication administration record reflected RN A administered the D5/NS to Patient 3 without scanning the bag to ensure it was the correct solution.

The hospital policy and procedure on "Medication Administration - Documentation and Storage," dated 11/2013, indicated: "To maintain patient safety, all medications and IV fluids with and without additives MUST be scanned, prepared and administered at the patient bedside."



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2. During an observation on 1/8/14 at 10 a.m. in the Telemetry Care Unit with registered nurse (RN) B, Patient 11 was in bed. RN B removed from a medicine cart an insulin pen (a device which injects a pre-set amount of insulin, a medication to control blood sugar). RN B scanned the insulin pen with the bar code reader. RN B stated the bar code on the insulin pen did not scan as it was supposed to, due to the time being later than when the insulin was ordered. RN B checked the dose she was going to give Patient 11 with another staff person, and then gave Patient 11 five units of the insulin by subcutaneous injection to the abdomen with the pen.

A review of Patient 11's medical record on 1/8/14 indicated the patient was to receive, per physician order, five units of Insulin Humalog mix 75/25 twice a day before meals. The ordered start time was 7:30 a.m.

On 1/8/14 at 10:50 a.m. RN B stated she was not sure what time Patient 11 had eaten his morning meal, but it was probably before 9:30 a.m. RN B stated she realized Patient 11's insulin was supposed to be administered before a meal. RN B stated she administered the insulin later than the ordered time.

The hospital policy and procedure on "Medication Administration - Documentation and Storage," dated 11/2013, indicated medications were to be administered at the prescribed time/frequency.