HospitalInspections.org

Based on record review and interview, the CAH failed to report and accurately identify errors in drug administration as evidenced by:

1) failing to have a system in place to accurately identify 14 medication errors in the hospital for 5 (#1, #3, #5, #8, #11) of 11 current patients.

2) failing to ensure documentation of medical errors, including notification to the practitioner, was in patients' medical records for 2 (#R1, #R2) of 2 patients reviewed with hospital discovered medical errors.

Findings:

1) Failing to have a system in place to accurately identify medication errors in the hospital.

Review of a list of medical errors provided by the hospital revealed 2 medication errors had been identified in 2016. Both of the errors were identified for Patient #R3 on 1/5/16 and 1/11/16.

Review of current patients' medical records on 2/8/16 revealed 14 medical errors in 5 patients' medical records (#1, #3, #5, #8, #11) not identified by the hospital.

In an interview on 2/10/16 at 10:00 a.m. with S10Pharmacist, she said she did not document medical errors, close calls or near misses discovered by the pharmacy. She also said the only system used by the hospital to identify medication errors was self-reporting by the staff. S10Pharmacist verified no retrospective review was performed of the medical records to capture medication errors.


2) Failing to ensure documentation of medical errors, including notification to the practitioner, was in patients' medical records.

Review of the hospital policy and procedure titled Reporting of Medication Errors, Policy Number 6-F, revealed in part:
A. All medication errors identified will be reported immediately upon detection to the attending physician and documented via "physician notification" task on the EMR (electronic medical record), with the appropriate indicated action taken.

Review of the hospital policy and procedure titled Medication Administration, revealed in part:
K. Medication errors and potential drug reactions shall be reported immediately to the patient's physician.
L. Medications and treatment omitted and the reason for omission, are to be documented in the electronic medical record. Those requiring special observation of the patient, are charted on the Nurse's Notes.

Review of known medication errors by the hospital revealed the following:
Patient #R1
Review of a physician's order for Patient #R1 dated 11/9/15 at 6:36 p.m. revealed an order for Norco 5mg/325 mg tablet x one dose. Review of the medication administration record revealed the dose had not been given to the patient. Further review revealed no documented evidence of the medication error or physician notification in the medical record.

Patient #R2
Review of the physician's order for Patient #R2 dated 8/5/15 at 10:54 a.m. revealed an order for Norco 7.5/325 mg tablet x one dose. Review of the medication administration record revealed the dose had not been given to the patient. Further review revealed no documented evidence of the medication error or physician notification in the medical record.

In an interview on 2/10/16 at 2:15 p.m. with S1Administrator, she verified the above referenced identified medical errors should have been documented in the patients' medical records.













30984

30984

Based on record review and interview, the CAH failed to ensure all drugs and biologicals were administered by, or under, the supervision of a registered nurse, in accordance with written and signed orders. This deficient practice was evidenced by failure of the nursing staff to administer sliding scale insulin and PRN antihypertensives as ordered by the patients' physician/ independent licensed practitioner for 7 (#1, #3, #5, #7,#8, #10, #11) of 11 current inpatient records reviewed.

Findings:


Review of the CAH policy titled Medication Administration, effective date: 2/2016, revealed in part: I. Purpose : To safely administer prescribed medications.
D. The five rights ensure safety in giving medications and treatments.
K. Medication Errors and Potential Drug reactions shall be reported immediately to the patient's physician.
L. Medications and treatments omitted and the reason for omission, are to be documented in the electronic medical record. Those requiring special observation of the patient, are charted on the nurses' notes.


Patient #1
Review of a physician's order for Patient #1 dated 2/6/16 revealed an order for Clonidine 0.1 mg oral tab, qid prn Hypertension Systolic Blood Pressure greater than 160 mm/Hg or Diastolic Blood Pressure greater than100 mm/Hg.

Review of documented blood pressures for Patient #1 revealed:
2/6/16 at 7:00 a.m. - 185/76
2/6/16 at 3:00 p.m. - 170/73
2/6/16 at 7:43 p.m. - 166/51
2/7/16 at 3:56 a.m. - 188/71
Review of the MAR for Patient #1 revealed no documentation that Clonidine had been administered as ordered.

The findings for Patient #1 were verified by S4LPN.

Patient #3

Review of the medical record for Patient #3 revealed a physician's order dated 1/16/16 at 10:36 a.m. for the following sliding scale insulin:
Insulin Lispro injection as needed for:
Administer 3 units subcutaneously for blood glucose 150-200.
Administer 6 units subcutaneously for blood glucose 201-250
Administer 9 units subcutaneously for blood glucose 251-300

Review of the medical record for Patient #3 revealed the following documentation:
1/16/16 at 11:00 a.m. - 2 units of insulin was administered for a BG of 192. (3 units ordered). 1/16/16 at 4:00 p.m. - 0 units given for BG of 177 (3 units ordered).
1/19/16 at 11:57 a.m. - 0 units given for BG of 158 (3 units ordered).
1/22/16- 4:48 p.m. - 4 units given for BG of 246 (6 units ordered).
1/29/16 at 9:20 p.m. - 2 units given for BG of 182 (3 units ordered).
2/2/16 at 8:08 a.m. - 0 units given for BG of 177 (3 units ordered).

The findings for Patient #3 were verified by S4LPN.

Patient #5

Review of the medical record for Patient #5 revealed an order dated 1/31/16 at 10:02 a.m. for Lopressor 1mg IV q3 hour prn for Hypertension, systolic blood pressure greater than 165 or diastolic blood pressure greater than 95.

Review of the medical record for Patient #5 revealed a documented blood pressure of 145/96 on 1/31/16 at 7:30 p.m. Further review revealed no documented administration of Lopressor.

The findings for Patient #5 were verified by S4LPN.


Patient #7

Review of Patient #7's EMR revealed an admission date of 12/26/15 with a diagnosis of Diabetes Mellitus Type II (Insulin Dependent). Further review revealed the patient was receiving insulin per sliding scale.

Review of the ordered insulin sliding scale for Patient #7 revealed coverage for a capillary blood glucose reading of 327 was 8 units of Insulin Lispro (capillary blood glucose 301-350= 8 units of Insulin Lispro subcutaneous injection as directed PRN for blood glucose).

Review of Patient #7's medication administration record revealed in part:
12/27/15 4:00 a.m.: capillary blood glucose 327; 10 units of insulin administered. Review of the ordered sliding scale for Patient #7 revealed he should have received 8 units of insulin. Further review revealed no documented evidence of a reason for administering 10 units of insulin instead of the ordered 8 units.

12/27/15 5:00 a.m.: capillary blood glucose 378. Further review revealed no documented evidence of administration of sliding scale insulin for the above referenced capillary blood glucose reading and no comment explaining why coverage was not administered.

In an interview on 2/8/16 at 3:00 p.m. with S3RN, he confirmed Patient #7 should have received 8 units of insulin per sliding scale and not the 10 units he received for the 327 capillary blood glucose reading referenced above. S3RN also confirmed there was no documented explanation for administration of insulin coverage outside of the ordered sliding scale. S3RN further confirmed there was no documented evidence explaining the lack of administration of sliding scale coverage for the above referenced capillary blood glucose reading of 378. He agreed an explanation should have been documented in the patient's EMR.

Patient #8

Review of the medical record for Patient #8 revealed a physician's order dated 1/14/16 at 3:14 p.m. for the following sliding scale insulin:
Insulin Lispro injection as needed for:
Administer 2 units subcutaneously for blood glucose 150-200.
Administer 4 units subcutaneously for blood glucose 201-250

Review of the medical record for Patient #8 revealed the following documentation:
1/18/16 at 5:00 p.m. - 0 units of insulin was administered for a BG of 210. (4 units ordered).
1/26/16 at 11:00 a.m. - 0 units of insulin was administered for a BG of 150. (2 units ordered).

The findings for Patient #8 were verified by S4LPN.

Patient #10

Review of Patient #10's EMR revealed an admission date of 12/18/15 with a diagnosis of Diabetes Mellitus Type II (Insulin Dependent). Further review revealed the patient was receiving insulin per sliding scale.

Review of the ordered insulin sliding scale for Patient #10 revealed coverage for a capillary blood glucose reading of 317 was 12 units of Insulin Lispro (capillary blood glucose 301-350 = 12 units of Insulin Lispro subcutaneous injection as directed PRN for blood glucose).

Review of Patient #10's medication administration record revealed the following:
12/19/15 12:25 p.m.: capillary blood glucose 317. Further review revealed no documented evidence of administration of sliding scale insulin for the above referenced capillary blood glucose reading and no comment explaining why coverage was not administered.

In an interview on 2/8/16 at 3:20 p.m. with S3RN, he confirmed there was no documented evidence explaining the lack of administration of sliding scale coverage for the above referenced capillary blood glucose reading of 317. He agreed an explanation should have been documented in the patient's EMR.

Patient #11
Review of the physician's order for Patient #11 dated 2/2/16 revealed if BG less than 45, and IV access, give 25ml D50W IV push. If no IV access available, 1mg Glucagon IM and 15 gm fast acting carbohydrates. Notify treating physician for further orders.

Review of the medical record for Patient #11 revealed a blood glucose of 43 on 2/6/16 at 4:45 p.m. There was no documentation of physician notification or intervention with D50W or Glucagon.

The findings for Patient #11 were verified by S4LPN.

Based on record review and interview, the CAH failed to ensure the nursing staff developed and kept current a nursing care plan for each patient. This deficient practice was evidenced by failure to individualize the patients' nursing care plans to include all of the patients' medical diagnoses for for 4 (#2, #5, #7,#10) of 11 ( #1-#11) sampled current inpatients' medical records reviewed for a nursing care plan.

Findings:

Patient #2
Review of the EMR for Patient #2 (with S3RN) revealed an admission date of 2/5/16 with diagnoses including Diabetes Mellitus Type II (Insulin Dependent) and Schizophrenia. Further review revealed the patient had been transferred to the CAH from an inpatient psychiatric facility.

Review of the plan of care for Patient #2 revealed no documented evidence that Diabetes Mellitus Type II (Insulin Dependent) and Schizophrenia had been included in Patient #2's plan of care.

In an interview on 02/8/16 at 3:00 p.m. with S3RN, he confirmed Diabetes Mellitus Type II (Insulin Dependent) and Schizophrenia had not been included in Patient #2's plan of care. He further confirmed the above referenced diagnoses should have been included as problems on the patient's plan of care.

Patient # 5
Review of a list of current patients in contact isolation for MRSA infections included Patient #5.
Review of the medical record for Patient #5 revealed he did not have a nursing care plan for the problem of MRSA infection and contact isolation.


Patient #7

Review of the EMR for Patient #7 (with S3RN) revealed an admission date of 12/26/15 with diagnoses including Diabetes Mellitus Type II (Insulin Dependent) and positive cultures for MRSA. Further review revealed the patient was currently on contact isolation for MRSA.

Review of the plan of care for Patient #7 revealed no documented evidence that Diabetes Mellitus Type II (Insulin Dependent), Actual infection (+ MRSA cultures) and Contact Isolation had been included in Patient #7's plan of care.

In an interview on 02/8/16 at 3:20 p.m. with S3RN, he confirmed Diabetes Mellitus Type II (Insulin Dependent), Actual infection (+ MRSA cultures) and Contact Isolation had not been included in Patient #7's plan of care. He further confirmed the above referenced diagnoses should have been included as problems on the patient's plan of care.

Patient #10
Review of the EMR for Patient #10 (with S3RN) revealed an admission date of 12/18/15 with diagnoses including Diabetes Mellitus Type II (Insulin Dependent) and positive cultures for MRSA. Further review revealed the patient was currently on contact isolation for MRSA.

Review of the plan of care for Patient #10 revealed no documented evidence that Diabetes Mellitus Type II (Insulin Dependent), Actual infection (+ MRSA cultures) and Contact Isolation had been included in Patient #10's plan of care.

In an interview on 02/8/16 at 3:25 p.m. with S3RN, he confirmed Diabetes Mellitus Type II (Insulin Dependent), Actual infection (+ MRSA cultures) and Contact Isolation had not been included in Patient #10's plan of care. He further confirmed the above referenced diagnoses should have been included as problems on the patient's plan of care.

Based on record review, interview and observation, the CAH failed to meet the Conditions of Participation for Clinical Records as evidenced by failing to ensure an effective system was in place to assure the confidentiality of personal health information contained in the patient's medical record. This is evidenced by the CAH failing to have safeguards in place to prevent employees from separately licensed and certified hospitals from accessing personal health information contained in the patient's medical record. (See findings at C-0308)

Based on record review, observation and interview, the CAH failed to ensure an effective system was in place to assure the confidentiality of personal health information contained in the patient's medical record. This is evidenced by the CAH failing to have safeguards in place to prevent employees from separately licensed and certified hospitals from accessing personal health information contained in the patient's medical record.

Findings:

Review of the hospital's document titled Notice of Privacy Practices revealed in part:
SMH is dedicated to maintaining the privacy of your Identifiable Health Information. In conducting our business, we will create records regarding you and the treatment of services we provide to you.

In an interview on 2/8/16 at 10:30 a.m. with S4LPN, she said she could access any medical record for any of the 3 other hospitals owned by Hospital "A" that used the same electronic medical records system. S4LPN indicated there were no safeguards to prevent her from accessing the medical records of patients hospitalized at the other hospitals and there were no safeguards in place to prevent employees of the other hospitals from accessing the medical records of patients hospitalized at St Martin Hospital.

In an interview on 2/10/16 at 12:40 p.m. with S11MedicalRecords, she said St. Martin Hospital was owned by Hospital "A". She said Hospital "A" also owned Hospital "B" and Hospital "C". S11MedicalRecords verified all four hospitals had different provider numbers. S11MedicalRecords also said all 4 hospitals used the same medical records documentation system. S11MedicalRecords said any employee at the hospital with an access to use the computer system could access any patients' medical record at any of the 4 hospitals. She verified there was no firewall to prevent unauthorized access of medical records between the hospitals.

In an interview on 2/10/16 at 1:10 p.m. with S1Administrator, she verified staff members at St. Martin Hospital, Hospital "A", Hospital "B" and Hospital "C" could access medical records of any patient at any of the 4 hospitals even if there was no medical necessity. S1Administrator verified the staff member accessing the medical records at another hospital would have to enter their title and a reason for viewing the medical record, but then access was granted.

In an observation on 2/11/16 at 9:10 a.m., S18RN logged onto a computer at St. Martin Hospital and accessed the census of the fourth floor at Hospital "A". S18RN randomly selected a patient from the census and after entering her job title and typing in a reason for accessing the record, she was then able to view the patient's entire medical record. S18RN verified Hospital "A" , Hospital "B" and Hospital "C" could also access the patients' medical records at St. Martin Hospital using the same procedure. S18RN verified any comment could be manually typed in for the reason the user was accessing the medical record and it would not preclude entry into the medical record.

Based on quality assurance program review, contract review and interview, the CAH failed to ensure the hospital wide quality assurance program evaluated the quality and appropriateness of all patient care services and other services affecting patient health and safety. This deficient practice was evidenced by failure of the CAH to include evaluation of all patient care services and other services affecting patient health/safety, including those services provided through contractual agreement, in the hospital wide quality assurance program.

Findings:

Review of the CAH's 2016 Performance Improvement Plan, presented by S12VPQuality as current, revealed in part: II. Purpose of Plan: The performance improvement plan describes the systematic, organization wide, process that is used to improve the quality and safety of care that is provided to the internal and external customers we serve at this hospital. The objectives of this plan are as follows: 1. To improve the quality of patient care through assessment and evaluation of the functions, processes and outcomes, utilizing identified measures of performances. 2. Aggregate the results of metrics of performance to analyze the results using statistical tools and techniques to identify trends and patterns that do not meet standards, expectations and/or desirable outcomes set forth by hospital leadership. 3. Communicate performance improvement activities, findings, actions and the effectiveness of improvement strategies by establishing specific reporting formats for performance improvement and subsequently to leadership and the governing body per policy and regulatory standards. 6. Evaluate the quality of services provided by outside contract services by requiring regular performance measurement reports from those services. 7. Develop performance indicators for critical and high risk, problem prone areas.

Review of the CAH's QAPI program documentation revealed the following departments and services had no documented performance improvement focus areas in the hospital wide QAPI program: Respiratory Care Services (related to provision of patient respiratory care/services), Stericycle (contracted biohazardous waste disposal), Blood Bank Services (contracted), resolution of complaints/grievances, Telemetry (related to patient monitoring), Outpatient services and Rehabilitation services.

In an interview on 2/11/16 at 1:00 p.m. with S12VPQuality, she confirmed, after review of the QAPI program documentation presented as current, that the above referenced departments/services had no identified performance improvement focus areas in the hospital wide QAPI program.

Based on record review and interview, the CAH failed to accurately evaluate medication therapy in the hospital wide quality assurance program report. This deficient practice was evidenced by the CAH failing to have a system in place to accurately identify, track and evaluate medication errors through the hospital wide quality assurance program.

Findings:

Review of the CAH's 2016 Performance Improvement Plan, presented by S12VPQuality as current, revealed in part:
II. Purpose of Plan: The performance improvement plan describes the systematic, organization wide, process that is used to improve the quality and safety of care that is provided to the internal and external customers we serve at this hospital. The objectives of this plan are as follows: 1. To improve the quality of patient care through assessment and evaluation of the functions, processes and outcomes, utilizing identified measures of performances. 2. Aggregate the results of metrics of performance to analyze the results using statistical tools and techniques to identify trends and patterns that do not meet standards, expectations and/or desirable outcomes set forth by hospital leadership. 3. Communicate performance improvement activities, findings, actions and the effectiveness of improvement strategies by establishing specific reporting formats for performance improvement and subsequently to leadership and the governing body per policy and regulatory standards. 6. Evaluate the quality of services provided by outside contract services by requiring regular performance measurement reports from those services. 7. Develop performance indicators for critical and high risk, problem prone areas.

Review of a list of medical errors provided by the hospital revealed 2 medication errors had been identified in 2016. Both of the errors were identified for Patient #R3 on 1/5/16 and 1/11/16.

Review of current patients' medical records on 2/8/16 revealed 14 medical errors in 5 patients' medical records (#1, #3, #5, #8, #11) not identified by the hospital.

Review of the QAPI program documentation revealed no documented evidence that near miss and close call medical errors were tracked through the hospital wide QAPI program.

In an interview on 2/10/16 at 10:00 a.m. with S10Pharmacist, she said she did not document medical errors, close calls or near misses discovered by the pharmacy. She also said the only system used by the hospital to identify medication errors was self-reporting by the staff. S10Pharmacist verified no retrospective review was performed of the medical records to capture medication errors.

In an interview on 2/11/16 at 1:00 p.m. with S12VPQuality, she agreed self reporting as the only means of capturing medication errors was inadequate based upon the findings referenced above. S12VPQuality also agreed near miss and close call medication errors should have been included in QAPI.