HospitalInspections.org

Based on review of facility policies and procedures, review of facility documents, and interviews with staff (EMP), it was determined the facility failed to ensure the QAPI program involved the review of specific quality indicators for all hospital services including laboratory, dietary, pharmaceutical services, cardiac catheterization, wound care, radiation oncology, and respiratory therapy.

Findings include:

Review on June 26, 2018, of the facility policy, "Performance Improvement Program", dated May 2017, revealed "Scope The comprehensive organization-wide Performance Improvement Program includes Medical Staff and Hospital departments ... IV. Responsibility The Board of Trustees shall be responsible for ensuring the provision of quality care and patient safety and for organization-wide performance improvement."

Review on June 26, 2018, of the facility documents, "Quality Steering Committee Minutes", from June 2017 through June 2018, revealed no documented evidence of the ongoing monitoring, review, and analysis of specific performance indicators and/or data elements for laboratory, dietary, pharmaceutical, cardiac catheterization, wound care, radiation oncology, and respiratory therapy services.

Interview with EMP5 and EMP6, on June 26, 2018, at 12:20 PM, confirmed there was no documented evidence of the ongoing monitoring, review, and analysis of specific performance indicators and/or data elements for laboratory, dietary, pharmaceutical, cardiac catheterization, wound care, radiation oncology, and respiratory therapy services.

Based on review of facility policy and procedures, review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure approved procedures were followed for the labeling of two or more intravenous infusions that resulted in a medication event for 1 of 1 medical records reviewed. (MR1)

Findings include:

Review on June 25, 2018, of facility policy "Tubing Identification-#1206" reviewed January 2018, revealed "Objective: To outline the process of when and how tubing should be labled in order to reduce the risk of errors. Policy: 1. For 2 or more continuous intravenous infusions, all IV tubing will be labled with the corresponding IV (intravenous) solution or medication name. a. ... each IV line should be physically traced from the solution or medication to the patient [insertion site] to validate that the correct solution or medication name is on the tubing. This is also done with each new infusion, bag change, and tubing change. b. Place a preprinted medication label or peice of tape with the IV solution/medication written on it at the connection end closet to patient ... 4. It is the responsibility of the person who inserts or assists with the insertion of a tube to label the tube ..."

Review on June 25, 2018, of MR1 nursing documentation "Medication Detail" revealed "fentanyl/Sodium Choloride 2,000 mcg 100 mls @ 3.75 mls/hour IV. Start May 15, 2018, 9:35 AM."

Review on June 25, 2018, of MR1 physician documentation "Physians Orders" revealed "May 15, 2018, 10:05 AM: 1 liter of LR (Lactaed Ringers) wide open now."

Interview on June 26, 2018, at 10:00 AM with EMP1 confirmed the patient had multiple IV lines at the time they started the fentanyl infusion and did not recall if they labeled the fentanyl infusion bag and tubing at the point of insertion. Further interview with EMP1 confirmed EMP2 was in the room assisting in the care of the patient.

Interview on June 26, 2018, at 11:15 AM with EMP2 confirmed they discontinued the fentanyl infusion when the patient's blood pressure became to low. EMP2 confirmed they did not remove the fentayl tubing from the pump after disconnecting the tubing from the patient connection site. EMP2 confirmed they notified the physician and the physician ordered 1 liter Lactated Ringers IV solution 'wide open' to raise the patient's blood pressure. EMP2 confirmed EMP5 assisted with preparing and administering the Lactated Ringers IV solution. Further interview with EMP2 confirmed the term 'wide-open' means to run IV solution on a pump at 999.99 mls per hour.

Interview on June 27, 2018 at 10:30 AM with EMP3 confirmed they interviewed the nursing staff caring for the patient at the time of the event and EMP5 confirmed they prepared and administered the Lactated Ringers IV and did not trace the IV lines back to the IV bag (fentanyl infusion or Lactated Ringers) and programmed the pump that contained the fentanyl infusion to 999.99 mls per hour. EMP5 then connected the fentanyl infusion bag to the patient and started the pump.