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Based on observation, interview and record review, the Governing Body did not fulfill its responsibilities in the conduct of the hospital as an institution. The following deficient practices were identified:

1. The hospital failed to meet the Condition of Participation for Quality Assessment and Performance Improvement Program which failed to maintain an effective assessment and improvement of the hospital's organization and services. (Refer to A-0263)

2. The hospital failed to ensure the quality of patient medical care through enforcement of the facility medical staff bylaws and hospital policies. (Refer to A-0049, A-0353 and A-0359)

3. The hospital failed to meet the Condition of Participation for Nursing Services, by failing to ensure that the nursing services were organized and that the delivery of nursing care was supervised. (Refer to A-0385 and A-0397)

The cumulative effect of these systemic problems resulted in the potential for patient harm in a universe of 71 patients.

Based on observation, interview and record review, the hospital's Governing Body failed to hold the facility Medical Staff accountable for adhering to approved and accepted hospital policies and procedures and for the care provided to 3 of 6 sampled patients as evidenced by the following:

1. Failure to supply complete treatment orders for 1 of 6 sampled patients (Patient 6) for an intravenous (within the vein) medication intended to increase blood pressure (Levophed).

2. Failure to complete and document a comprehensive and updated patient physical examination for 2 of 6 sampled patients (Patient's 1 and 4) prior to an invasive procedure (any surgical or exploratory activity in which the body is pierced by a device, instrument or by manual digitation) being performed.

These deficient practices had the potential to contribute to negative health outcomes and increase the risk of harm for those patients affected as well as for a universe of 71 patients.

Findings:

1. A record review of Patient 6 was conducted on March 27, 2013 at 10:15 AM. Patient 6 was transported to the Emergency Department (ED) via ambulance on March 27, 2013 at 1:40 AM with a diagnosis of exacerbation (worsening) of Chronic Obstructive Pulmonary Disease (a lung disease that causes difficulty breathing). At 2:45 AM, Patient 6's nursing documentation at 3 AM indicated that Patient 6 coded (required resuscitation/restoration of life), the patient was placed on mechanical ventilation (a machine used to provide an artifical means of breathing) and physician orders read to admit to the Intensive Care Unit (ICU).

A telephone order obtained by Registered Nurse (RN) 2, dated March 27, 2013 at 4 AM for Patient 6 read, "Levophed drip (a continuous infusion of medication into the vein), titrate to keep systolic blood pressure (the pressure exerted within the blood vessels when the heart contracts) greater than or equal to 120." The physician order did not contain complete orders or instructions specifying the start rate or titration instructions (a process used to increase or decrease a medication that is specific to a patient's response to the medication) for the Levophed. The order also did not include instructions for the nurses as to when to turn off or hold the Levophed.

An observation was made on March 27, 2013 at 10:30 AM of Patient 6. The patient was in the ICU, both eyes were closed, was on mechanical ventilation, was on a Levophed drip and had a Foley catheter in place (a tube inserted to relieve the bladder of urine).

An interview was conducted on March 27, 2013 at 10:30 AM with RN 3 (Patient 6's ICU RN). She stated that she did not know when she was supposed to turn off the Levophed drip because there were no orders for that but that if the blood pressure dropped too much, she would increase the rate that the medication was given and that if the blood pressure increased too much, she would decrease the rate that the medication was given. RN 3 also stated that she did not have specific titration orders and "I just titrate according to my judgment. It's a nursing judgment." RN 3 was asked by the surveyor how she felt about titrating the medication and she stated, "I don't feel good about it but that's how the doctors write the orders."

An interview was conducted on April 2, 2013 at 9 AM with RN 2 (the RN who obtained the initial order dated March 27, 2013 at 4 AM for the Levophed). RN 2 stated that she obtained the telephone order for the Levophed and started the medication at 10 micrograms per minute then increased it to 15 micrograms. RN 2 stated that she had recently been in-serviced by the hospital staff and understood that the initial order she received from the physician on March 27, 2013 at 4 AM was not a complete order. RN 2 stated that the physicians did not provide a start rate or titration orders, they only provided the blood pressure parameter. RN 2 also stated that the nurses titrated differently and it depended on a patient's response to the medication.

A record review on April 2, 2013 at 2:40 PM was conducted of the hospital policy titled, Medication Administration, revised on 10/11", it read in part, "...Titrating orders are initiated (started) by the physician and monitored by the nurse..."




28066

2a. A record review was conducted on March 26, 2013 at 10:54 AM, of Patient 1's clinical record. The review revealed that the patient was admitted on March 26, 2013 at 1:35 AM with the diagnosis of repeat cesarean section (c-section; the surgical removal of a live baby from the mother's body). According to the "Operating Room Progress Note," Patient 1 had undergone a scheduled repeat c-section on March 26, 2013 at 6:30 AM.

A further record review of Patient 1's clinical record and a concurrent interview was conducted on March 26, 2013 at 3:15 PM, with RN 7. The RN stated that there was no updated examination of Patient 1 completed by the MD prior to the surgery and that there was no physician's documentation on a "History & Physical Short Form" in the medical record.

During an additional record review of Patient 1's clinical record and a concurrent interview, on March 27, 2013 at 9:15 AM, with the Director of Maternal Child, she verified that there was no physician's documentation on a "History & Physical Form" in the clinical record. The Director of Maternal Child located a handwritten "Physician's Progress Note" in Patient 1's medical record. The handwritten note was illegible, had no date and time recorded and the Director of Maternal Child was unable to read the information.

b. A record review was conducted on March 26, 2013 at 3:00 PM, of Patient 4's clinical record. The record noted that the patient was admitted on March 26, 2013 at 6:39 AM with the diagnosis of pregnancy/induction of labor (the artificial initiation of childbirth). Patient 4 underwent a scheduled epidural anesthesia (the injection of a numbing medicine into the space around the spinal nerves in the lower back, the medicine numbs the area below the point of injection and allows the patient to remain awake during the delivery of the baby) and delivered the baby at 2:30 PM.

During an interview conducted on March 26, 2013 at 3:30 PM, with RN 8, she stated that there was no updated examination of Patient 4 completed by the physician prior to the epidural anesthesia procedure and there was no physician's documentation on a "History & Physical Short Form" in the medical record. RN 8 stated that she was informed to use the prenatal examination record when the History and Physical was not completed. A concurrent review of Patient 4's clinical record noted that the last prenatal exam was on March 22, 2013.

During an interview, on March 27, 2013 at 9:15 AM with the Director of Maternal Child, she stated that the prenatal examination record may be used if the prenatal exam was completed within 30 days of the procedure and when the History & Physical Short Form had not been completed.

A record review, on March 27, 2013, of the hospital's "Medical Staff Bylaws and General Rules & Regulations of Medical Staff, revised on 12/6/11", noted the following: "...All medical record entries shall be dated, timed and authenticated...When performing surgery or any potentially hazardous diagnostic procedure and the History & Physical is not recorded in the chart, the procedure will be cancelled unless the attending physician states in writing "such delay would be detrimental to the patient." If so, the case shall be deemed an emergency case and the physician must provide a brief admission note in the chart that includes the heart rate, respiratory rate, and blood pressure. If the History & Physical has been dictated but is not recorded in the chart, the attending physician must document that he/she has dictated the History & Physical and the dictation must be verified with the Health Information Management Department. Once the dictation has been verified and prior to surgery or any potentially hazardous diagnostic procedure, the attending physician must document in the chart, the patient's history, all positive physical findings and the admitting diagnosis."

Based on observation, interview and record review, the Hospital failed to ensure that an effective quality assessment and performance improvement program of the hospital's organization and services was maintained when the Hospital failed to ensure the following:

1. Ensure that the hospital had an ongoing quality appraisal and performance improvement program that included tracking and trending of findings and integrated interdisciplinary efforts to address deficient practices and effectively implement changes to improve patient quality of care. (Refer to A-0273)

2. Ensure that ED (Emergency Department) and ICU (Intensive Care Unit) Registered Nurses were competent and had the specialized qualifications and/or training prior to assigning Registered Nurses to specialized units. (Refer to A-0397)

3. Ensure that all Intensive Care Unit (ICU) Registered Nurses (RNs) and Emergency Department RNs administered intravenous (IV) vasopressor medications (medications to increase blood pressure) to patients in a safe manner and with proper guidance. (Refer to A-0405)

4. Ensure that all physicians provided complete orders for an intravenous medication intended to increase patients' blood pressure (Levophed) and failed to ensure that the Medical Staff enforced and adhered to the hospital policies, creating the risk of substandard medication administration and poor health outcomes for 1 of 6 sampled patients (Patient 6) for whom incomplete orders were written. (Refer to A-0353)

The cumulative effect of these systemic problems resulted in the hospital being unable to provide safe and effective patient care in a safe setting for a universe of 71 patients.

Based on interview and record review, the Quality Assurance (QA) program did not monitor the system that allowed Registered Nurses (RN) to administer IV (intravenous - within the vein) vasopressor medications to patients without established physician protocols and allowing RN's to select starting doses and titration rates, creating the risk of substandard medication administration and the potential for poor health outcomes for patients receiving intravenous medications via those order sets.

Findings:

During an observation on March 27, 2013 at 10:30 AM of Patient 6 in the Intensive Care Unit (ICU), the patient was observed to be on mechanical ventilation, receiving the intravenous medication Levophed (a medication used for blood pressure control) drip (a continuous infusion of medication into the vein), and had a Foley catheter in place (a tube inserted to relieve the bladder of urine).


An interview was conducted on March 27, 2013 at 10:30 AM with the Registered Nurse (RN 3) who was caring for Patient 6. RN 3 stated that she did not know when she was supposed to turn off the Levophed drip because there were no physician's orders regarding turning off the medication. RN 3 stated that if Patient 6's blood pressure dropped too much that she would increase the medication dose and if the patient's blood pressure increased too much she would decrease the medication. RN 3 also stated that she did not have physician orders specific to the titration (the process of adding medication in carefully measured amounts until a definite and known reaction is completed) of the Levophed Drip and she stated "I just titrate according to my judgment. It's a nursing judgment". RN 3 was asked by the surveyor how she felt about titrating the medication without specific physician orders, she stated, "I don't feel good about it but that's how the doctors write the orders". RN 3 was not familiar with any hospital policy or guidelines regarding Levophed.

On March 27, 2013 at 4:30 PM, an interview and a concurrent record review of the Performance Improvement quality assurance data was conducted with the Director of Quality and Case Management (DQCM) and the Director of Nursing for the Intensive Care Unit (ICU).


The DQCM stated that she had established performance indicators, based on the findings of the December 18, 2012 Validation Survey.


The DQCM stated that the QA program planned to conduct daily monitoring of all patients that received the medication Levophed, intravenously, to ensure that the nursing staff titrated the medication under the guidance of complete physician orders.


The DQCM stated that the QA program had planned to conduct daily monitoring of all patients that received the medication Versed (a drug that causes relaxation and sleepiness), intravenously, to ensure that nursing staff initiated the medication with a physician's complete order.


The DQCM stated that the monitoring from December 2012 to March 27, 2013 was not conducted for the oversight of patients who received Levophed intravenous medication and monitoring was not conducted for patients who received Versed intravenous medication. The DQCM stated that the daily monitoring had not been done because no current staff member had been assigned to the task of monitoring the performance indicators.

The DQCM further stated that the QA program had not reviewed any of the established performance indicators to be monitored as noted in the February 22, 2013 Statement of Deficiencies plan of correction. The DQCM stated that she had no documentation to indicate that the QA program had conducted the tracking and trending of the established performance indicators.


A record review, on March 28, 2013, of the facility's Quality and Risk Management Scope of Service, dated 10/11, noted, "...The intent of the Quality and Risk Management Department...is to coordinate the entire Quality and Risk Management program. This is done by systematically and objectively designing, measuring, assessing and improving the quality and outcomes of patient care and the services/systems that support high quality care to all of our customers ....There is a planned, systematic, organization-wide approach to performance improvement, which is collaborative and interdisciplinary. It is necessary to use a variety of information sources to formulate plans about a new service, extend an existing service, or develop meaningful information. Data is then aggregated and analyzed to be able to draw conclusions about the performance of a process of the nature of an outcome. Objectives are identified to create or improve the quality of services based upon the collected data and feedback from those that deliver and receive the services....When an opportunity for improvement is identified, actions are determined and accountabilities are established and documented. Action is determined based on analysis of the source of the problem. Evaluation of effectiveness of actions taken is attained through follow-up measures and achieving and sustaining improvements....".


16613

Based on observation, interview and record review, the hospital failed to ensure the quality of patient medical care through enforcement of the hospital policies and medical staff bylaws.

1. The hospital failed to ensure that physicians supplied complete orders for intravenous (within the vein) blood pressure medications. (Refer to A-0353 and A-0405)

2. The hospital failed to ensure that physicians documented a complete history and physical before all invasive procedures. (Refer to A-0359)

The cumulative result of these deficient practices meant that the hospital did not organize the medical staff to operate under the medical staff bylaws in order to provide quality patient medical care to a universe of 71 patients in the hospital.

Based on observation, interview and record review, the hospital's Medical Staff failed to ensure that all physicians supplied complete orders for an intravenous medication intended to increase patients' blood pressure (Levophed) and the hospital failed to ensure that the Medical Staff enforced and adhered to the hospital policies, creating the risk of substandard medication administration and poor health outcomes for 1 of 6 sampled patients (Patient 6) for whom incomplete medication orders were written for.

Findings:

A record review of Patient 6 was conducted on March 27, 2013 at 10:15 AM. Patient 6 was transported to the Emergency Department (ED) via ambulance on March 27, 2013 at 1:40 AM with a diagnosis of exacerbation (worsening) of Chronic Obstructive Pulmonary Disease (a lung disease that causes difficulty breathing). At 2:45 AM, Patient 6's nursing documentation at 3 AM indicated that Patient 6 coded (required resuscitation/restoration of life), the patient was placed on mechanical ventilation (a machine used to provide an artifical means of breathing) and physician orders read to admit to the Intensive Care Unit (ICU).

A telephone order obtained by Registered Nurse (RN) 2, dated March 27, 2013 at 4 AM for Patient 6 read, "Levophed drip (a continuous infusion of medication into the vein), titrate to keep systolic blood pressure (the pressure exerted within the blood vessels when the heart contracts) greater than or equal to 120." The telephone order did not contain complete orders or instructions specifying the start rate or titration instructions (a process used to increase or decrease a medication that is specific to a patient's response to the medication) for the Levophed. The order also did not include instructions for the nurses as to when to turn off or hold the Levophed.

An observation was made on March 27, 2013 at 10:30 AM of Patient 6. The patient was in the ICU, both eyes were closed, was on mechanical ventilation, was on a Levophed drip and had a Foley catheter in place (a tube inserted to relieve the bladder of urine).

An interview was conducted on March 27, 2013 at 10:30 AM with RN 3 (Patient 6's ICU RN). She stated that she did not know when she was supposed to turn off the Levophed drip because there were no orders for that but that if the blood pressure dropped too much, she would increase the rate that the medication was given and that if the blood pressure increased too much, she would decrease the rate that the medication was given. RN 3 also stated that she did not have specific titration orders and "I just titrate according to my judgment. It's a nursing judgment." RN 3 was asked by the surveyor how she felt about titrating the medication and she stated, "I don't feel good about it but that's how the doctors write the orders."

An interview was conducted on April 2, 2013 at 9 AM with RN 2 (the RN who obtained the initial order dated March 27, 2013 at 4 AM for the Levophed). RN 2 stated that she obtained the telephone order for the Levophed and initiated the medication at 10 micrograms per minute then increased it to 15 micrograms. RN 2 stated that she had recently been in-serviced by the hospital staff and understood that the initial order she received from the physician on March 27, 2013 at 4 AM was not a complete order. RN 2 stated that the physicians did not provide a start rate or titration orders, they only provided the blood pressure parameter. RN 2 also stated that the nurses titrated differently and it depended on a patient's response to the medication.

A record review on April 2, 2013 at 2:40 PM was conducted of the hospital policy titled, Medication Administration, revised on 10/11", it read in part, "...Titrating orders are initiated by the physician and monitored by the nurse..."

Based on interview and record review, the hospital failed to ensure that the attending physician completed and documented a complete and updated patient physical examination for 2 of 6 sampled patients (Patient's 1 and 4) prior to an invasive procedure (any surgical or exploratory activity in which the body is pierced by a device, instrument or by manual digitation). This failure had the potential to contribute to negative outcomes for those patients.

Findings:

1. A record review was conducted on March 26, 2013 at 10:54 AM, of Patient 1's clinical record. The review revealed that the patient was admitted on March 26, 2013 at 1:35 AM with the diagnosis of repeat cesarean section (c-section; the surgical removal of a live baby from the mother's body). According to the "Operating Room Progress Note," Patient 1 had undergone a scheduled repeat c-section on March 26, 2013 at 6:30 AM.

A further record review of Patient 1's clinical record and a concurrent interview was conducted on March 26, 2013 at 3:15 PM, with Registered Nurse (RN) 7. The RN stated that there was no updated examination of Patient 1 completed by the physician prior to the surgery and that there was no physician's documentation on a "History & Physical Short Form" in the medical record.

During an additional record review of Patient 1's clinical record and a concurrent interview, on March 27, 2013 at 9:15 AM, with the Director of Maternal Child, she verified that there was no physician's documentation on a "History & Physical Form" in the clinical record. The Director of Maternal Child located a handwritten "Physician's Progress Note" in Patient 1's medical record. The handwritten note was illegible, had no date and time recorded and the Director of Maternal Child was unable to read the information.

2. A record review was conducted on March 26, 2013 at 3:00 PM, of Patient 4's clinical record. The record noted that the patient was admitted on March 26, 2013 at 6:39 AM with the diagnosis of pregnancy/induction of labor (the artificial initiation of childbirth). Patient 4 underwent a scheduled epidural anesthesia (the injection of a numbing medicine into the space around the spinal nerves in the lower back, the medicine numbs the area below the point of injection and allows the patient to remain awake during the delivery of the baby) and delivered the baby at 2:30 PM.

During an interview conducted on March 26, 2013 at 3:30 PM, with RN 8, she stated that there was no updated examination of Patient 4 completed by the physician prior to the epidural anesthesia procedure and there was no physician's documentation on a "History & Physical Short Form" (H&P) in the medical record. RN 8 stated that she was informed to use the prenatal examination record when the H&P was not completed. A concurrent review of Patient 4's clinical record noted that the last prenatal exam was on March 22, 2013.

During an interview, on March 27, 2013 at 9:15 AM with the Director of Maternal Child, she stated that the prenatal examination record may be used if the prenatal exam was completed within 30 days of the procedure and when the short form H&P had not been completed.

A record review, on March 27, 2013, of the hospital's "Medical Staff Bylaws and General Rules & Regulations of Medical Staff, revised on 12/6/11", noted the following: "...All medical record entries shall be dated, timed and authenticated...When performing surgery or any potentially hazardous diagnostic procedure and the History & Physical is not recorded in the chart, the procedure will be cancelled unless the attending physician states in writing "such delay would be detrimental to the patient." If so, the case shall be deemed an emergency case and the physician must provide a brief admission note in the chart that includes the heart rate, respiratory rate, and blood pressure. If the History & Physical has been dictated but is not recorded in the chart, the attending physician must document that he/she has dictated the History & Physical and the dictation must be verified with the Health Information Management Department. Once the dictation has been verified and prior to surgery or any potentially hazardous diagnostic procedure, the attending physician must document in the chart, the patient's history, all positive physical findings and the admitting diagnosis."


28020

Based on observation, interview and record review, the hospital failed to ensure that the Nursing Services were organized and that the delivery of nursing care was supervised.

Nursing Services failed to:

1. Ensure that all Intensive Care Unit (ICU) Registered Nurses (RNs) and Emergency Department RNs administered intravenous (IV) vasopressor medications (medications to increase blood pressure) to patients in a safe manner and with proper guidance (Refer to A-0405).

2. Ensure that ED (Emergency Department) and ICU (Intensive Care Unit)Registered Nurses were competent and had the specialized qualifications and/or training prior to assigning Registered Nurses to specialized units (Refer to A-0397).

The cumulative effect of these systemic problems resulted in the Nursing Department's inability to ensure the provision of quality health care in a safe environment for a universe of 71 patients.

Based on interview and record review, the facility failed to ensure that ED (Emergency Department) and ICU (Intensive Care Unit) Registered Nurses (RNs) were competent and had the specialized qualifications and/or training prior to assigning an ED RN to care for 1 of 6 sampled patients (Patient 6) who required specialized care from RNs in the ICU.

This failure had the potential to contribute to poor patient outcomes and contribute to the potential of the patient not being appropriately cared for by staff in the ICU.

Findings:

1. A record review of Patient 6 was conducted on March 27, 2013 at 10:15 AM. Patient 6 was transported to the ED via ambulance on March 27, 2013 at 1:40 AM with a diagnosis of exacerbation (worsening) of Chronic Obstructive Pulmonary Disease (a lung disease that causes difficulty breathing). At 2:45 AM, Patient 6's oxygen saturations dropped to 86% (this is the amount of the total oxygen carrying capacity fulfilled by the blood; the normal value typically is greater than 91%). At 3 AM, nursing documentation indicated that Patient 6 coded (required resuscitation/restoration of life), the patient was placed on mechanical ventilation (a machine used to provide a means of artificial ventilation) and physician orders read to admit to the ICU. Patient 6 remained in the ED under the care of an ED nurse (RN 2) until a bed was available in the ICU at approximately 6:15 AM.

An interview was conducted on March 27, 2013 at approximately 11:20 AM with the ED Director. He stated that the ED RNs did not have ICU competencies. The only competencies that they required to have were for the ED.

A record review of RN 2's employee file was reviewed on March 27, 2013 at 3:45 PM. RN 2's job description indicated that she was an ED RN and received ED competencies. However there was no documented evidence that ICU competencies were provided by the hospital for RN 2.

2. Further record review was conducted on March 27, 2013 at 3:45 PM, of two additional ED RNs (RNs 5 and 6), who also provided nursing care to ICU patients in the ED until beds were available in the ICU. RN 5's and RN 6's job descriptions indicated that both RNs were hired as ED RNs and both did not have ICU competencies.

An interview was conducted on April 2, 2013 at 9 AM with RN 2 (the ED RN who cared for Patient 6, an ICU patient). She stated that she was hired to work in the ED and that she did not have any ICU specific competencies. Additionally, she stated, "I guess it makes sense that we should have ICU competencies if we're taking care of ICU patients."

Based on staff interview and facility record review, the hospital failed to ensure that all Levophed vasopressor intravenous medication drips (a medication used to treat low blood pressure) in the Emergency Department (ED) and Intensive Care Unit (ICU) were initiated/started and titrated (adjusted) according to a physician's specific orders and according to approved hospital-wide titration policies for 1 of 6 sampled patients (Patient 6).

This same deficient practice was reported during the facility's December 18, 2012 sample validation survey, under the Condition of Participation for Nursing Services (A-0385, finding #5).

This failure had the potential for unsafe dosages being administered affecting the health and safety of Patient 6 and those patients in the ICU or the ED who required Levophed.

Findings:

A record review of Patient 6 was conducted on March 27, 2013 at 10:15 AM. Patient 6 was transported to the ED via ambulance on March 27, 2013 at 1:40 AM with a diagnosis of exacerbation of Chronic Obstructive Pulmonary Disease (lung disease that causes difficulty breathing). At 2:45 AM, Patient 6's 3 AM nursing documentation indicated that Patient 6 coded (required resuscitation/restoration of life), the patient was placed on mechanical ventilation (a machine used to provide a means of artificial ventilation) and physician orders read to admit to the ICU.

A physician telephone order obtained by Registered Nurse (RN) 2, dated March 27, 2013 at 4 AM for Patient 6 read, "Levophed drip (a continuous infusion of medication into the vein), titrate to keep systolic blood pressure (the pressure exerted within the blood vessels when the heart contracts) greater than or equal to 120." The physician order did not contain complete orders or instructions specifying the start rate of drug administration or titration instructions (a process used to increase or decrease a medication that is specific to a patient's response to the medication) for the Levophed. The order also did not include instructions for the nurses as to when to turn off the Levophed.

An interview was conducted on March 27, 2013 at 10:30 AM with RN 3 (Patient 6 ICU RN). She stated that she did not know when she was supposed to turn off the Levophed drip because there were no orders for that but that if the blood pressure dropped too much she would increase the medication given and if the blood pressure increased too much she would decrease the medication given. RN 3 also stated that she did not have specific titration orders and stated "I just titrate according to my judgment. It's a nursing judgment." RN 3 was asked by the surveyor how she felt about titrating the medication and she stated, "I don't feel good about it but that's how the doctors write the orders." RN 3 was not familiar with any hospital policy or guidelines regarding Levophed.

An interview was conducted on April 2, 2013 at 9 AM with RN 2 (the RN who obtained the initial order for the Levophed on March 27, 2013 at 4 AM). RN 2 stated that she obtained the telephone order for the Levophed on March 27, 2013 at 4 AM and initiated the medication at 10 micrograms per minute then increased it to 15 micrograms. RN 2 stated that she was recently in-serviced by the hospital staff and understood that the order she received from the physician was not a complete order. RN 2 stated that the physicians did not provide a start rate or titration orders, they only provided the blood pressure parameters. RN 2 stated that the nurses titrated differently and it depended on a patient's response to the medication.

A record review was conducted on April 2, 2013 at 2:40 PM of the hospital policy and procedure titled: "MEDICATION ADMINISTRATION, revised on October 2011." The policy stipulated in section 7 (b): "Medication orders must have the following elements:

a. Exact strength and/or concentration.
b. Exact dose, frequency and route.
c. Quantity and duration.
d. Specific instructions for use ..."

A record review was conducted on March 27, 2013 of the Hospital's policy and procedure, on titled, "INTRAVENOUS MEDICATION POLICY revised on 2/13." The policy revealed the following information regarding Levophed Drips:
Standard Dilution: 8 milligrams (a unit of mass or weight equal to one thousandth of a gram) in 250 milliliters (a unit of volume equal to one thousandth of a liter) of 5 % Dextrose and water (an intravenous [IV] solution) - peripheral ...
Initial Rate: up to 8-12 Micrograms/minute. (micrograms: a unit of mass or weight equal to one millionth of a gram.)
Usual Titration: Increments of 0.02 micrograms/kilogram/minute (or more in emergency cases) - to desired hemodynamic response (relating to the circulation of blood in the body) (usually SPB 80-100. Systolic blood pressure: the pressure exerted within the blood vessels when the heart contracts).
Maintenance Rate: 2-4 Micrograms/minute up to 47 micrograms/minute may be required.

The hospital's policy guidelines for Levophed provided an initiation range; however, a Registered Nurse must use their judgment as to what the starting dose rate would be.

An interview was conducted on March 27, 2013 at 12 PM with the hospital's Medical Director, who reviewed the hospital's policy for "Intravenous Medication" which addressed Levophed. He stated that the policy needed to be revised because the initial rate is in a range format. The Medical Director stated that nurses required parameters which included as to when the medication was to be turned off. Additionally, he stated that the nurses should not use their judgment because it was not a safe practice.



26502

Based on observation, interview and record review, the hospital failed to ensure that all patient medical records were kept confidential and secured to prevent unauthorized individuals from accessing the records. This failure had the potential for unauthorized individuals to access patient personal health information for a universe of 71 patients.

Findings:

During a tour of the hospital's pediatric unit and accompanied by Registered Nurse (RN) 1, on March 26, 2013 at 11:40 AM, an observation was made of an unlocked soiled utility room located near the nurses' station. The soiled utility room contained a bin with dimensions approximately 2.5 feet by 2 feet. The bin was overfilled with various copies of patients' personal health information such as patient names, medical record numbers, patient diagnoses and physician orders among other information.

During an interview with RN 1, on March 26, 2013 at 11:40 AM, she stated that their unit's "shred it box" was taken from them about 2 months ago and placed in another department. She also stated that their current practice was to wait until the bin was full and then a certified nurse assistant would carry the bin out of the pediatric unit and into another unit to dispose of the patient records. RN 1 stated that the housekeeping staff had access to the unlocked soiled utility room.

A record review was conducted on April 2, 2013 at 1:30 PM of the hospital policy titled, "Destruction of Paper Personal Health Information." The policy documented the following, "Protected Health Information (PHI) - PHI refers to individually identifiable health information that is transmitted or maintained in any form (including written, verbal or electronic) which is protected under federal regulations. Examples include the patient's name and other demographic information, medical records, ..." The policy also instructed staff to maintain and secure records which contain PHI in a secure and locked area.

28020


Based on observation, interview and record review, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs were not available for patient use. In the hospital's Medical Surgical Unit's medication room, there were eight (8) cans of Dermoplast Spray (pain relieving spray), three (3) of which contained labels with patient names. All 8 cans did not contain expiration or manufacturer dates and the medications were available for patient use. This failure had the potential to increase the risk of adverse reactions to patients who received the Dermoplast Spray in a universe of 71 patients.

Findings:

During a tour of the Surgical Unit, on March 26, 2013 at 11:10 AM, 8 cans of Dermoplast Spray were found in the medication room. All 8 cans contained no expiration or manufacturer dates (3 of the cans were labeled with patient names).

During an interview with the Medical Surgical Director, on March 26, 2013 at 11:10 AM, she stated that she could not find the expiration on the cans and that they should be labeled with expiration dates.

During an interview with the Director of Maternal Child/Neonatal Intensive Care Units, on March 26, 2013 at 11:15 AM, she stated that she could not find the expiration dates on the cans and that they should have at least been labeled with the manufacturer dates. The Director stated that the cans were single dose and used only on the patient which it was ordered for. Additionally, she stated "But we just see if it's yucky and we don't use them." The Director of Maternal Child stated that she did not know how long the 8 cans of Dermoplast had been in the medication room and pharmacy told her that they have never had a date on the cans or the box that they were packaged in.

A record review was conducted on April 2, 2013 at 1:30 PM, of the hospital policy titled, "Medication Labeling, revised on 10/11." The policy documented the following, "It is the policy of ... (hospital's name) to ensure all drug labels are legible and in compliance with state and federal requirements." The policy informed staff to ensure that medications used for patients included an expiration date.