HospitalInspections.org

Based on observations, interviews and records reviewed for two of ten sampled patients (Patients #1 & #9) the Hospital's Quality Assessment Performance Improvement activities failed to identify that Nursing Staff were not clamping (closing) intravenous tubing according to manufacturer direction and implement immediate corrective action(s) after Patient #1's adverse patient event; and failed to report to CMS a patient death (Patient #9) in restraint.

Findings included:

1.) Nurses Note, dated 5/30/17 at 7:19 P.M., indicated Patient #1's adverse event of 5/24/17. The Nurses Note indicated Patient #1 received an unknown amount of intravenous Fentanyl (powerful narcotic) while discontinuing the intravenous infusion.

The intravenous tubing packing titled Continu-Flo Solution Set, undated, indicated directions to close the regulating clamp until the roller met the bottom frame.

The document titled Infusion System, dated 2015, indicated direction for unloading (discontinuing) an intravenous infusion was when the roller (regulator) clamp was in the closed position.

The Surveyor interviewed Registered Nurse (RN) #2, at 10:00 A.M. on 7/27/17. RN #2 said that nursing practice for closing the regulating clamp was not a consistent nursing practice. RN #2 said that some nurses use the regulating clamp and others use the slide clamp (another clamp connected to the intravenous tubing).

The Surveyor interviewed and observed, at 10:30 A.M. on 7/27/17, RN #3. RN #3 said nurses administered intravenous constant infusions of cardiovascular, narcotic, and insulin medications in the Intensive Care Unit. At 10:30 A.M. on 7/27/17, the Surveyor observed that RN #3 did not close the regulating clamp until the roller met the bottom frame.

The Surveyor interviewed the Quality and Patient Safety Director at 11:50 A.M. and 1:00 P.M. on 7/26/17. The Quality and Patient Safety Director said the Hospital's internal investigation, dated 6/20/17, included the finding that the roller (regulating) clamp was not engaged (clamped closed). The Quality and Patient Safety Director said the Hospital was still working on the corrective action plan (one month after Patient #1's adverse patient event and one month after the Hospital discovered that RN #1 did not properly close the regulating clamp). The Quality and Patient Safety Director said that the Nursing Safety Alert (re-education regarding proper closure of intravenous tubing regulating clamp) was not distributed until today, 7/26/17 (the day of the Survey).

The Surveyor interviewed the Quality and Patient Safety Director and Senior Risk Manager #1 at 9:00 A.M. on 7/27/17. The Quality and Patient Safety Director and Senior Risk Manager said that the Hospital's internal investigation did not analyze if Intensive Care Units, Medical Surgical Units, Operating Rooms and the Emergency Department administered intravenous constant infusion medications.

The document titled, Infusion Locations, undated, indicated Intensive Care Units, Medical Surgical Units, Procedural Units (Endoscopy) and Ambulatory Care Units were where patients received intravenous medication infusions.

The Hospital did not provide documentation to indicate that there was reeducation to all areas of the Hospital that administered intravenous constant infusion medications.

The Surveyor interviewed the Quality and Patient Safety Director at 11:50 A.M. on 7/26/17 and 11:15 A.M. on 7/27/17. The Quality and Patient Safety Director said Patient #1's medication adverse patient event did not appear in the Medication Events Report, dated 2/26/17-7/26/17, because the nurse reporting the event did not categorize the event as a medication event and the Hospital reclassified medication events at the closing of the event.

2.) The policy titled, Event Reporting System & Medical Device Reporting, dated 3/1/17, indicated the Hospital reports to the Center for Medicare and Medicaid (CMS) any death while a patient was in restraint or seclusion.

The report titled, Death in Restraints, dated 1/1/17-7/26/17, indicated Patient #9 died while in side rails and two-point soft wrist restraint.

The document titled, Hospital Restraint Seclusion Death Report Worksheet, dated 4/6/17, indicated Patient #9 died while in side rail and two-point soft wrist restraint. The Hospital Restraint Seclusion Death Report Worksheet indicated that side rails when marked as checked were used as a restraint to restrict the patient's freedom to leave the bed.

The Surveyor interviewed Senior Risk Manager #2, at 11:15 A.M. on 7/27/17. Senior Risk Manager #2 said that the Hospital did not report to CMS Patient #9's death while in restraint.

The Surveyor interviewed the Clinical Nursing Director, at 2:00 P.M. on 7/27/17. The Clinical Nursing Director said that Patient #9's medical record did not contain documentation that Patient #9 was in restraint.

A review of Patient #9's Medical Record did not indicate that Patient #9 died while in restraint.

The Surveyor interviewed Senior Risk Manager #2, at 9:00 A.M. on 7/28/17. Senior Risk Manager #2 said the Hospital sent CMS the report of Patient #9's death in restraint.