HospitalInspections.org

Based on record review and interviews with key staff on February 23, 2012 and February 24, 2012, it was determined that the CAH:

a) failed to issue appropriate discharge instructions and orders (see Tag 0259);

b) failed to act upon abnormal laboratory values (see Tag 0259);

c) failed to recognize the signs and symptoms of a potential drug overdose (see Tag 0259);

d) failed to diagnose the patient prior to discharge (see Tag 0259); and

e) failed to have an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes (see Tag 0259).

These findings represent an Immediate Jeopardy to the inpatients and Emergency Department patients of Redington Fairview General Hospital.

Based on review of inpatient and Emergency Department medical records, review of meeting minutes, review of a timeline provided, review of nursing home documentation and interviews with key staff in the nursing home and the hospital on February 23 and 24, 2012, it was determined that the CAH failed to issue appropriate discharge instructions and orders; the CAH failed to act upon abnormal laboratory values; the CAH failed to recognize the signs and symptoms of a potential drug overdose; the CAH failed to diagnose the patient prior to discharge; and the CAH failed to have an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes. These findings represent an Immediate Jeopardy to the inpatients and Emergency Department patients of Redington Fairview General Hospital.

The evidence is as follows:

Failure to issue appropriate discharge instructions and orders

1. A review of Patient A ' s inpatient medical record revealed that Patient A was a 59 year-old patient admitted to Redington Fairview General Hospital (RFGH) after being assessed in the Emergency Department, on February 2, 2012. The patient ' s chief complaint in the Emergency department was fever. Patient A had arrived from Woodlawn Rehab & Nursing Center. Patient A ' s current medications were included in the paper work that came from the nursing home. The list of current medications included Keppra Oral 1250 milligrams at 10:00 and 1500 milligrams at 18:00 daily. Patient A had been taking this anticonvulsant medication while in the nursing home.

2. Patient A was admitted to an inpatient unit for further evaluation and treatment on February 2, 2012. Patient A ' s History and Physical documentation also included a list of the current medications, which listed Keppra 1250 milligrams in the morning and 1500 milligrams at night. It was noted that the current medication list was obtained from the medication list provided by the nursing home.

3. A review of Patient A ' s inpatient medical on February 23, 2012, revealed documentation that Patient A received the Keppra as ordered. There was no documentation in the medical record of any change to this medication or of discontinuing that order.

4. Patient A ' s Discharge Summary, dated February 7, 2012, was reviewed. Although it included a list of medications that were labeled "unchanged," this list did not include Keppra but did include Lamictal 1250 milligrams oral in the morning and 1500 milligrams oral at night. There was no documentation that Patient A had been ordered this anticonvulsant medication during the hospitalization or for discharge.

5. A review of Nursing2012 Drug Handbook (edited by Karen Comerford, 2012, p. 783-784) revealed that the initial dose of Lamictal is 25 milligrams per day for 2 weeks, then gradually increase to the maintenance dose of a maximum of 800 milligrams per day.

6. The Redington Fairview General Hospital policy titled ' Medication Orders Reconciliation & Mediation Discharge Instructions ' stated, " POLICY: 1. A medication list will be developed for all acute admissions, observations and short term surgery patients and will be reconciled at each transition of care. This will be a cooperative process, amongst the nursing staff, the medical staff and the pharmacy ....3. If an Emergency Department patient is expected to be discharged to home, staff will develop a medication list using the available resources. (E.g. PCP office, community pharmacy, patient provided list, etc.) ...5. The pharmacy printed Medication Profile will be used by the physician, for indicating which drugs are to be continued at transfer or discharge; unless the physician provides a computerized order entry list that reconciles the medications. "

7. During an interview with Nurse A, on February 24, 2012, at 7:50 a.m. Nurse A was asked if she was the nurse who handled Patient A ' s discharge. Nurse A answered " yes " . Nurse A stated that the home medication list and the Discharge Summary were used to reconcile the medications. When Nurse A was asked if she was familiar with Lamictal, she stated that she was somewhat familiar. Nurse A further stated that she did not pick up on the increased dose of Lamictal.

8. During an interview with a Physician ' s Assistant (PA) on February 23, 2012 at 12:05 p.m., she was asked if she had dictated the Discharge Summary for Patient A. The PA stated " yes. " When asked what resources she had available to her to dictate the medications that Patient A was to continue to take, she stated, " We take the med profile done at 6 a.m. each morning..the chart is in front of us and the yellow med reconciliation sheet from the Pharmacy ..and what meds the patient came in on..and lastly the med profile from the nursing home. " The PA continued, " I looked at Patient A ' s profile and it said Keppra ...Lamictal was not on her list of meds..if it had been generic names maybe I would have been confused..that wasn ' t the case ...I don ' t know why I dictated Lamictal..I just did " .

9. During an interview with Physician B on February 24, 2012, he was asked if he co-signed the Discharge Summary dictated by the PA. He stated, " Yes..I did " . When asked if he reconciled the medications he stated, " No..I did not..it is part of my job..I made the wrong assumption that the Registered Nurse and the PA had reconciled the medications " .

Failure to Address Abnormal Lab Values

10. Patient A ' s Emergency Department medical record revealed that Patient A was admitted to the Emergency Department at RFGH on February 8, 2012, with a chief complaint of decreased mental status.

11. Patient A ' s Emergency Department medical record of February 8, 2012, revealed a New Critical Lab Values Report that revealed a platelet count of 64,000. There was another critical value related to the urine glucose of higher than 1000. Additionally, Patient A had a blood glucose level of 330. There was no documentation that any of these laboratory findings had been further investigated or addressed.

12. Emergency Medicine 6th Edition (edited by J. Tintinalli, published by the American College of Emergency Physicians, 2004, p. 1297) stated that causes of hyperglycemia should be identified, and that "the history and physical examination should focus on finding an underlying cause for the hyperglycemia and include a thorough medication history to ascertain the potential contributions of glucose-altering medications...."

Failure to recognize the signs and symptoms of a potential medication overdose

13. Patient A ' s Emergency Department note dictated by the physician, on February 8, 2012, did not include a list of Patient A ' s current medications.

14. During an interview with Physician A on February 24, 2012, he stated that he assessed Patient A during the Emergency Department visit of February 8, 2012. He further stated that when he dictated the Emergency Department Note, he did not have the list of Patient A ' s current medications. He stated, " I click a button and since the nurse documents the current medications in the record, they will transfer to my documentation .....in Patient A ' s case the medications did not transfer " . He continued that he had the MAR from the nursing home and usually doesn ' t question that. When asked if he reviewed the MAR from the nursing home he stated, " I don ' t remember looking at the MAR ....if I had looked it is tough to say if I would have noticed the high dose of Lamictal...I usually don ' t question the meds that a neurologist orders " .

15. Patient A ' s Emergency Department Note of February 8, 2012, documentation by the nurse, did include a list of the patient ' s current medications. Included in that list was Lamictal Oral 1250 milligrams p.o. daily and 1500 milligrams at bedtime " .

16. During an interview with Nurse B on February 23, 2012, she stated that she cared for Patient A during that Emergency Department visit of February 8, 2012. When asked how she would reconcile Patient A ' s medications, she stated, " I would use the MAR from the nursing home but it didn ' t come with the patient and we had to call and ask for it ...I used Patient A ' s last visit to the Emergency Department. " When asked if she noticed differences in the medications from the visit February 2, 2012 compared to the February 8, 2012 visit, she stated, " I didn ' t recognize anything different..I didn ' t use the inpatient Discharge Summary " .

17. Both the nurse and the physician during their telephone interviews on February 24, 2012 stated that they did not notice the different medication or the high dose.

18. Patient A ' s February 8, 2012 Emergency Department medical record revealed that Patient A's chief complaint was decreased mental status. The Emergency Department note of February 8, 2012, included a neurological system review that stated, " Altered mental status. Eyes open to pain. Best verbal response: none. Best motor response: withdrawal " .

19. The Nursing Transfer Form from discharge the previous day, February 7, 2012, clearly documented a different neurological assessment, " Behavior: Flat affect, makes eye contact ....Mental Status: Alert, responds to name, unable to cognitively verbalize time & place " .

20. Emergency Medicine 6th Edition (edited by J. Tintinalli, published by the American College of Emergency Physicians, 2004, p. 1390-1391) stated that delirium, acute cognitive impairment, and other synoyms refer to a transient disorder with impairment of attention and cognition. This reference continued that the physical excamination is directed at discovering the underlying process and that medication history should be "examined in detail."

21. Patient A ' s Emergency Department Note of February 8, 2012 stated, " Disposition: Discharged to nursing home in stable condition." There was no documentation of any chnage to Patient A's medications.

22. Documentation received via fax from the Director of Nursing at Woodlawn Rehab & Nursing Center stated that Patient A had received 4 doses of Lamictal while in Woodlawn Rehab and Nursing Center {WRNC). One dose of 1500 milligrams on February 8, 2012 and 1250 milligrams on February 10, 12 and 14, 2012. Patient A expired on February 16, 2012.

23. During a telephone interview with Physician C, Patient A ' s Primary Care Provider and the Medical Director of WRNC on February 23, 2012, she stated that the medication error contributed to Patient A ' s death.

Failure to diagnose a patient prior to discharge

24. Patient A ' s Emergency Department medical record revealed a chief complaint of decreased mental status. The Emergency Department note of February 8, 2012, included a neurological system review that stated, " Altered mental status. Eyes open to pain. Best verbal response: none. Best motor response: withdrawal " .

25. The Nursing Transfer Form from discharge the previous day, February 7, 2012, clearly documented a different neurological assessment, " Behavior: Flat affect, makes eye contact ....Mental Status: Alert, responds to name, unable to cognitively verbalize time & place " .

26. Emergency Medicine 6th Edition (edited by J. Tintinalli, published by the American College of Emergency Physicians, 2004, p. 1390-1394) stated that the physical examination of a patient with impairment of attention and cognition is directed at discovering the underlying process and that medication history should be "examined in detail." This reference listed "important medical causes of delirium in elderly patients" as infection, metabolic/toxic, neurologic, cardiopulmonary, and drug-related.

27. In spite of the documentation by the physician related to the altered mental state including non-verbal status of Patient A in the Emergency Department Note of February 8, 2012, the nurses ' notes stated, " Condition at departure: stable. Patient reports pain level on departure as 0/10 " .

28. Patient A ' s Emergency Department Note of February 8, 2012 stated, " Disposition: Discharged to nursing home in stable condition .....Course of Care:..Patient stable. ....Clinical Impression ....Changed mental status ...Multiple Sclerosis." There was no discharge diagnosis documented.

Failure of the Quality Program

29. The Director of Nursing at RFGH stated, " I received a call on February 17, 2012 from the hospitalist ...she said that Patient A ' s neurologist had called her after receiving Patient A ' s Discharge Summary and saw the wrong medication was ordered at a too high dose ...it looked like we had prescribed the medication " .

30. During a telephone interview with Physician C on February 23, 2012, she stated WRNC received orders related to Patient A ' s medications from RFGH. The Discharge Summary acts as orders from RFGH to WRNC.

31. RFGH ' s Time Line related to the incident was reviewed on February 23, 2012. The Time Line documented that because several key people could not be reached that day, that the investigation would continue on Monday February 20, 2012. (February 17, 2012 was a Friday.)

32. The documentation of Patient A ' s Case Review by RFGH, to discuss the incident and the bad outcome of an untimely death, was held 8:00 a.m. on February 23, 2012.

33. Interviews were held with the Medical Director and the Director of Nursing on February 23, 2012. During that meeting the question was asked about what changes the hospital had been initiated to ensure that the scenario did not repeat itself. The surveyor was told that a meeting had been held that a.m. to start the discussion. The Medial Director stated that the most significant was the need to increase awareness of the providers and the nurses. When asked if all the providers and nurses had been informed of the incident, the answer was " no, " it had not been conveyed to everyone yet.

34. The Director of Nursing also stated that the transition of care nurses would be responsible to do medication reconciliation on all patients, as currently it was only being done by them on patients at risk for re-admission. She stated that it started that day February 23, 2012.

35. There was no other indication that the hospital had initiated changes in how the medication reconciliation would be done from February 17 - 23, 2012, to ensure that no other patients were discharged from the inpatient unit or the Emergency Department with the wrong medication orders.

36. In spite of the multiple systems in place to ensure the reconciliation of Patient A ' s medications and the multiple opportunities for the hospital to identify a medication order error, the hospital did not recognize the error in the medication order from February 7 through February 17, 2012 and took no action from February 17 to February 23, 2012.

37. Patient A ' s Emergency Department medical record of February 8, 2012 contained documentation of critical lab values. In spite of these results, there was no documentation of action taken by the physician to investigate these values further. In fact, the physician and the nurse both documented that Patient A was ' stable ' at discharge, and there was no discharge diagnosis documented.

38. There was no documentation that the hospital ' s quality program took immediate action on the failure of the hospital to issue appropriate discharge instructions and orders; the failure to recognize the wrong medication order with an extremely high dose; the failure to recognize and act upon the signs and symptoms of a potential drug overdose; the failure to address abnormal lab values prior to discharge; and the failure to diagnose a patient, to prevent future negative paient outcomes, like that of Patient A.