HospitalInspections.org

Based on medical record review, policy review, administrative document review, and staff interview, it was determined the CAH failed to ensure medications were correctly administered and documented for 1 of 6 patients (Patient #1), whose medical records were reviewed. This resulted in medications administered without proper patient identification and had the potential for negative patient outcomes for all patients receiving medication at the CAH. Findings include:

A CAH policy, "Patient Identification," dated 8/31/15, was reviewed. The policy included:
- "Patients are to be provided with a safe, universal means of identification to include two (2) identifiers: Name and Birth Date. This will be used whenever a patient is to receive services from Shoshone Medical Center."
- "Identification bands are to be placed on persons: inpatient, emergency room patients, and outpatient survey and radiology patients."
- "Place the band on the patient's wrist at time of admission."
- "Before performing a procedure, inspect the wristband and verify stay number. Additional identification will also be confirmed by asking the patient to state his [sic] name and date of birth."
- "If an inpatient does not have an identification band in place, the charge nurse or a designate [sic] is to be notified and the problem corrected."

The CAH failed to follow their policy. Examples include:

Patient #1 was an 84 year old female admitted to observation status on 3/18/16 with a diagnosis of status post fall and thrombocytosis, whose medical record was reviewed.

An incident report for Patient #1 dated 3/20/16, at 9:30 AM, was reviewed. The incident report included "Pt had the wrong wrist band on. Pt family noticed that the wrist band was the wrong pt." The incident report included documentation that a night shift CNA removed Patient #1's ID band and replaced it with a different patient's ID band early in the morning of 3/20/16. The incident report also included documentation that the correct ID band was placed on Patient #1 on 3/20/16, at 9:30 AM, after the issue was made known to staff by Patient #1's family. The incident report documentation was completed by the Nurse Manager and Director of Quality and Risk Management on 3/21/16.

Patient #1's medical record included documentation she received several medications the morning of 3/20/16, prior to her incorrect ID band being noticed by her family at 9:30 AM. Additionally, Patient #1's medical record included a CAH document "Q-Shift Nursing Assessment," dated 3/20/16 at 7:10 AM, and signed by an RN. The document included a section titled "Safety" with a checked checkbox next to "Bracelets: ID."

The Nurse Manager was interviewed on 10/24/16, beginning at 10:00 AM. She confirmed Patient #1 had an incorrect ID band on the morning of 3/20/16, and stated she completed an incident report. The Nurse Manager stated a CNA incorrectly removed Patient #1's ID band and replaced it with a different observation patient's ID band. She stated when a patient presented to the ED, a temporary ID band is placed. If the patient is admitted as an inpatient or observation status, a new ID band is placed for the remainder of their stay. The Nurse Manager stated the CNA did not verify Patient #1's identity before removing her armband and replacing it with a new one.

The Director of Quality and Risk Management was interviewed on 10/24/16, beginning at 1:30 PM. Patient #1's medical record was reviewed in her presence. She confirmed Patient #1's "Q-Shift Nursing Assessment," dated 3/20/16 at 7:10 AM, had incorrect documentation in the "Safety" section regarding Patient #1's ID band. The Director of Quality and Risk Management confirmed Patient #1 received medications the morning of 3/20/16, prior to her incorrect ID band being noticed. She confirmed staff did not follow policy and properly identify Patient #1 prior to medication administration.

The CAH failed to ensure proper patient identification was performed prior to medication administration.