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Based on record review and interview the facility staff failed to ensure standards of practice were followed regarding medication administration for 1 of 5 patients (#4) which resulted in the patient experiencing an allergic reaction to medication given during an Emergency Department visit. Findings include:

A 0405 - Medications not administered per policy and acceptable standards of practice

Based on record review and interview the facility staff failed to follow standards of practice for medication administration for 1 of 5 patient's (#4) which resulted in the patient experiencing an allergic reaction to medication given during an Emergency Department (ED) visit. Findings include:

On 10/18/21 at 1415 during record review of Patient #4's chart, all admission information was listed on the "initial nursing assessment" including known allergies for the patient which was dated and signed electronically by nursing staff on 09/11/21.

Allergies listed include "Codeine /Hives 07/08/14, Darvocet-N 100/Personality change 07/08/14, Flagyl/Yeast infection 07/08/14, Levaquin / Joint Problems 07/08/14, Blueberries / Hives 07/08/14, Norco /unknown 06/24/21, Penicillin's / Hives 07/08/14, Solu-Medrol / flushed skin, tachy (high heart rate) hypotension (low blood pressure), Vicodin / Hives 07/08/14".

On 10/18/21 at 1500 it was determined that the ED physician wrote an order for "Solu-Medrol 125 mg IVP(Intravenous Push)" at 1451 and was given by nursing staff at 1530. During review of the document titled "Nurses Notes" it was determined at "1610 Patient became very anxious, SOB (Short of Breath), chest heaviness, skin reddened,hypotensive (low blood pressure), and tachycardia (fast heart rate). Benadryl (antihistamine) 50 mg and Epinephrine (vasopresser) 0.3 given. Patient is being admitted to the ICU (Intensive Care Unit).

On 10/19/21 at 1215 during review of the policy titled "Medication Administration" under "5.5.14 Before administering a medication, the authorized individual administering the medication completes the following: 5.4.14.4 Verifies there is no contraindications with respect to allergy, sensitivity or diagnosis."

On 10/18/21 at 1400 during an interview with Accreditation Manager Staff D, it was determined that the "ED nurses work off of a Tri-fold form. They are supposed to ask the patient upon arrival and before giving any kind of medications as to what their allergies are."

Based on record review and interview the facility failed to follow facility policies related to reporting medication administration errors, when one (1) patient (#4) was administered a medication to which she had a documented allergy, from a total of five (5) patients reviewed for medications, resulting in the potential for adverse drug reactions. Findings include:

On 10/18/21 at 1100 during review of patient #4's medical record it was documented from a previous hospitalization on 01/05/20, that she had an allergy to Solu-Medrol (flushed skin, high heart rate, low blood pressure). Review of patient #4's clinical record revealed the information related to the Solu-Medrol allergy was not transferred/communicated from the Emergency Department (ED) computer documentation system to patient's hospital computer documentation system where the allergy was listed.

On 10/18/21 at 1130 during review of the facility adverse event logs and grievance logs from 01/01/21 to current did not reveal documentation of an event related to patient #4.

On 10/18/21 at 1400 during an interview with the Accreditation Manager, Staff D, it was determined that the facility was not aware of this adverse event. Staff D confirmed that there was no "Safety First" report, or any other kind of communication in regard to this specific incident. The Chief of Emergency Medicine, Staff S, was made aware of the situation and he stated that he initiated a mitigation plan and entered an adverse event on the date of notification to the facility (10/18/21, the date of the State Agency survey).

On 10/19/21 at 1300 review of facility policy MHC-SE001 titled "Safety Event Reporting Policy" effective 5/1/2016 documented the following: 1.1. To provide a systematic multidisciplinary approach in reporting and investigating patient safety events and other safety risks in order to achieve and maintain a safe environment for patients. . .

3.4. Adverse Event: Any event that is not consistent with routine patient care or routine operation of the facility and may adversely affect or threaten to affect the health, life,comfort, or property of a patient visitor employee, or independent contractor. Each Event is categorized in (Facility Name) Safety First based on the level of impact or severity. Examples of adverse events that are to be reported in (Facility Name) Safety First ordinarily shall include (but not limited to ):

3.4.9. Medication events including adverse reactions...

4.1. (Facility name) employees are required to report any and all safety events including but not limited to sentinel events, serious adverse events, near misses, human errors, existence of hazardous conditions and related areas for improvement. It is the responsibility of all employees to report such events in the electronic safety event reporting tool. . .within 24 hours following the occurrence of the event."