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Based on review of patient medication administration record, medication administration policy, and staff interview the facility failed to administer patient medication in accordance with federal and state laws and regulations and in accordance with approved facility policy and procedure.

The findings included:
a. Review of patient (A23) chart and medication administration record on 4/12/11 at 9:46 am at the nurses station on the tenth floor revealed an order from 4/9/11 for Rocephin 1GM IVPB Q 24 hours. Review of the medication administration record showed two (2) entries documented as the medication being given on 4/9/11 at 0802 and at 1047.
b. Review of Medication Administration policy on 4/12/11/at 1053 showed procedure steps 12 and 13 that address editing documentation and how to undo documentation on wrong doses or doses not given. These functions were not used in this instance to document the reason for the two(2) doses of Rocephin administered by the nurse.
c. During an interview with staff members A25 and A26 at the nurses station on 10th floor staff member A26 presented an administration edit history for the 0802 administration that had under new comments-wrong abx- and under the code of given it stated Yes. A26 stated the medication was not given for this reason and the nurse probably did not know how to delete the medication. No evidence was provided that the 0802 dose of medication was indeed not administered prior to the 1047 dose being administered to the patient.


Based on observation, interview and record review the registered nurse failed to obtain a written or verbal physician's order prior to administering a prescribed potassium dialysate to 1 out of 1 patient reviewed.

The findings included:
a. During observation of patient MR# A31 receiving dialysis treatment on 4/13/11 at 9:45 a.m. in the Coronary Care Unit found that the patient was receiving a 3 potassium (k) and 2.5 (Ca) 35 HCO3(bicarbonate) dialysate formulation.
b. A review of the patients chart found that the last physician order was dated 4/12/11 and the order was prescribed for a 2k/2.5Ca/33HCO3 dialysate formulation. A review of the patients treatment sheets for the previous dialysis treatment on 4/11/11 date revealed the patient dialyzed on a 2k/2.5Ca/35HCO3 dialysate formulation. Review of the patient labs revealed a potassium(k) of 4.5 on 4/11/11 and 4.2 on 4/13/11.
c. An interview on 4/13/11 at 9:58 a.m. with the dialysis nurse, A27, who was taking care of the patient and who was the RN on the record for administering the above prescription to the patient revealed that she did change the patient's dialysate formulation. She reported that they used a protocol to adjust the dialysate prescription and she had not written the order for the change yet. She could not produce a copy of the protocol for the prescription change and none was available in the patient record.. In an interview at 10:21 a.m. in the surgical intensive care unit, the dialysis charge nurse, A16, revealed there was not a protocol for adjusting the physician orderaccording to the patient lab work and they would have to get a physician order to make the adjustment in the patient dialysate prescription.

Based on review of documentation in 152 medical recordsand interviews with staff, the facility failed to ensure that all verbal orders were dated, timed and authenticated by the ordering practitioner or another practitioner responsible for the care of the patient according to facility Medical Staff Rules and Regulations. In the medical records reviewed 63 of 152 applicable medical records for Methodist Healthcare System provider # 45-0388 reviewed contained verbal/telephone orders that were not authenticated according to the 48-hour requirement adopted by the hospital Medical Staff.

Findings were:

1. Review of Policy
Methodist Healthcare Rules and Regulations of the Medical Staff, last revised March 17, 2011, Article Three: Care of the Patient, section 3.2.3, states that " All orders, including verbal/telephone orders must be dated, timed and authenticated within forty eight (48) hours ... "

2. Review of Medical Records
Methodist Main/Children Hospital (Facility A)

a. Review of 21 closed medical records (Patient# A1-A21) revealed that 16 out of 21 (76%) patient records reviewed at this facility contained verbal/telephone orders that were not dated, timed, and authenticated by the practitioner within 48 hours of the order.

b. These records were confirmed in an in-person interview conducted with Staff A3 Regulatory Director and Staff A1, vice president of quality at 2:00pm on April 13, 2011 either staff member could not provided evidence that this requirement was met with these patients records.


Methodist Transplant and Specialty Hospital (Facility B)

a. Review of the closed medical records of Patients # B1-B30 revealed that 24 of 30 (80%) of patient ' s records reviewed contained verbal/telephone orders that were not dated, timed, and authenticated by the practitioner within 48 hours of the order. For example, Patient #B1 ' s record contained a telephone order taken on 11/22/2010; the practitioner electronically authenticated the order on 11/27/2010. Additionally, Patient #B4 ' s record contained verbal orders taken on 2/11/2011, 2/19/2011, and 3/1/2011, but not authenticated by the practitioner until 3/23/2011.

b. These findings were confirmed in an in-person interview conducted with Staff #B3 in a facility conference room the morning of 4/13/2011.

Methodist TexSan (Facility C)

a. Review of the closed medical records of Patients # C1-C12 revealed that 12 out of 12 (100%) of patient ' s records reviewed contained verbal/telephone orders that were not dated, timed, and authenticated by the practitioner within 48 hours of the order.

b. These findings were confirmed in an in-person interview conducted with Staff #C9, Director of Health Information Management in a facility conference room 2:30pm on 4/14/2011. Staff member interviewed could not provided evidence that this requirement was met with these patients records.


Northeast Methodist (Facility D)

a. Reviewed 31 medical records (D1-D31) revealed that 5 out of 31 records (16%) Patients # D1-D5 revealed that patient ' s record contained verbal/telephone orders that were not dated, timed, and authenticated by the practitioner within 48 hours of the order. For example, Patient #B3 ' s record contained a telephone order taken on 12/13/2010; the practitioner authenticated the order on 1/18/2011. Additionally, Patient #D5 ' s record contained a telephone order taken on 2/3/2010, but not authenticated by the practitioner until 2/10/2011.

b. These findings were confirmed in an in-person interview conducted with Staff #D1 in the facility Medical Records Department office the afternoon of 4/19/2011. Staff member interviewed could not provided evidence that this requirement was met with these patients records

Metropolitan Methodist (Facility E)

a. Reviewed 10 medical records (E1-E10) revealed that 6 out of 10 (60%) Patients records #E-3,4,6,7, 9 and E-10 (60%) contained verbal/telephone orders that were not dated, timed, and authenticated by the practitioner within 48 hours of the order.

b. These findings were confirmed in an in-person interview conducted with Staff D-12 Director of Health Information Management department at 3:00pm on April 19, 2011 in the facility ' s conference room. Staff member interviewed could not provided evidence that this requirement was met with these patients records.

Borne ED ((Facility F )
No medical record deficiencies

Based upon review of inpatient medical records and interview with hospital staff-a medical history and physical examination was not authenticated in written or electronic form by the person responsible for providing or evaluating the service provided.

The findings included:

a. In review of 23 inpatient medical records, 3 of the 23 medical records had a discrepancy by the person responsible for providing or evaluating the services provided. Examples of incomplete documentation include the following: 3 of 23 had history and physical exam not authenticated by dictating physician within 48 hours of transcription, MR # A34, C11, and E12, review of electronic records showed all 3 were still in draft form and MR# A34 being 12 days from admission.
b. Interviews were held on the various nursing units with senior nursing personnel including, A5, C9, C12, and E13. The staff members interviewed could not provide evidence that these discrepancies met requirements.

Based on observation, interview, and record review the facility failed to ensure that outdated and mislabeled drugs were not available for patient use in the facility ' s Emergency Department.

Findings:

During a tour of facility C ' -Methodist TEXSAN Emergency Department on 4/14/2011 at approximately 1:15pm the following outdated medications were found in a pediatric crash cart:

· 15 Atropine vials; expired 2/2011
· 1 Dobutamine vial; expired 2/2011
· 2 Dopamine vials; expired 10/2010
· 4 Bicarbonate vials; expired 2/2011
· 4 Sodium Bicarbonate vials; expired 10/2010

The above findings were confirmed in an interview with the facility ' s Director of Pharmacy Services on 4/14/2011 at approximately 1:20pm in the Emergency Department.

A facility policy entitled " Selection, Procurement, Storage, Preparation, Dispensing, Control of Medications ...ID/Version: 2412/1 " was reviewed on 4/14/2011. This policy stated " All expired and unusable drugs are returned to the Central Pharmacy and quarantined in an area set aside by the Pharmacy Director. "

During the same tour a mislabeled Tuberculin multidose vial was found in a refrigerator in the Emergency Department. This vial had been opened, but it was not labeled with the date it was opened or initialed by the person who opened it.

The above finding was confirmed by the facility ' s Risk Manager during an interview on 4/14/2011 at approximately 1:25pm in the Emergency Department. The Risk Manager confirmed that it could not be determined if the vial had been opened for greater than 28 days, therefore it could not be determined if the vial needed to be discarded.

A facility policy entitled " Parental Multidose vials ...ID/Version: 1687/1 " was reviewed on 4/14/2011. This policy stated " Tuberculin PPD must always be stored in the refrigerator. All PPD vials will be dated with the expiration date and discarded after 28 days. "

Based on observation and interview, during a tour of Methodist Transplant and Specialty facility (B) it was determined that the facility did not ensure a sanitary environment for staff and patients.

Findings were:

Tour of the facility on 4/12/11 revealed the following infection control issues:
· Operating Room # 1, chipped paint noted to the doorframe, dust was observed on high horizontal surfaces, a 3 inch vertical tear to the head pillow, 10 small 0.5 inch tears to body of the mattress, and a 6 X 7 inch area covered with tape at the base of the main mattress on the surgical table. Also noted 3 gouges to the floor approximately 1 inch in size, one 0.5 inch piece missing to side stripping on cabinet, and a 1.5 inch area of cracked/peeling paint to the corner of the wall above the cabinet making disinfection impossible and cross contamination likely.
· Operating Room # 6, noted the arm board to the surgical table had 3 holes, approximately 0.5 mm in size making disinfection impossible and cross contamination likely.
· Operating Room # 8, noted a 2 X 4 inch hole and a 5 X 5 area covered with tape to the main body of the surgical table making disinfection impossible and cross contamination likely. Noted tape with the words " Water Leak " affixed to a light fixture in the ceiling.
· Operating Room # 11, chipped paint on the doorframe, a 2 X 5 inch tear to the wall plaster, 2 vertical cracks in the wall paint: one 7 inches in long and one 5 inches long, and 4 horizontal cracks on the floor near baseboards approximately 3 inches wide making disinfection impossible and cross contamination likely.
· Operating Room # 12, dust was observed on high horizontal surfaces, chipped paint on the doorframe, foot boot had 3 holes with exposed foam approximately 3 mm in size, and a 3 inch tear to the main mattress of the surgical table, and 2 circular indentations to the floor approximately 1 inch in size making disinfection impossible and cross contamination likely.
· Substerile Room, the autoclave door gasket was cracked with a 4 inch piece missing making disinfection impossible and cross contamination likely.
· In the Sterile Storage Room, 1 Forceps and 3 Scissors were observed in the closed position, therefore not all surfaces were exposed to the sterilizing agent
· Hallway between Operating Room # 9 and # 10, 2 large holes in the floor: one 15 X 6 inches in size and one 13 X 4 inches in size making disinfection impossible and cross contamination likely.

In an interview with the Surgical Nurse Supervisor and Surgical Nurse Educator on 4/12/11, the above infection control issues were confirmed.