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Based on record review and interview, the Governing Body of the Hospital failed to ensure the medical staff provided quality care to Patient #2 as evidenced by an undiagnosed fracture of his right femur (upper leg bone). This failed practice exposed Patient #2 to undue pain, harm, and delayed treatment.

The findings are:

A. Facility medical staff failed to complete the reading of a Computed Tomography (CT) scan of the Abdomen and Pelvis on 01/25/18 for Patient #2. Nurses and physicians also failed to assess Patient #2's fracture via alternative assessment methods until an x-ray of the hip identified the fracture on 01/28/18.


B. Record review of Patient #2's medical record revealed the following:

1. Patient #2 is a developmentally delayed 77 year old male who lives in a group home. He was described as non-verbal. He did follow commands.

2. Patient #2 visited the hospital twice on 01/25/18. On the first trip, he was transported to the Emergency Department (ED) in the morning at approximately 7:00 am with concerns by caregivers for an unknown abdominal problem. A possible urinary tract infection was identified [treated with antinausea and antianxiety medication] and he was returned to his group home later that day.

3. Patient #2 was transported back to the ED later that same day (01/25/18) arriving at 8:15 pm because he was found on the floor in the home. The caregiver communicated the concern of injury to the ED staff. Patient #2 indicated pain by pointing to his knees. The assessment in the ED included an Electro Cardio Gram (EKG) to assess his heart, blood assays, regular vital signs which included heart rate, blood pressure, temperature, and oxygen saturation. The EKG indicated "severe global ischemia." His urine assay indicated a urinary tract infection.

4. The CT impression or result indicated:

"a. No acute abdominal abnormality indented.
b. Colonic diverticulosis (pockets within the colon).
c. Simple cysts in the liver and right kidney [benign]."

5. Review of physician, nursing, and aide notes indicated no range of motion, either passive or active, was performed by physicians, nurses, or aides from 01/25/18 to 01/28/18. No skin assessments were found in patient record. No mention of a fracture in either hip was found. No hip x-ray was ordered until 01/28/18.


C. On 08/06/18 at 8:26 am during interview, the ICU/PCU2 Nurse Manager, the Quality Program Manager, and the Hospital Chief Executive could not provide any answers when asked why there was no documentation in Patient #2's medical chart regarding Range of Motion (ROM) assessments.

1. The same staff agreed they were concerned the broken hip was not identified and could not provide answers when asked if the patient's broken hip would have been noticed had they done the assessments.

2. The Quality Program Manager stated the ED records documented a fall with trauma.

3. The Hospital Chief Executive stated, "I spoke to the Hospitalist [about Patient #2]. The concern was the GI [gastro intestinal] issues."

4. The ICU/PCU2 Nurse Manager stated, "It [the fractured hip] probably wasn't too much of a concern because he was moving around in the bed. With him moving around in the bed, and keeping him safe, then the extremity is not the focus."


D. On 08/06/18 at 11:15 am during interview, the Legal Counsel for the hospital indicated the re-read of the CT of the Abdomen and Pelvis taken on the 01/25/18 second ED visit for Patient #2 indicated a fracture of the right hip. She stated, "It was a difficult read. There was a fracture evident. It was caught on the second read. It appears it was missed [on the first read]."


E. Record review: surveyors requested a re-read of the 01/25/18 CT of the Abdomen and Pelvis on 08/06/18 by a Radiologist. The Hospital's Legal Counsel response was:

"...a physician (not the original provider who read the film) to look at the scan and received a verbal only confirmation that there does appear to be evidence of a fracture from the diagnostic test performed on the 25th."









38043

Based on record review and interview, the hospital failed to ensure that patients receive care in a safe setting by 1) not addressing Patient #1 and her family's concerns regarding medication administration, medication disposal, and the management of a wound device (wound vac), and 2) not identifying Patient #2's fractured femur and not taking appropriate treatment action. These failed practices exposed Patient #1 to the likelihood of physical harm to Patient #1 and caused Patient #2 unnecessary pain. (see Tag A 144)


Based on record review and interviews, the facility failed to ensure the Registered Nurses (RN) supervised and evaluated the Nursing Staff and Aides regarding medication administration and disposal, and management of the wound device (wound vac) for Patient #1 and the assessment of Patient #2's fractured hip. This failure to evaluate standard care exposes patients to unnecessary pain and suffering. (See A 395).


The cumulative effect of the systemic deficient practices resulted in the hospital's inability to ensure the safety of patients.





38043

38043

Based on record review and interview, the hospital failed to ensure that patients receive care in a safe setting by 1) not addressing Patient #1 and her family's concerns regarding medication administration, medication disposal, and the management of a wound device (wound vac), and 2) not identifying Patient #2's fractured femur and not taking appropriate treatment action.


These failed practices exposed Patient #1 to the likelihood of further potential physical harm to Patient #1, and caused Patient #2 unnecessary pain.


The findings are:


MEDICATION ADMINISTRATION

A. Record review of Patient #1's medical record for her stay between 06/26/18 and 07/03/18 revealed the following:

1. Patient #1 was admitted to Hospital for an elective follow-up surgery to address pain issues secondary to endometriosis and an abdominal abscess. The surgeon had written orders on 06/26/18 for six different pain medications including morphine, Dilaudid, Demerol, Fentanyl, and Toradol in different forms including intravenous injection, personal care administration (PCA) pumps, and patches. A suction device (wound vac) was applied by the surgeon to drain Patient #1's abdominal wound. The wound device was set up by the surgeon and monitored by designated wound nurses.


2. A physician's assistant (PA) to the surgeon (physician #1) ordered a Fentanyl Patch 75 mcg per hour (dose) on 06/28/18. The 75 mcg patch of Fentanyl was applied around 2:00 pm on 06/28/18.


3. On 07/31/18 at 1:45pm during interview, the pharmacy staff confirmed the pharmacist reviewed and discussed the Fentanyl Patch 75 mcg per hour order with the physician and the nurse (Staff #1) on duty on 06/28/18. However, there was no written record in this discussion in the patient's medical chart.


4. At 06/29/18 at 4:01 am (the next day) Patient #1's heart rate increased to 170 beats per minute (normal is around 80 bpm) and her oxygen saturation was less than 20 percent (normal is above 90 %).


5. Staff monitoring Patient #1 at a nurses station noticed the change in status on their monitors. Patient #1 was assessed by nurses and the emergency room physician was called. The physician ordered a dose of Narcan, a reversal agent for the Fentanyl. This medication was administered by a nurse. Patient #1's status normalized as measured by heart rate and oxygen saturation.


6. The RN (Staff #1) on duty the morning of 06/29/18 at 4:11 am for Patient #1 was not available to interview on day of survey 08/06/18.


B. On 07/03/18 at 2:00 pm during interviews, Patient #1 and her family stated the following:

1. A nurse (Registered Nurse #1) applied a Fentanyl patch (Pain medication) 75 mcg per hour in the afternoon of 06/28/18 around 2:00 pm. The patient and her family thought this was too much but did not feel anyone was concerned about the high dosage.

2. Patient #1 stated she told the nurses she "didn't feel good," she "didn't feel right," and she "felt sick" after the Fentanyl patch was applied. "I stopped breathing, I was at 12" [oxygen saturation was at 12%. Normal range is 90-100%]. She stated, "I was gone ...dying. I don't even know what happened. I just wasn't breathing." She stated "the nurse [RN Staff #1] did not respond to our concern."


C. On 07/31/18 at 3:00 pm during interview, Patient #1's husband stated, "This whole situation with my wife has been traumatizing. I seen (sic) her dead. I'm up every night checking on her. All day she [Patient #1] kept saying she didn't feel well. She was nauseated and red all over. The nurse [he could not recall her name] came in around 3:30 or 4 [pm] and said it's normal. Around 12 [midnight] I had to go look for a nurse. No one explained anything at all. All they did was give her meds [medications]. Their [nurses] attitude was 'Let me do my job and shut up.' Alarms were going off. I had to go find someone. They told me, 'I'm doing my rounds.' The charge nurse [he could not recall her name] finally came in and called a 'Code Blue' and all of a sudden 15 people are (sic) in the room ...They just wanted to give her more drugs and I had to say 'no' because she was just waking up."


D. On 08/01/18 at 11:52 am during interview, the Charge Nurse (Staff #17) stated, "the nurse who applied the Fentanyl patch to Patient #1 was not concerned with the dosage amount of 75 micrograms. [Staff #1's name] did not check with any peers or anyone else because she was not concerned about it." The administering nurse (Staff #1) was not available for interview during survey on 08/06/18.


E. On 07/31/18 at 9:50 am during interview, the Charge Nurse (Staff #17) was asked if she had spoken to a pharmacist to verify the dosing of the Fentanyl patch for Patient #1. She stated she had not spoken to a pharmacist. She also stated she did not know if the pharmacy conducted their own investigation.



WOUND VAC

F. On 07/31/18 at 9:50 am during interview, the Charge Nurse (Staff #17) stated she did not follow-up with Patient #1's family to check if the wound-vac was working. She stated she spoke to the wound nurse who confirmed she [the wound nurse] only changed the patient's dressing.


G. On 08/01/18 at 9:20 am during interview, Patient #1's husband stated, "...the vac-machine [wound-vac] was not plugged into the wall. The lady who came to clean noticed the machine was not plugged in. The sponge was stinky. The [charge] nurse [Staff #17] said it wasn't working."


H. Record review of the Hospital's Policy titled "Patient Complaint and Grievance Management," Current Effective Date 01/01/17, page 5 indicated, "If the patient grievance is resolved on the spot but involves a quality of safety related issue, the issue shall be processed as a grievance, and shall be submitted via Advocate [computer software reporting program]."


I. On 07/31/18 at 3:00 pm during interview, the Director of Quality/Patient Safety indicated she could find no record of any events or complaints by Patient #1 or her family for her stay between 06/26/18 and 07/03/18. The Director of Quality/Patient Safety also stated the respiratory event on 06/29/18 was not reported to her or her department as an adverse or safety event.



MEDICATION DISPOSAL

J. Record review of photos supplied by Patient #1's family via phone of medications left in the room by nursing staff indicated:

1. A open medication (Toradol) vial was left on the counter on 06/26/18.

2. A closed vial of dry medication (possibly an antibiotic) and sterile water for mixing were left on the counter on 06/26/18 at 6:57 pm.

3. A used syringe (no needle) was was left on the counter on 06/29/18 at 8:32 pm.

4. An empty intravenous bag of Flagyl (an antibiotic) was left on the counter and not discarded in the bio-hazard container on 06/29/18 at 2:48 pm.


K. On 07/30/18 at 2:00 pm during interview Patient #1 stated, "the nurses were very negligent with needles. They left stuff in the room. Anyone could've come in and shot me up with anything, anytime."


L. On 08/01/18 at 9:20 am during interview Patient #1's husband stated, "When we questioned the nurses, [about leaving the medications in the room] they would get mad at us."


M. On 08/06/18 at 8:15 am during interview, Staff were shown the photos provided by the family via phone of medications left in Patient #1's room. Staff confirmed, "This should not have happened and it is not proper procedure."


N. Record review of the hospital's policy on medication administration titled "Medication Administration PC.PDS.272" with a current effective date 12/14/16 on page 6 of 22 pages indicated:

"19.2 Medications shall not be left at the patient's bedside.

19.3 Partially used, contaminated or damaged medications shall be disposed of in a accordance with applicable laws, regulations and [hospital] Policy."



PATIENT #2

A. Record review of Patient #2's medical record revealed the following:

1. Patient #2 is a developmentally delayed 77 year old male who lives in a group home. He was described as non-verbal. He did follow commands.

2. Patient #2 visited the hospital twice on 01/25/18. He was transported to the Emergency Department (ED) with concerns by caregivers for an unknown abdominal problem. A possible urinary tract infection was identified [treated wiith antinausea and antianxiety medications] and he was returned to his group home later that same day around noon.

3. Patient #2 was transported back to the ED later that same day (01/25/18) arriving at 8:15 pm because he was found on the floor in the home. The caregiver communicated the concern of injury to the ED staff. Patient #2 indicated pain by pointing to his knees. The assessment in the ED included an Electro Cardio Gram (EKG) to assess his heart, blood assays, regular vital signs which included heart rate, blood pressure, temperature, and oxygen saturation. The EKG indicated "severe global ischemia." His urine assay indicated a urinary tract infection.

4. The CT (Computed Tomography) of the abdomen and pelvis impression or result indicated:

"a. No acute abdominal abnormality indented.
b. Colonic diverticulosis (pockets within the colon).
c. Simple cysts in the liver and right kidney [benign]."

5. Review of physician, nursing, and aide notes indicated no range of motion, either passive or active, was performed by physicians, nurses, or aides from 01/25/18 to 01/28/18. No skin assessments were found in patient record. No mention of a fracture in either hip was found. No hip x-ray was ordered until 01/28/18.

6. A Hospitalist note on the first emergency room visit on 01/25/18 referred to abnormal urine lab results for Patient #2 as "questionable."

7. The surgery to repair the fractured hip was performed 01/29/18. He was transferred to a rehabilitation facility on 02/03/18. He returned to the Hospital on 02/04/18 (the next day) and died in the Hospital on 02/24/18.


B. Record review of the orthopedic surgeon's consultation requested by the Hospitalist on 1/29/18 indicated:

1. "patient has cognitive impairments...unable to participate in exam but does indicate pain with any motion of his right hip.

2. CC: R hip pain

3. Radiographs of the right hip and pelvis taken yesterday show a displaced fracture of the femoral neck.

4. Plan: I discussed the exam and findings and the pathology with the patient's legal guardian today. We discussed options and I recommended surgery: cemented right hip hemiarthroplasty [one-sided joint repair]..."


C. Record review of the medical record for Patient #2 indicated no documentation of range of motion for the period between his admission on 01/26/18 and 01/29/18. No range of motion was performed in the emergency department (ED) or on the unit after admission; nor was an assessment ordered for physical therapy after the surgery on 01/19/18. P#2 was ambulating on his first visit to the ED on 01/25/18 but not the second visit later that day.


D. On 08/06/18 at 8:26 am during interview, the ICU/PCU2 Nurse Manager, the Quality Program Manager, and the Hospital Chief Executive could not provide any answers when asked why there was no documentation in Patient #2's medical chart regarding Range of Motion (ROM) assessments.

1. The same staff agreed they were concerned the broken hip was not identified and could not provide answers when asked if the patient's broken hip would have been noticed had they done the assessments.

2. The Quality Program Manager stated the ED records documented a fall with trauma.

3. The Hospital Chief Executive stated, "I spoke to the Hospitalist [about Patient #2]. The concern was the GI [gastro intestinal] issues."

4. The ICU/PCU2 Nurse Manager stated, "It [the fractured hip] probably wasn't too much of a concern because he was moving around in the bed. With him moving around in the bed, and keeping him safe, then the extremity is not the focus."


E. On 08/06/18 at 11:15 am during interview, the Legal Counsel for the hospital indicated the re-read of the CT of the Abdomen and Pelvis taken on the 01/25/18 second ED visit for Patient #2 indicated a fracture of the right hip. She stated, "It was a difficult read. There was a fracture evident. It was caught on the second read. It appears it was missed [on the first read]."


F. Record review: surveyors requested a re-read of the 01/25/18 CT of the Abdomen and Pelvis on 08/06/18 by a Radiologist. The Hospital's Legal Counsel response was:

"...we did contact our radiology services provider (an independent practice) and requested that they look into the matter. They did ask a physician (not the original provider who read the film) to look at the scan and received a verbal only confirmation that there does appear to be evidence of a fracture from the diagnostic test performed on the 25th..."

Based on interview and record review, the Hospital failed to listen and respond to patient concerns, collect and track concerns regarding nursing staff competencies regarding medication administration and disposal, and the management of a wound device (wound vac). The hospital's failure to collect, track, and trend this data has the potential to put all patients at risk for emotional and physical harm.
(see Tag A 283)


Based on record review and interviews, the facility failed to ensure the Registered Nurses (RN) supervised and evaluated the Nursing Staff and Aides regarding medication administration and disposal, and management of the wound device (wound vac) for Patient #1 and the assessment of Patient #2's fractured hip.


This failure to evaluate standard care exposed patients to unnecessary pain and suffering and has the potential to expose patients to emotional and physical pain and suffering.
(see Tag A 395)


Based on interview and record review, the hospital Nurse(s) failed to follow the facility's policy for medication administration and disposal for Patient #1 during her stay from 06/26/18 to 07/03/18. This failed practice has the potential to expose patients to emotional and physical harm from unsafe medication administration and disposal.
(see Tag A 405)

The cumulative effect of the systemic deficient practices resulted in a significant breakdown in the assessment and quality improvement.




38043

38043

Based on interview and record review, the Hospital failed to track and trend 1) Patient #1's Fentanyl overdose incident and her family's reaction to it, 2) proper disposal of other medications, and 3) management of the wound vac. The hospital's failure to collect, track, and trend this data did not allow for performance improvement. This failure has the potential to cause harm to other patients.
The findings are:

ISSUES #1 AND 2

A. On 07/03/18 at 2:00 pm during interview, Patient #1 and her family stated the following:
1. A nurse (RN #1) applied a Fentanyl (pain medication) patch of 75 mcg per hour in the afternoon of 06/28/18 around 2:00 pm. The patient thought this was too much but did not feel like anyone was concerned about the high dosage. Patient #1 stated, "I thought I was going to die."
2. Patient #1 stated she told the nurses she "didn't feel good," she "didn't feel right," and she "felt sick" after the Fentanyl patch was applied. Patient #1 stated, "I stopped breathing, I was at 12 [oxygen saturation was at 12%, normal range is 90-100%]. She also stated, "I was gone ...dying. I don't even know what happened. I just wasn't breathing. The nurse [RN #1] did not respond to our concern."


B. Record review of Patient #1's medical record for her stay between 06/26/18 and 07/03/18 revealed the following:
1. A physician's assistant (PA) to the surgeon (Physician #1) ordered a Fentanyl Patch 75 mcg per hour (dose) ordered on 06/28/18. The 75 mcg patch of Fentanyl was applied 06/28/18 at 2:00 pm.
2. On 07/31/18 at 1:45pm during interview, the pharmacy staff confirmed the pharmacist reviewed and discussed the Fentanyl Patch 75 mcg per hour order with the physician and the nurse (Staff #1) on duty on 06/28/18. However, there was no written record in this discussion in the patient's medical chart.
3. At 06/29/18 4:01 am (the next day) Patient #1's heart rate increased to 170 beats per minute (normal is around 80 bpm), her oxygen saturation was 20% (normal is above 90 %).
4. Staff monitoring Patient #1 at a nurses station noticed the change in status on their monitors. Patient #1 was assessed by nurses and the emergency room physician was called. The physician ordered a dose of Narcan, a reversal agent for the Fentanyl. This medication was administered by a nurse. Patient #1's status normalized as measured by heart rate and oxygen saturation.
5. The RN on duty the morning of 06/29/18 at 4:01 am for Patient #1 was not available for interview during survey on 08/06/18.

C. On 07/31/18 at 3:00 pm during interview, the Director of Quality indicated she could find no record of any events or complaints by Patient #1 or her family for her stay between 06/26/18 and 07/03/18. She also stated the respiratory event on 06/29/18 was not reported because it was not a true "code blue."

D. On 07/31/18 at 2:10 pm during interview, the Director of Quality/Patient Safety stated that they recognized the severity of a Code for Patient #1 and that "we should have put it through the Quality process."

E. On 08/01/18 at 11:52 am during interview, the Charge Nurse (Staff #17) stated, "the nurse [Staff #1] who applied the Fentanyl patch to [Patient #1's name] was not concerned with the dosage amount of 75 micrograms. The Charge Nurse stated, "[Staff #1's name] did not check with any peers or anyone else because she was not concerned about it."

F. On 07/31/18 at 9:45 am during interview, the Facility Administrator stated, "I did not write anything formal regarding this complaint [Patient #1 and her family]. I did not feel the severity of the complaint rose to the level of concern for a formal grievance."

G. On 07/31/18 at 9:45 am during interview, the Director of Quality/Patient Safety stated the Patient #1's family did not ask for a formal complaint or grievance. "During the admission process, all the Patient Consent Forms, Grievance Policy and Procedures, and Rights and Responsibilities are explained to the patient. Boxes are 'checked-off' by the Admitting Staff but no documents are given to the patient. The expectation is that the patient understands the process. There is no way to tell if the patient actually understands the process."

H. On 07/31/18 at 2:30 pm during interview, the Supervisor for Patient Access stated, "Patients don't sign for their patient rights or HIPPA [Health Insurance Privacy and Portability Act]. It's a given that it was given. The patient accepts or denies, and a box is checked. We hand it [patient information] to them [the patients] and assume they read it. I've been here for 30 years and I've never given the patient anything to sign."

I. Record review of the Hospital's Policy titled "Patient Complaint and Grievance Management," 19 pages Current Effective Date 01/01/17, page 5 indicated:
"When to use the 'Grievance or an Appeal' Form"
"If the patient grievance is resolved on the spot but involves a quality of safety related issue, the issue shall be processed as a grievance, and shall be submitted via Advocate [computer reporting software]."

INCIDENT #3
J. Record review of photos supplied by Patient #1's family via phone of medications left in the room by nurses indicated:
1. An open medication (Toradol) vial was left on the counter on 06/26/18.
2. A closed vial of dry medication (possibly an antibiotic) and sterile water for mixing was left on the counter 06/26/18 at 6:57 pm.
3. A used syringe (no needle) was left on the counter at on 06/29/18 at 8:32 pm.
4. An empty intravenous bag of Flagyl (an antibiotic) was left was left on the counter and not discarded in the bio-hazard container on 06/29/18 at 2:48 pm.

K. Record review of the hospital's policy on medication administration titled "Medication Administration PC.PDS.272 with a current effective date 12/14/16 on page 6 of 22 pages" indicated:
"19.2 Medications shall not be left at the patient's bedside.
19.3 Partially used, contaminated or damaged medications shall be disposed of in a accordance with applicable laws, regulations and [hospital] Policy."

38043

Based on record review and interviews, the facility failed to ensure the Registered Nurses (RN) supervised and evaluated the Nursing Staff regarding medication administration and disposal, and management of the wound device (wound vac) for Patient #1 and the assessment of Patient #2's fractured hip.
This failure to evaluate standard care exposes patients to unnecessary pain and suffering.
The findings are:

MEDICATION ADMINISTRATION

A. Record review of Patient #1's medical record for her stay between 06/26/18 and 07/03/18 revealed the following:

1. Patient #1 was admitted to the Hospital for an elective follow-up surgery to address pain issues secondary to endometriosis and an abdominal abscess. The surgeon had written orders on 06/26/18 for six different pain medications including morphine, Dilaudid, Demerol, Fentanyl, and Toradol in different forms including intravenous injection, personal care administration (PCA) pumps, and patches. During post-surgical care, RN #1 applied a Fentanyl patch 75 mcg per hour in the afternoon of 06/28/18 around 2:00 pm. The patient and her family thought this was too much but did not feel anyone was concerned about the high dosage.

2. On 08/01/18 at 11:52 am during interview, the Charge Nurse (Staff #17) stated, "the nurse who applied the Fentanyl patch to [Patient #1's name] was not concerned with the dosage amount of 75 micrograms. [RN #1's name] did not check with any peers or anyone else because she was not concerned about it." The administering nurse (Staff #1) was not available for interview during survey on 08/06/18.

MEDICATION DISPOSAL

B. Record review of photos supplied by Patient #1's family via phone of medications left in the room by nurses indicated:
1. A open medication (Toradol) vial was left on the counter on 06/26/18
2. A closed vial of dry medication (possibly an antibiotic) and sterile water for mixing was left on the counter on 06/26/18 at 6:57 pm
3. A used syringe (no needle) was left on the counter on 06/29/18 at 8:32 pm
4. An empty intravenous bag of Flagyl (an antibiotic) was left on the counter and not discarded in the bio-hazard container on 06/29/18 at 2:48 pm.

C. On 08/06/18 at 8:15 am during interview, Staff were shown the photos of medications taken by the family via phone left in Patient #1's room. Staff confirmed, "This should not have happened and it is not proper procedure."

D. Record review of the hospital's policy on medication administration titled "Medication Administration" PC.PDS.272 with a current effective date 12/14/16 on page 6 of 22 pages indicated:
"19.2 Medications shall not be left at the patient's bedside.
19.3 Partially used, contaminated or damaged medications shall be disposed of in a accordance with applicable laws, regulations and [hospital] Policy."

WOUND VAC

E. On 07/31/18 at 9:50 am during interview, the Charge Nurse (Staff #17) stated she did not follow-up with Patient #1's family to check if the wound-vac was working. She stated she spoke to the wound nurse who confirmed she [the wound nurse] only changed the patient's dressing.

F. Record review of Patient #1's wound care discharge plan note by wound care physician dated 07/03/18 indicated, "POD2 [post op day 2] wound vac noted to have about 1 cm of subcutaneous tissue exposed but otherwise the vac looked to be in place. I asked the RN to make sure wound team was notified. By POD3 AM, the wound vac had lost further suction..."

G. On 08/01/18 at 9:20 am during interview, Patient #1's husband stated, "Everyone agrees the [75 mcg] patch [Fentanyl] was a high dose but the pharmacist signed off on it. The ER Doctor didn't talk to anyone [after the Code Blue]. The vac-machine [wound-vac] was not plugged into the wall. The lady who came to clean noticed the machine was not plugged in. The sponge was stinky. The [charge] nurse [Staff #17] said it wasn't working. When we questioned the nurses, [about leaving the medications in the room] they would get mad at us."

PATIENT #2

A. Record review of Patient #2's medical record revealed the following:
1. Patient #2 was a developmentally delayed 77 year old male who lived in a group home. He was described as non-verbal. He did follow commands.
2. Patient #2 visited the hospital twice on 01/25/18. On the first trip, he was transported to the Emergency Department (ED) in the morning at approximately 7:00 am with concerns by caregivers for an unknown abdominal problem. A possible urinary tract infection was identified [treated with antinausea and antianxiety medication] and he was returned to his group home later that day.
3. Patient #2 was transported back to the ED later that same day (01/25/18) arriving at 8:15 pm because he was found on the floor in the home. The caregiver communicated the concern of injury to the ED staff. Patient #2 indicated pain by pointing to his knees. The assessment in the ED included an Electro Cardio Gram (EKG) to assess his heart, blood assays, regular vital signs which included heart rate, blood pressure, temperature, and oxygen saturation. The EKG indicated "severe global ischemia." His urine assay indicated a urinary tract infection.
4. The CT impression or result indicated:
"a. No acute abdominal abnormality indented.
b. Colonic diverticulosis (pockets within the colon).
c. Simple cysts in the liver and right kidney [benign]."
5. Review of physician, nursing, and aide notes indicated no range of motion, either passive or active, was performed by physicians, nurses, or aides from 01/25/18 to 01/28/18. This technique is common care for bed bound patients like Patient #2 and likely would have helped to identify a fractured hip. No skin assessments were found in patient record. No mention of a fracture in either hip was found. No hip x-ray was ordered until 01/28/18.

B. On 08/030/18 at 10:15 am during interview, the Nurse Manager confirmed no documentation of a skin assessment or the performance of range of motion, either passive or active, was conducted by Nurses or Aides for the period of 01/25/18 to 01/28/18 on Patient #2.

C. On 08/06/18 at 8:26 am during interview, the ICU/PCU2 Nurse Manager, the Quality Program Manager, and the Hospital Chief Executive could not provide any answers when asked why there was no documentation in the patient's medical chart regarding Range of Motion (ROM) assessment.
1. The same staff agreed they were concerned the broken hip was not identified and could not provide answers when asked if the patient's broken hip would have been noticed had they done the assesments.
2. The Quality Program Manager stated the ED records documented a fall with trauma.
3. The Hospital Chief Executive stated, "I spoke to the Hospitalist [about Patient #2]. The concern was the GI [Gastrointestinal] issues."
4. The ICU/PCU2 Nurse Manager stated, "It [the fractured hip] probably wasn't too much of a concern because he was moving around in the bed. With him moving around in the bed, and keeping him safe, then the extremity is not the focus."

Based on interview and record review, the hospital Nurse(s) failed to follow the facility's policy for medication administration and disposal for Patient #1 during her stay from 06/26/18 to 07/03/18. This failed practice has the potential to expose patients to emotional and physical harm from unsafe medication administration and disposal.
The findings are:

A. On 07/03/18 at 2:00 pm during interviews, Patient #1 and her family stated the following:
1. A nurse (RN #1) applied a Fentanyl patch (Pain medication) 75 mcg per hour in the afternoon of 06/28/18 around 2:00 pm. The patient and her family thought this was too much but did not feel anyone was concerned about the high dosage.
2. Patient #1 stated she told the nurses she "didn't feel good," she "didn't feel right," and she "felt sick" after the Fentanyl patch was applied. "I stopped breathing, I was at 12" [oxygen saturation was at 12%. Normal range is 90-100%]. She stated, "I was gone ...dying. I don't even know what happened. I just wasn't breathing." She stated "the nurse [RN Staff #1] did not respond to our concern."

B. Record review of Patient #1's medical record for her stay between 06/26/18 and 07/03/18 revealed the following:
1. A physician's assistant (PA) to the surgeon (Physician #1) ordered a Fentanyl Patch 75 mcg per hour (dose) on 06/28/18. The 75 mcg patch of Fentanyl was applied by a nurse around 2:00 pm on 06/28/18.
2. On 06/29/18 at 4:01 am (the next day) Patient #1's heart rate increased to 170 beats per minute (normal is around 80 bpm) and her oxygen saturation was less than 20%.
3. Staff monitoring Patient #1 at a nurses station noticed the change in status on their monitors. Patient #1 was assessed by nurses and the emergency room physician was called. The physician ordered a dose of Narcan, a reversal agent for the Fentanyl. This medication was administered by a nurse. Patient #1's status normalized as measured by heart rate and oxygen saturation.

C. On 07/31/18 at 1:45 pm during interview, the pharmacy staff confirmed the pharmacist reviewed and discussed the Fentanyl Patch 75 mcg per hour order with the physician and the nurse (Staff #1) on duty on 06/28/18. However, there was no written record of this discussion in the patient's medical chart.

D. On 08/01/18 at 11:52 am during interview, the Charge Nurse (Staff #17) stated, "the nurse who applied the Fentanyl patch to [Patient #1's name] was not concerned with the dosage amount of 75 micrograms. [Staff #1's name] did not check with any peers or anyone else because she was not concerned about it." The administering nurse (Staff #1) was not available for interview during survey 08/06/18.

E. On 07/31/18 at 9:50 am during interview, the Charge Nurse (Staff #17) was asked if she had spoken to a pharmacist to verify the dosing of the Fentanyl patch for Patient #1. She stated she had not spoken to a pharmacist. She also stated she did not know if the pharmacy conducted their own investigation.

F. Record review of photos supplied by Patient #1's family via phone of medications left in the room by nurses indicated:
1. An open medication (Toradol) vial was left on the counter on 06/26/18
2. A closed vial of dry medication (possibly an antibiotic) and sterile water for mixing were left on the counter on 06/26/18 at 6:57 pm
3. A used syringe (no needle) was left on the counter on 06/29/18 at 8:32 pm
4. An empty intravenous bag of Flagyl (an antibiotic) was left on the counter and not discarded in the bio-hazard container on 06/29/18 at 2:48 pm.

G. On 08/06/18 at 8:15 am during interview after facility Staff was shown the photos of medications left in Patient #1's room, they confirmed this should not have happened and it is not proper procedure.

H. Record review of the hospital's policy on medication administration titled "Medication Administration PC.PDS.272 with a current effective date 12/14/16 on page 6 of 22 pages indicated:
"19.2 Medications shall not be left at the patient's bedside.
19.3 Partially used, contaminated or damaged medications shall be disposed of in a accordance with applicable laws, regulations and [hospital] Policy."







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