HospitalInspections.org

Based on observation and interview the hospital failed to ensure they had made changes to the hospital's antibiotic medication vials which could be used for intravenous (IV) push administration, which had been available to the licensed nurses throughout the hospital.

As a result, there was the potential for nursing staff to administer antibiotics using the IV push route which could result in patient deaths or severe injury.

Findings:

In an interview with the Director of Regulatory Affairs (DRA) on 2/13/23 at 2 P.M., the facility had indicated that they had ended the practice allowing nurses to administer antibiotic medications via the IV push route. The hospital's Director of Regulatory Affairs (DRA), indicated that all antibiotics must now be administered via IVPB (Intravenous Piggy Back, a slower IV bag drip), which the hospital had indicated that they had already implemented, as the pharmacy had already removed all antibiotic vials from the hospital's automated medication dispensing system.

On 2/16/23 at 11:20 A.M., an inspection/observation of the hospital's automated medication dispensing system was conducted which revealed multiple vials of unreconstituted (not mixed) antibiotics, which were being stored inside of the hospital's automated drug delivery machines, as follows:

In the hospital's 4th floor Custody unit's automated medication dispensing system contained multiple vials of Piperacillin/ Tazobactam (Zosyn) 3.375mg, Ceftriaxone (Rocephin) 1 GM, Cefazolin (Ancef) 2 GM, Ceftriaxone (Rocephin) 2 GM.

In the hospital's ICU 2nd Floor's automated medication dispensing system contained multiple vials of Cefazolin (Ancef) 1 GM, Ceftriaxone (Rocephin) 1 GM, Cefepime (Maxipime) 1 GM, Cefepime (Maxipime) 2 GM.

In the hospital's 6th Floor's automated medication dispensing system contained multiple vials of Cefepime (Maxipime) 1 GM, Cefepime 2 GM, Cefazolin (Ancef) 1 GM, Ceftriaxone (Rocephin) 1 GM.


The hospital had failed to ensure that there would be no way that their nursing staff would have been able to administer these antibiotics in an unsafe manner (via IV push), which had previously contributed to a patient's death in this hospital.

Based on interview with facility hospital Pharmacy staff and review of the hospital's policy and procedures, the hospital failed to implement the hospital's policies and procedures for medication order stop dates for 12 out of 31 patient records. This failure had the potential for patients to receive medications (which could be unsafe) for periods of time which were outside of the drug manufacturer's specifications.

Findings:

Interview with the hospital's Cheif Nursing Officer CNO during team's previous visit to the hospital in November of 2022, the Pharmacy surveyor was told by the CNO, that the hospital's Electronic Medical Record (EPIC), automatically implemented/generated stop order dates for all the hospital's drugs, which had been ordered by each patient's physician.

During the survey team's most recent visit to the hospital in Feburary 2023, and after a review of the hospital's policy and procedure entitled "Medication Orders- Administration", which had a policy approval date of January 2023, the hospital's Policy: "Medication Orders-Administration", read: "medications orders: A. medication orders will be entered by physicians into the epic electronic health record. B. Pharmacist will review and verify accuracy of orders in EPIC (the hospital's computerized electronic medical record system). C. Automatic stop orders, unless renewed by physicians are as follows: ...4. Control substances: 14 days.... 11. Propofol: 3 days... 13. Protonix drip (80mg/250mL at 25 mL/H) For GI bleed: 72 hours". E. All medications are automatically canceled when a patient ...is transferred to or from the ICU and must be rewritten." The hospital failed to follow and implement their policy and procedure, as outlined by the examples below:

Patient 2 had been admitted to the hospital on 1/15/23. A physician's order dated 1/15/23 for Diprivan (propofol) an anesthetic and sedative medication, with an infusion rate of 5-50 micrograms per kilograms per minute (patient's weight was 103 kilograms), which resulted in a dosage range of 515 to 5,150 micrograms per minute. This medication order can only be given for 3 days (as outlined in the hospital's policy and procedure entitled: "Medication Orders-Administration"), without this medication having been reordered. Patient 2 received this medication from 1/16/23 until 1/24/23, a total of 8 days, without being reordered. The hospital's Pharmacy staff failed to identify and correct the excessive length of time that this medication had been administered to this patient. The hospital had no other system in place to catch the excess duration of administration for this medication.

Patient 3 had been admitted to the hospital on 1/15/23. A physician's order dated 1/15/23 for Diprivan (propofol) an anesthetic and sedative medication, with an infusion rate of 5-50 micrograms per kilograms per minute (patient's weight was 65.8 kilograms), which resulted in a dosage range of 329 to 3,290 micrograms per minute. This medication order can only be given for 3 days (as outlined in the hospital's policy and procedure entitled: "Medication Orders-Administration"), without this medication being reordered. Patient 3 received this medication from 1/23/23 to 2/5/23 this patient received this medication for a total of 13 days, without this medication having been reordered. The hospital's Pharmacy staff failed to identify and correct the excessive length of time that this medication had been administered to this patient. The hospital had no other system in place to catch the excess duration of administration for this medication.

Patient 4 had been admitted to the hospital on 1/14/23. A physician's order dated 1/14/23 for Diprivan (propofol) an anesthetic and sedative medication, with an infusion rate of 5-50 micrograms per kilograms per minute (patient's weight was 115 kilograms), which resulted in a dosage range of 515 to 5,150 micrograms per minute. This medication order can only be given for 3 days (as outlined in the hospital's policy and procedure entitled: "Medication Orders-Administration"), without this medication being reordered.
Patient 4 received this medication from 1/14/23 to 1/20/23 (for a total of 6 days) and then again from 1/20/23 until 1/27/23, an additional 7 days, without this medication having been reordered. The hospital's Pharmacy staff failed to identify and correct the excessive length of time that this medication had been administered to this patient. The hospital had no other system in place to catch the excess duration of administration for this medication. This patient was transferred from the hospital's ICU (Intensive Care Unit) to the Telemetry unit on 1/27/23, when this patient's propofol had been stopped, but no discontinue order had been written for this patient's propofol. This patient's propofol order did not have a physician's discontinuation order in the patient's medical record, contrary to the hospital's policies and procedures ("Medication Orders-Administration" and "Medication Reconciliation"), until 1/30/23 at 2:08 am (almost 3 days after the patient had been transferred to the Telemetry Unit), and as confirmed in an interview on 2/21/23 at 3:00 pm with the hospital's ICU Charge Nurse (CN ICU). The hospital's Medication Reconciliation policy and procedure, dated 4/23/18, read: " ...If during the course of the hospitalization the patient is transferred to a different level of care, the Transfer Medications will be reconciled by the physician ....". The hospital also failed to follow it "Medication Reconciliation policy and procedure regarding this patient's care.

Patient 5 had been admitted to the hospital on 1/15/23. A physician's order dated 1/15/23 for Diprivan (propofol) an anesthetic and sedative medication, with an infusion rate of 5-50 micrograms per kilograms per minute (patient's weight was 68.9 kilograms), which resulted in a dosage range of 344 to 3,445 micrograms per minute. This medication order can only be given for 3 days (as outlined in the hospital's policy and procedure entitled: "Medication Orders-Administration"), without this medication having been reordered. Patient 5 received this medication from 1/28/23 until 2/4/23, resulting in this patient having received this medication for a total of 7 days, without this medication being reordered. The hospital's Pharmacy staff failed to identify and correct the excessive length of time that this medication had been administered to this patient. The hospital had no other system in place to catch the excess duration of administration for this medication.

Patient 10 had been admitted to the hospital on 1/28/23. A physician's order dated 1/28/23 for lorazepam (Ativan) tablet 0.5 milligrams by mouth every 4 hours as needed for anxiety. This medication order can only be given for 14 days (as outlined in the hospital's policy and procedure entitled: "Medication Orders-Administration"), without this medication being reordered. Patient 10 had received this medication from 1/29/23 and continued until 2/22/23, a total of 25 days, without this medication having been reordered. The hospital's Pharmacy staff failed to identify and correct the excessive length of time that this medication had been administered to this patient. The hospital had no other system in place to catch the excess duration of administration for this medication.

Patient 30 had been admitted to the hospital on 1/25/23. A physician's order dated 1/25/23 with a reorder dated 1/26/23 for oxycodone- acetaminophen (Percocet) an opioid pain reliever which is combined with Tylenol (a non-opioid pain reliever). Patient 30 received 5- 325 milligrams per tablet 1 tablet orally daily as needed for moderate pain (4- 6 out of 10). This medication can only be given for 14 days, (as outlined in the hospital's policy and procedure entitled: "Medication Orders-Administration"), without this medication needing to be reordered. Patient 30 received a dose of Percocet each day from 1/26/23 until 2/22/23, (a total of 28 days), without this medication having been reordered. The hospital's Pharmacy staff failed to identify and correct the excessive length of time that this medication had been administered to this patient. The hospital had no other system in place to catch the excess duration of administration for this medication.

Patient 31 had been admitted to the hospital on 12/21/22. A physician's order dated 1/24/23 for lorazepam (Ativan) a benzodiazepine had been used to treat this patient's anxiety disorders. The Ativan had been ordered as: 0.5 milligrams intravenous every six hours as needed for anxiety. This medication order can only be given for 14 days, (as outlined in the hospital's policy and procedure entitled: "Medication Orders-Administration"), without this medication needing to be reordered. Patient 31 had received this medication from 1/24/23 and continued until 2/19/23, a total of 26 days, without this medication having been reordered. The hospital's Pharmacy staff failed to identify and correct the excessive length of time that this medication had been administered to this patient. The hospital had no other system in place to catch the excess duration of administration for this medication.

Patient 32 had been admitted to the hospital on 1/23/23. A physician's order dated 1/14/23 for lorazepam (Ativan) tablet 0.5 milligrams by mouth every 4 hours as needed for anxiety not to exceed 2 milligrams in a 24-hour period. This medication order can only be given for 14 days (as outlined in the hospital's policy and procedure entitled: "Medication Orders-Administration"), without this medication being reordered. Patient 32 had received this medication from 1/24/23 and continued until 2/19/23, a total of 26 days, without this medication having been reordered. The hospital's Pharmacy staff failed to identify and correct the excessive length of time that this medication had been administered to this patient. The hospital had no other system in place to catch the excess duration of administration for this medication.

Patient 33 had been admitted to the hospital on 12/8/22. A physician's order dated 12/8/22 for lorazepam (Ativan) tablet 0.5 milligrams by mouth every 4 hours as needed for anxiety had been written for this patient. This medication order can only be given for 14 days (as outlined in the hospital's policy and procedure entitled: "Medication Orders-Administration"), without this medication being reordered. Patient 33 had received this medication from 12/9/22 and continued until 1/7/23, a total of 29 days, without this medication having been reordered. The hospital's Pharmacy staff failed to identify and correct the excessive length of time that this medication had been administered to this patient. The hospital had no other system in place to catch the excess duration of administration for this medication.

Patient 34 had been admitted to the hospital on 1/23/23. A physician's order dated 1/23/23 for morphine narcotic pain relief, to be given by injection 2 milligram intravenous every four hours as needed for severe pain (7- 10) had been written for this patient. This medication order can only be given for 14 days (as outlined in the hospital's policy and procedure entitled: "Medication Orders-Administration"), without this medication being reordered. Patient 34 had received this medication from 1/24/23 and continued until 2/11/23, a total of 15 days without this medication having been reordered. The hospital's Pharmacy staff failed to identify and correct the excessive length of time that this medication had been administered to this patient. The hospital had no other system in place to catch the excess duration of administration for this medication.

Patient 35 had been admitted to the hospital on 1/19/23. A physician's ordered dated 1/19/23 for a continuous pantoprazole (Protonix) decreases the amount of acid produced in the stomach, infusion of 8 milligrams per hour had been written for this patient. This order can only last for 72 hours (as outlined in the hospital's policy and procedure entitled: "Medication Orders-Administration"), without this medication having been reordered. Patient 35 had received this medication from 1/19/23 at 1:28 P.M., until 1/23/23 at 8:10 P.M. approximately 103 hours without being reordered. The hospital's Pharmacy staff failed to identify and correct the excessive length of time that this medication had been administered to this patient. The hospital had no other system in place to catch the excess duration of administration for this medication.

Patient 36 had been admitted to the hospital on 12/25/22. A physician's order dated 12/25/22, 12/26/22 and 12/29/22 for Diprivan (propofol) an anesthetic and sedative medication, with an infusion rate of 5-50 micrograms per kilograms per minute times (with the patient's weight of 91.2 kilograms) which resulted in a dosage range of 456- 4560 micrograms per minute. This medication order can only last 3 days (as outlined in the hospital's policy and procedure entitled: "Medication Orders-Administration"), without this medication being reordered. Patient 36 had received this medication from 12/29/22 until 1/3/23, for a total of 6 days, without this medication having been reordered. The hospital's Pharmacy staff failed to identify and correct the excessive length of time that this medication had been administered to this patient. The hospital had no other system in place to catch the excess duration of administration for this medication.

Patient 37 had been admitted to the hospital on 12/15/22. A physician's order dated 12/26/22 for Diprivan (propofol) an anesthetic and sedative medication, with an infusion rate of 5-50 micrograms per kilograms per minute (with a patient's weight of 75.1 kilograms) which resulted in a dosage range of 375.5 to 3755 micrograms per minute. This medication order can only be given for 3 days (as outlined in the hospital's policy and procedure entitled: "Medication Orders-Administration"), without this medication being reordered. Patient 37 had received this medication from 12/26/22 until 12/29/22, a total of 4 days, without this medication having been reordered. The hospital's Pharmacy staff failed to identify and correct the excessive length of time that this medication had been administered to this patient. The hospital had no other system in place to catch the excess duration of administration for this medication.

Patient 38 had been admitted to the hospital on 1/8/23. A physician's order dated 1/11/23 for Diprivan (propofol) an anesthetic and sedative medication, with an infusion rate of 5-50 micrograms per kilograms per minute (patient's weight was 95.7 kilograms), which resulted in a dosage range of 478.5 to 4785 micrograms per minute. This medication order can only be given for 3 days (as outlined in the hospital's policy and procedure entitled: "Medication Orders-Administration"), without this medication being reordered. Patient 38 had received this medication from 1/11/23 until 1/30/23, a total of 19 days, without this medication having been reordered. The hospital's Pharmacy staff failed to identify and correct the excessive length of time that this medication had been administered to this patient. The hospital had no other system in place to catch the excess duration of administration for this medication.