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Based on record review, policy review, and staff interview, it has been determined that the hospital failed to meet the Condition of Participation: Nursing Services relative to ensuring that the registered nurse supervise and evaluate the nursing care for each patient, Patient ID #1. Additionally, the hospital failed to follow hospital policy relative to medication administration resulting in a medication error for Patient ID #2.

Findings are as follows:

1. The hospital failed to ensure the nursing care of each patient is supervised and evaluated by the Registered Nurse as it relates to the expectations of care delivery by a student nurse who was involved in a medication error of a medication used to induce the labor of an approximately 40 week pregnant patient via an infusion pump resulting in a decrease in fetal heart rate, requiring the administration of another medication for Patient ID #1, (refer to A-0395).

2. The hospital failed to provide nursing care in accordance with hospital policies for, "Medication Use Policy & Procedure, Subject: Intravenous Medications", "Medication Administration", and "Administration and Recording of Medications for Patient ID #2, (refer to A-0405)


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Based on record review and staff interview, it has been determined that the hospital failed to ensure student nurses understand the expectations of care delivery when paired with a Registered Nurse as a preceptor who must supervise the care of a patient for 1 of 2 patients reviewed who received Pitocin, a medication used to induce labor, via an infusion pump, a medical device used to deliver medications, fluids, or nutrients into a patient's body in controlled amounts, Patient ID #1.

Findings are as follows:

An incident report submitted by the hospital on 2/23/2023 revealed that Patient ID #1 received an "increased dose" of Pitocin over a "90 second period" after the tubing connected to Pitocin was removed from the infusion pump [by a student nurse].

The incident report indicated that as a result of this increased dose, the fetus responded with decelerations, a decrease in fetal heart rate, requiring the administration of another medication.

A document titled, "Clinical Education Agreement" in effect as of 2/26/2009 between the University of Rhode Island Nursing Department and the hospital states in part,

" ...2. Program Instruction/Patient care. Facility shall allow school's students participating in the program to work with the appropriate Facility personnel, assisting when and where appropriate and applicable, and observing them in the performance of their daily duties; provided, however, that no student shall perform any patient care task in or on behalf of Facility without the assistance, presence or permission, as the case may be under the circumstances, of an active member of Facility's professional staff ..."

Record review of correspondence dated 11/30/2022 between the Professional Development Manager and the Nurse Manager of the Women and Newborn Care Unit, the Professional Development Manager stated that the student nurse " ...should not make any adjustments to the IV [intravenous] pump without the RN [Registered Nurse] preceptor watching and confirming all is correct ..."

Record review revealed that Patient ID #1 presented to the hospital in February of 2023 after it was determined that she would be admitted for induction of labor.

Review of a document titled "LD [Labor and Delivery]-Flowsheet" dated 2/21/2023, revealed a nursing note which stated that on this day at 7:50 AM, Employee A, RN, instructed a student nurse to adjust Patient ID #1's fetal heart rate monitor. According to Employee A, while in Patient ID #1's room, the student nurse removed the tubing off the infusion pump after it alarmed with "air in line" and adjusted the fetal heart rate monitor which revealed a fetal heart rate in the 70s. Employee A states in her note that when she entered the room at 7:52 AM, she observed that the tubing infusing Pitocin was off the pump and infusing into Patient ID #1. Employee A indicates in her note that she "immediately clamped Pitocin tubing" assessed the patient and "noted tachysystole" (excessively frequent uterine contractions). Further review of Employee A's note revealed that 0.25 milligrams of Terbutaline, (a medication used to help prevent or slow contractions of the uterus), were administered to Patient ID #1 and prolonged decelerations were identified in the fetal heart rate. Additionally, Employee A revealed that approximately 100 milliliters of Pitocin were infused into Patient ID #1.

Review of a document titled "Interval Note" dated 2/21/2023 at 8:35 AM completed by a Certified Nurse Midwife revealed that the fetal heart rate returned to its baseline of 160 after Patient ID #1 received Terbutaline.

During a surveyor interview on 2/27/2023 at 4:24 PM with the Student Nurse, she revealed that Patient ID #1's fetal heart rate monitor stopped working and her preceptor, Employee A, asked her to go into the room and adjust it. She stated that when she entered the room, she saw the infusion pump alarming "air in line," she paused the infusion, opened the door to the pump to access the infusion line and saw an air bubble and pulled out the tubing from the pump. She indicated that she then adjusted the fetal heart monitor and noticed the fetal heart rate in the 70s and left the room to get her preceptor. She indicated that she has not received specialty training on the administration of Pitocin nor was she aware of the dosage, precautions, or side effects of the medication. Additionally, she revealed that at the beginning of her clinical rotation at the hospital, it was not made clear to her what tasks she could and could not do while on the unit.

During a surveyor interview on 2/27/2023 at 5:18 PM with Employee A, she revealed she entered Patient ID #1's room, noticed the Pitocin infusion line was out of the pump and the medication was "free flowing" into the patient. She indicated that she immediately clamped the line to stop the medication from infusing into the patient.

During a surveyor interview on 2/27/2023 at 9:12 AM with the Director of Risk Services, she acknowledged that the student nurse removed the tubing from the infusion pump causing the patient to receive an increased amount of Pitocin resulting in the administration of Terbutaline to address the decrease in fetal heart rate. Additionally, she indicated that the student nurse must practice under the direct supervision of the preceptor.





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Based on policy review, record review and staff interview, it has been determined that the hospital failed to administer medications in accordance with Federal and State laws for 1 of 3 patients reviewed who received medications intravenously, Patient ID #2.

Findings are as follows:

A report submitted by the hospital on 2/24/2023 revealed that Patient ID #2 received Phenergan (promethazine), a medication used to prevent and treat nausea and vomiting, when the nurse intended to give Toradol for pain.

The following hospital policies were reviewed:

A. The hospital's policy titled, "Medication Administration" dated 12/2022 states in part,

...Medication Administration Procedure

1. Before administration, it is the responsibility of the individual administering the medication...to validate the Five (5) Rights of Medication Administration. This validation includes, but is not limited to:

a. verifying that the medication selected matches the medication order and product label...

...e. verifying that the medication is being administered at the proper time, in the prescribed dose, and by the correct route..."

B. The hospital's policy titled, "Administration and Recording of Medications last revised on 1/2015 states in part,

...eMAR [electronic medication administration record] Administration and Recording...

...5. Remove medication from Pyxis Medstation [automated dispensing system for medication management]...

6. Compare removed medication with desired medication due for administration, using the eMAR...

8. Take medication and a computer to the bedside...Perform a final check of eMAR and compare with medication selected from the Pyxis..."

Record review revealed that Patient ID #2 presented to the hospital in February of 2023 for an elective left total hip arthroplasty (hip replacement surgery).

Record review of "Nurse Notes" dated 2/23/2023 at 8:30 AM revealed a note completed by Employee B, Registered Nurse, which stated that Patient ID #2 was complaining of pain and was administered Phenergan via "IV push" (direct intravenous injection).

During a surveyor interview on 2/27/2023 at 12:47 PM with the Administrative Director of Allied Health, she stated that Phenergan should be administered in a 50-milliliter bag of 0.9% Normal Saline solution intravenously as an infusion and not as a direct intravenous injection.

During a surveyor interview on 2/27/2023 at 3:57 PM with Employee B, she indicated that on 2/23/2023, she pulled Patient ID #2's morning medications from the Pyxis to be administered. She stated that after arriving to the patient's room, she scanned the medications, prepared what she thought was Toradol by retrieving half of the medication from the vial and diluting it in a 10-milliliter flush and administered it. She revealed that she realized she administered Phenergan instead of Toradol when she went over to her computer. She acknowledged that she did not compare the medication she had in her hand with the physician's order, and she did not confirm that the medication in the vial was Toradol when she removed it from the Pyxis nor prior to administering it to the patient.





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