HospitalInspections.org

Based on observation, interview and document review, the critical access hospital (CAH) failed to ensure the security for 2 of 3 crash carts which were located in the emergency department (ED) and nursing station. In addition, 1 of 1 drawers of medication located in the ED. This had the potential to affect all patients seen at the CAH.

Findings include:

On 4/20/15, during the initial tour of the ED from 3:40 p.m. until 4:05 p.m. there was observed in the trauma room (ED-1054) a crash cart with red numbered break away tabs on the drawers labeled medications. In addition, drawer #11 which had a key lock on the outside of the drawer was unlocked. The contents of the medication drawer included [not an inclusive list]:
· Dilantin (an anticonvulsant)
· Atropine (treats slow heart rate)
· Apresoline (treats high blood pressure)
· Lasix (diuretic)
· Epinepherine (treats cardiac arrest)
· Mannitol (medication used for reducing intracranial pressure and treat acute sudden onset of kidney disease)
· Toradol (treats pain and inflammation)
· Labetolol (treats high blood pressure)
· Romazicon (a reversal agent)
· Lidocaine with epi (local injectable anesthetic)
· Narcan (reversal agent for narcotics and treats shock)

On 4/20/15, at 3:55 p.m. the outpatient supervisor (OS)-A confirmed that at times patients and visitors were left alone in these rooms leaving the contents of the crash cart and unlocked medication drawer accessible.

On 4/21/15, at 10:00 a.m. registered nurse (RN)-B provided a tour of the nursing unit. Observed in the unlocked dictation room, in the nursing station was a pediatric crash cart. All of the drawers of the crash cart were found unlocked including the top drawer containing a full inventory of emergency medications wrapped in a clear plastic covering. RN-B stated she didn't think the medications in the cart were "real" as she thought the cart was for training.

On 4/22/15, at 9:45 a.m. the director of nursing (DON) stated she didn't realize the pediatric crash cart was unlocked. She confirmed the medications in the cart were real and the pediatric crash cart should have been locked. In addition, she stated her expectation was for the medication drawer in the ED to be locked.

On 4/22/15, at 2:25 p.m. the pharmacy director (PD) verified the medication drawer in the ED should have been locked. In addition, at 2:40 p.m. the PD confirmed at times patients and families could be left alone in ED-1054, thus the security of the crash cart could be compromised. At 2:45 p.m. the PD verified the pediatric crash cart located in the unsecured dictation room should have been locked.

The PD provided an inventory list of the adult ED and pediatric crash carts [not an inclusive list]:
· Amiodarone (treats life threatening heart rate)
· Adenosin (treats irregular heart rate)
· Nitroglycerine (treats chest pain)
· Epinephrine (treats cardiac arrest)
· Dobutamine (treats heart failure)
· Heparin (blood thinner - considered a high risk medication)
· Ephedrine (treats low blood pressure)
· Verapamil (treats irregular heart rate and severe chest pain
· Valium (a hypnotic - controlled substance)
· Atropine (treats slow heart rate)

The CAH's Medication Security policy dated 9/13, indicated all medications would be secured.

The CAH's Pharmacy Mission Statement and Scope of Pharmacy Services dated 10/14, indicated the pharmacy department was responsible for storage and control of all inpatient and outpatient medications.

Based on interview and document review, the critical access hospital (CAH) failed to ensure appropriate investigation and follow up interventions had been developed to minimize the reoccurrence of further adverse drug reactions (ADR) for 7 of 7 adverse drug reactions (ADR-1, ADR-2, ADR-3, ADR-4, ADR-5, ADR-6, ADR-7) reviewed. This had the potential to affect all patients seen at the CAH.

Findings include:

ADR-1 dated 12/11/14, indicated a lesser dose of medication had been administered to a patient then what had been ordered. The medication had not been video verified. The director of nursing (DON)'s follow up read "encouraged to ensure the five rights of medication administration are carried out each and every time." The ADR report lacked any investigation and/or follow up from the pharmacist.

ADR-2 dated 12/10/14, indicated a missed dose. The ADR report lacked documentation of any follow up from DON or pharmacy.

ADR-3 dated 11/11/14, indicated patient (P33) had been administered two days' worth of medication at one time resulting in a significant medication error. ADR report included the investigation of the incident. The follow up of this incident by the DON included written education had been sent out to all nursing staff regarding the importance of the five rights to medication administration and that each medication needed to be scanned. The ADR report lacked documentation of any follow up or involvement in the ADR review from the pharmacist.

ADR-4 dated 11/7/14, indicated a patient had been administered morphine (narcotic pain medication) 1 milligram (mg) times three doses instead of the prescribed morphine 0.5 mg. The ADR report indicated the DON's follow up was a reminder to scan and verify medications. The ADR report lacked documentation of any follow up or involvement in the ADR review from the pharmacist.

ADR-5 dated 6/10/14, indicated a medication had been administered after it had been discontinued. The ADR report indicated the DON would do education with staff. The ADR report lacked documentation of any follow up or involvement in the ADR review with the pharmacist.

ADR-6 dated 4/20/14, indicated a medication dose had been missed. The ADR report lacked documentation of follow up from DON or pharmacist.

ADR-7 dated 4/20/14, indicated a patient had received the incorrect medication. The ADR report lacked documentation of investigation and follow up from the DON or pharmacist.

On 4/22/15, at 3:15 p.m. the pharmacist (P)-A confirmed the DON completed the follow up on the ADR's and then risk management in Fargo reviewed the reports. P-A verified the ADR reports noted above lacked documentation of pharmacy's involvement with the investigation, follow up and review of the ADR's.

On 4/23/15, at 8:30 a.m. the DON stated the process for reporting ADR's included staff initiation of the incident report in the computer, a notification was then sent to the DON and the risk management department at Sanford in Fargo. The follow up was then completed by the DON. The DON verified the pharmacist did not even have access to the ADR reports and that the documentation of the above reviewed reports lacked documentation of pharmacy's involvement, investigation, follow up and the development of interventions to prevent reoccurrence of future ADR's.

The Adverse Drug Reactions, Medication Errors, and Incident Reports policy dated 4/2012, indicated registered nurses and pharmacists were responsible for monitoring adverse drug reactions

Based on observation, interview and document review, the facility failed to ensure preventative maintenance was performed on 1 of 1 intravenous contrast warmers in the radiology department. This practice had the potential to affect all patients who received warmed contrast fluid.


Findings include:


During observation on 4/22/15, at 12:24 p.m. there was a metal device, identified by the manufacturers specifications as 0.8 cubic feet in size, and for use as a back-up incubator for hospitals. The device was set on a counter across from the hospital's computerized tomography (CT) scanner. When the surveyor and supervisor of radiology (RS)-A examined the device, there was no evidence of preventive maintenance (PM).


During interview on 4/22/15, at 12:30 p.m. RS-A stated the device was utilized as a warming unit for intravenous radiological contrast fluid administered to patients prior to CT scans. RS-A stated intravenous contrast fluid was warmed for patient comfort. RS-A further confirmed there was no evidence of PM performed on the warmer and indicated it would be the responsibility of the RS to set up a schedule for PM for the device. RS-A further confirmed the warmer had been utilized in the hospital for approximately 13 years and the last PM on the warmer had probably been, "around six years ago."


During interview on 4/23/15, at 8:53 a.m. the hospital maintenance director (MD)-A stated preventative maintenance on the warmer would have been the responsibility of the hospital biomedical personnel and he did not have evidence of PM.


Review of hospital radiology policy titled, Equipment Preventive Maintenance, dated 2/2015, directed inspection and periodic maintenance of all imaging equipment according to manufacturer's recommendations. However, the policy did not specifically include identification of the warmer utilized in the radiology department.

Based on interview and document review, the critical access hospital (CAH) failed to ensure nursing services provided appropriate medical monitoring for 1 of 1 patient (P33) reviewed for a significant medication error.

Findings include:

P33 was admitted to the CAH for recuperation secondary to bilateral lower extremity injuries. On 11/12/14, at 9:34 a.m. registered nurse (RN)-C administered two days' worth of medication (a total of 26 medications) at one time to P33. This resulted in a significant medication error which was discovered within 30 minutes of the administration of the medications. Medical doctor (MD)-A performed gastric lavage on P33 following the notification of the medication error.

The 11/12/14, 10:20 a.m. nursing progress note indicated P33's vital signs would be monitored for the next few hours.

MD-A's provider progress note dated 11/12/14, at 2:38 p.m. indicated P33's vital signs would be monitored hourly for the next four hours following the incident.

P33's medical record indicated a complete set of vital signs (to include blood pressure, pulse, and respirations) was conducted on 11/12/14, at the following times:
· Noon which resulted in a blood pressure of 117/75, pulse 80, respirations 18
· 1:11 p.m. which resulted in a blood pressure of 119/78, 84 pulse, respirations 18
· 3:58 p.m. which resulted in a blood pressure of 114/50, pulse 77, respirations 18

On 4/23/15, at 8:30 a.m. the director of nursing (DON) verified a complete set of vital signs should have been conducted every 15 minutes for at least two hours and then hourly for four hours following the significant medication error. The DON stated P33 had been placed on a cardiac monitor, however the monitor had not been plugged in so the battery went dead and all the vital sign readings had been lost. The DON confirmed P33's medical record lacked the documentation of the frequent monitoring of vital signs for this patient. In addition, the DON confirmed the record lacked documentation of the cardiac monitor being unplugged and the reason the vital signs had been lost.

Based on interview, the critical access hospital (CAH) failed to maintain a current physician privileges roster listing in the surgical suite. This had the potential to affect all patients that were scheduled for surgeries.



Findings include:


An interview on 4/21/15, at 2 p.m. with outpatient supervisor (OS)-A who stated staff could go to the credentialing office and look in the practitioners file if they needed to know what a surgeon was privileged for.


During an interview on 4/21/15, at 2:07 p.m. registered nurse (RN)-A stated she didn't know about any list or any website to go to in order to verify physician privileges. She said she would ask the physician what procedures they could do

Based on interview and document review, the critical access hospital (CAH) failed to ensure quality assurance/performance improvement (QA/PI) projects were developed and integrated into the CAH's quality improvement program for the following services: ambulance and medication errors. This had the potential to affect all patients of the CAH.

Findings include:

On 4/21/15, at 1:00 p.m. the ambulance director (AD) stated the ambulance services departmental QA/PI project involved conducting quality control checks on their glucometers. The AD confirmed this was their only current QA/PI project. The AD stated she normally doesn't attend the hospital QA/PI meeting as she works part-time.

On 4/22/15, at 3:15 p.m. the pharmacy director (PD) confirmed medication error review was not a part of the pharmacy's QA/PI program; nor was medication error review incorporated into the hospital-wide QA/PI program. The PD stated he did not submit anything to the QA/PI committee with regards to medication errors; however he thought they may get a tally of the number of medication errors which occurred.

On 4/23/15, at 8:30 a.m. the QA registered nurse (RN)-D was interviewed and verified there was no QA program for ambulance service or medication errors.


The CAH's Quality Assessment and Performance Improvement Plan dated 1/13/15, indicated ambulance services and pharmacy would provide a monthly report to the QA/PI committee. The philosophy of continuous improvement was to be patient centered, data driven, with use of intelligent metrics and evidence based improvements. Some examples of data sources for identifying problems included facility incident reports. In addition, a responsibility for the QA/PI committee was to identify, report, review and analyze adverse events.





29433