HospitalInspections.org

Based on interviews and review of documents it was determined hospital staff failed to complete CIWA-Ar assessments and administer medications in accordance with the orders of the practitioner for two (2) of eight (8) sampled patients. (Patient #7 and Patient #8)

The findings include:

1. Patient #7 was admitted to the hospital's intensive care unit (ICU) on 8/28/23 with diagnoses to include acute kidney injury, encephalopathy, acute on chronic respiratory failure with hypoxia and hypercapnia, and elevated troponin. Patient #7's medical record was reviewed on 8/26/24.

An order was placed on 8/28/23 at 4:29 AM to calculate CIWA (Clinical Institute Withdrawal Assessment from Alcohol) score. The following was found in the "Comments" section of the order: "Every 4 hours while awake for CIWA score of less than or equal to 10. Every 2 hours while awake for CIWA score of 11-19. Every 1 hour while awake for score equal to or greater than 20. Notify physician if score greater than 20 and for transfer to
cardiorespiratory-monitored bed".

The CIWA score is used to determine the initiation of symptom triggered dosing ordered by the physician. The following orders for Lorazepam (aka Ativan, a benzodiazepine sometimes used for the treatment of acute alcohol withdrawal) oral or IV were placed on 8/28/23 at 4:29 AM and discontinued at discharge on 9/9/23 at 5:26 PM:
· CIWA-Ar score less than 10: give 0.5mg every 4 hours PRN until CIWA score is less than 8 or RASS -1 to 0
· CIWA-Ar score 10-12: give 1 mg every 2 hours PRN until CIWA score is less than 8 or RASS -1 to 0
· CIWA-Ar score 13-15: give 2 mg every 2 hours PRN until CIWA score is less than 8 or RASS -1 to 0
· CIWA-Ar score 16-17: give 3 mg every 2 hours PRN until CIWA score is less than 8 or RASS -1 to 0
· CIWA-Ar score 18-19: give 4 mg every 2 hours PRN until CIWA score is less than 8 or RASS -1 to 0

An order addressing scores of 20 to 67 was placed at the same time for lorazepam (Ativan) oral or IV as follows:
· CIWA-Ar score 20-30: Give Ativan 2 mg every 15 minutes until CIWA score less than 8 or RASS -1 to 0
· CIWA-Ar score 31-40: Give Ativan 3 mg every 15 minutes until CIWA score less than 8 or RASS -1 to 0
· CIWA-Ar score 41-50: Give Ativan 4 mg every 15 minutes until CIWA score less than 8 or RASS -1 to 0
· CIWA-Ar score 61-67: Give Ativan 6 mg every 15 minutes until CIWA score less than 8 or RASS -1 to 0

Hospital policy "Alcohol Withdrawal, Management" dated 12/11/23, indicates team members will use the CIWA-Ar scale to assess the severity of alcohol withdrawal and provide treatment to the patients. A nurse will complete the scale assessment and follow the CIWA-Ar provider orders. The CIWA-Ar score will be documented in the medical record. Reassessment of the score will occur based on the initial and subsequent patient score. Scores of 10-19 indicate mild to moderate withdrawal and scores of 20 or above indicate severe withdrawal. The provider should be notified as needed based on the patient's response to treatment. Use of the RASS (Richmond Agitation-Sedation Scale) may be indicated when the patient is unable to communicate or respond. Optional sedation for AWS using the RASS tool is suggested to be 0-2 with monitoring frequency every 15-30 minutes to every hour with effective dosing.

Review of the medical record found more than 45 documented CIWA-Ar scores between 8/28/23 at 4:29 AM and discharge on 9/9/23. Multiple scores were equal to or greater than 20. Orders for scores 20 and above indicate administration of Ativan 2mg every 15 minutes until the score is below 8. This would require the reassessment 15 minutes after the administration of the prescribed amount of Ativan to determine the new score; if the score remains 8 or above Ativan would be administered based on the prescribed amount for that score. On multiple occasions, the clinical record failed to reveal evidence of reassessments after 15 minutes to determine the need for more medication and failed to provide documentation of why a reassessment was not completed.

2. Patient #8 was admitted to the hospital's intensive care unit (ICU) on 7/29/24 with diagnoses to include alcohol withdrawal hallucinations, alcoholic hepatitis and hypertension. Patient #8's medical record was reviewed on 8/26/24.

On 7/29/24 at 9:17 PM, orders were placed to calculate the CIWA-Ar score, (same parameters as noted above) and for Ativan using the same scale and parameters as noted above.

Review of the medical record found more than 50 documented CIWA-Ar scores between 7/29/24 at 9:18 PM and discharge on 8/7/24. Multiple scores were equal to or greater than 20. Orders for scores 20 and above indicate administration of Ativan 2mg every 15 minutes until the score is below 8. This would require the reassessment 15 minutes after the administration of the prescribed amount of Ativan to determine a new score; if the score remains 8 or above Ativan would be administered based on the prescribed amount for that score. On multiple occasions, the clinical record failed to reveal evidence of reassessments after 15 minutes to determine the need for more medication and/or failed to provide documentation of why a reassessment was not completed.

Interviews conducted the afternoon of 8/28/24 with Staff #11 and Staff #12 (providers) related to the CIWA-Ar protocol indicate the expectation is that nursing staff will follow the orders as they are written. Nursing staff are to contact provider with questions. The failure to follow the CIWA-Ar protocol as it is written places the patient at increased risk of delirium tremens, respiratory difficulties, seizure, etc. and may result in the need to order additional medications or make medication changes to control withdrawal symptoms.