HospitalInspections.org

The Condition of Participation: Patient Rights was out of compliance.

Based on records reviewed and interviews, the Hospital failed to provide care in a safe setting for 3 of 12 sampled patients (Patients #7, #8, and #11). 1) The Hospital failed to notify a physician of abnormal vital signs for Patient #11. Patient #11 subsequently experienced a change in condition during which a Registered Nurse (RN) failed to monitor the Patient and Patient #11 was transferred to an outside hospital, and 2) Patient #7 failed to receive medication as ordered and Patient #8 erroneously received the medication ordered for Patient #7, resulting in both Patients being transferred to the Emergency Department (ED) for evaluation and treatment.

Cross Reference:
482.13 (c)(2), (e)(3): Patient Rights: Care in a Safe Setting (0144)

Based on records reviewed and interviews, the Hospital failed to provide care in a safe setting for 3 of 12 sampled patients (Patients #7, #8, and #11). 1) The Hospital failed to notify a physician of abnormal vital signs for Patient #11. Patient #11 subsequently experienced a change in condition during which a Registered Nurse (RN) failed to monitor the Patient and Patient #11 was transferred to an outside hospital, and 2) Patient #7 failed to receive medication as ordered and Patient #8 erroneously received the medication ordered for Patient #7, resulting in both Patients being transferred to the Emergency Department (ED) for evaluation and treatment.

Findings included:

1. Review of Facility Protocol 'Inpatient Detoxification Protocols', approved 3/27/23, indicated the following alcohol withdrawal protocol: call physician if pulse is greater than 120 or if temperature is elevated.

Review of Hospital Policy 'Assessment of Acute Chest Pain', reviewed 1/22, indicated the following:
-Place patient in bed or stretcher.
-STAT page a Nursing Supervisor or Nurse Manager.
-Assess the following data: Subjective data-location, radiation, duration, intensity (scale of 1-10), greater on inspiration or expiration (cardiac pain is constant), nausea. Objective data- history of cardiac disease, diaphoresis (sweating), apical pulse (1 minute) rate, rhythm, blood pressure, respiration, color, history reflux disease.
-Call MD, Nurse Practitioner for orders.
-Give Aspirin (ASA) 325 milligrams (mg) by mouth (PO).
-If patient has suspicion of Gastroesophageal reflux disease (GERD) give Gaviscon 30 milliliters by mouth x 1.

Review of Hospital Policy 'Medical Emergencies', reviewed 3/23, indicated that a Code Blue will be called for any major medical emergency, not just an arrest. Such conditions such as seizures, hemorrhaging, fainting, suspected overdose, striking head, and suicide attempts, etc. require quick, professional medical and nursing response.

Patient #11 was admitted to the Hospital on 3/14/24 for alcohol dependence/ withdrawal.

Patient #11's medical record indicated on 3/14/24 at 3:08 P.M., the Patient's pulse was documented as 132. Further review of Patient #11's medical record failed to indicate this abnormal vital sign was communicated to the physician in accordance with Hospital policy.

Patient #11's medical record further indicated on 3/14/24 at approximately 8:00 P.M. he/she reported difficulty breathing and Patient #11's pulse at 8:00 P.M. was 145. Patient #11 received intramuscular (IM) Ativan (an anxiety medication) 3 milligrams (mg), Hydroxyzine 50 mg by mouth (PO) and Metoprolol Tartrate (medication to slow heart rate) 25 mg PO, with no effect and subsequently reported chest pain and was emergently transferred to an outside hospital on 3/14/24 at approximately 8:46 P.M.

Review of Patient #11's Daily Progress Note written by Registered Nurse (RN) #4, dated 3/15/24, indicated on 3/14/24 at approximately 8:00 P.M., RN#4 responded to a call light for Patient #11's room. Patient #11 reported to RN#4 that he/she did not feel well and had gotten up to use the bathroom and became short of breath. RN#4 notified the charge nurse (RN#5) and returned to Patient #11's room with RN #5. Patient #11 appeared anxious and agitated and reported his/her left shoulder was hurting. Patient #11's blood pressure was 113/63, and his/her pulse was 145. RN#4 prepared and administered Ativan (an anxiety medication 3 milligrams (mg) intramuscularly (IM) and Hydroxyzine (a medication used to treat anxiety) 50 mg orally (PO) around 8:05 P.M. and RN#5 notified the physician of Patient #11's symptoms and vital signs via telephone. At approximately 8:10 P.M., RN#4 prepared and administered Metoprolol Tartrate ((medication to slow heart rate) 25 mg PO per new physician orders. The note further indicated that after Patient #11 received the IM Ativan, PO Hydroxyzine and PO Metoprolol Tartrate, the Patient stated he/she did not feel any relief and that his/her chest was starting to hurt when breathing in. RN #4 reported to RN #5 that Patient #11 was having chest pain with inspiration and it was decided to implement the chest pain protocol of giving Aspirin (ASA) 325 mg and Gaviscon (a medication to treat heartburn and indigestion) 30 milliliters (mL) and to page the physician for an order to send Patient #11 to the Emergency Department and page the Nursing Supervisor to assist. The Note indicated RN #4 stayed by the phone to wait for the doctor and RN #5 went to get the Aspirin and Gaviscon. The Nursing Supervisor (RN #6) arrived at the unit and went to check on Patient #11. The Note indicated RN #6 called out to RN #4 from the Patient's room that he/she appeared to be having a seizure and to call Code Blue and 911.

During an interview on 4/10/24 at 2:25 P.M., RN #4 said certain vital signs, such as elevated pulse or blood pressures require physician notification. RN #4 said a pulse above 120 warrants physician notification. RN #4 said nurses and Treatment Assistants (TAs) can obtain patient vital signs and that if a TA obtains vital signs that are outside of the parameters, they should notify the nurse. RN #4 said she was admitting patients the night of Patient #11's event and happened to be admitting another patient to Patient #11's unit and observed the Patient's call light was going off, so she responded. RN #4 said Patient #11 reported getting up to use the bathroom and having trouble catching his/her breath. RN#4 said she immediately notified RN #5, who was the charge nurse and assessment nurse that night. RN#4 said she and RN #5 assessed Patient #11 together and the Patient's pulse rate was fast, but his/her oxygen saturation (O2) was good. RN #4 said she prepared and administered Ativan intramuscularly (IM) and Hydroxyzine by mouth (PO) and RN #5 telephoned the physician and obtained new orders for Metoprolol PO and RN #4 prepared the medication. RN #4 said she went to Patient #11's room to give him/her the Metoprolol and Patient #11 was having visible trouble catching his/her breath and reported he/she was having pain in his/her chest. RN #4 said she notified RN #5 and they decided to initiate the Hospital's chest pain protocol, which involves administering Aspirin (ASA) and Gaviscon (a medication to treat heartburn and acid indigestion). RN #4 said she then left Patient #11 to go to the nursing station to page the nursing supervisor and MD and RN #5 left the room to get the ASA and Gaviscon from the med nurse. RN #4 said the nursing supervisor, RN #6, responded to the unit within a minute and RN #6 went into Patient #11's room and yelled to call a Code (an overhead page used for a medical emergency). RN #4 said she called the Code, grabbed the code cart, and brought it to Patient #11's room and called 911. RN #4 said Patient #11 was transferred to an outside hospital after this. RN #4 said she doesn't think anyone stayed with Patient #11 after he/she reported chest pain and was having visible difficulty catching his/her breath after receiving IM Ativan and PO Metoprolol and said she was unaware of any re-education done after this event.

During an interview on 4/10/24 at 4:30 P.M., RN #5 said she was told Patient #11 was not feeling well by another nurse (RN #4), so she went to see the Patient. RN #5 said at that time she was the charge nurse and responsible for patient assessments, so she immediately went to the room to assess Patient #11 and he/she said he/she wasn't feeling well. RN #5 said Patient #11 said he/she was anxious and appeared anxious and she, RN #4, and a Treatment Assistant (TA) were all in the Patient's room and checked his/her vital signs which indicated an elevated heart rate in the 140s. RN #5 said she immediately went to call the doctor on call to notify them of the abnormal pulse and also got an order for Metoprolol to help lower the heart rate. She said RN #4 administered medications to Patient #11 and that a short time later, RN #4 came to her and reported Patient #11 said that his/her chest hurts when he tries to breathe, and he/she still was not feeling well. RN #5 said the Hospital has a chest pain protocol which indicates if chest pain is involved, patients get transferred out to an acute care hospital and there is a protocol to give ASA and Gaviscon. RN #5 said when she asked Patient #11 where the pain was, he/she pointed to his/her left shoulder, so she explained to Patient #11 that she is applying chest pain protocol. RN #5 said she then went to the medication nurse to get the Gaviscon and ASA so she could administer it to the Patient and RN #4 went to the nurses' station and paged the doctor and nursing supervisor (RN #6). RN #5 said the nursing supervisor arrived after RN #4 paged her and when RN #6 arrived, RN #5 was still waiting for the medications. She said after RN #6 arrived, RN #6 yelled to call a code and when RN #5 entered the room with the medications, Patient #11 was observed to be leaning on one side, couldn't take any PO meds and was no longer verbal. RN #5 said she and RN #6 elevated the head of the Patient's bed and nursing staff responded to the Code that had been called and the Patient was eventually transferred to an outside hospital. RN #5 said she tried her best to make sure staff remained with Patient #11 after he/she reported chest pain but was unable to say if an RN remained with Patient #11 after the Patient reported chest pain and trouble breathing.

During an interview on 4/10/24 at 4:22 P.M., RN #6 said Treatment Assistants (TA) can obtain vital signs and that normally once a TA is done checking vital signs, they put it in the computer and write it on the paper census and give it to charge nurse to review for abnormal readings. RN #6 said for vital signs outside of parameters, the nurse will re-check the pulse manually, and if it's still elevated would notify the physician. RN #6 said the night of Patient #11's event she was filling in for the normal nursing supervisor and she was the only nursing supervisor in the Hospital. RN #6 said she was in the supervisor's office completing another patient's admission and was going to bring that patient's medications to the medication room. RN #6 said she received a call from RN #4 that it was busy on Patient #11's unit and she needed help and when RN #6 arrived to the unit, RN #4 said Patient #11 didn't feel well and told her that the Patient had reported chest pain. RN #6 said she went to go assess Patient #11, and that the Patient's room was adjacent to the medication room, so as she was walking to drop another patient's medications off to the med room, she could see into Patient #11's room. RN #6 said Patient #11 was sitting on his/her bed and was observed gasping. RN #6 said she quickly went into Patient #11's room and the Patient was not talking, so she yelled to call a Code. RN #6 said Patient #11 was not responding to a sternal rub (application of the knuckles of a closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli). RN #6 said no one was in the room with Patient #11 when she first arrived to the room, but a Treatment Assistant (TA) was going back in to recheck vital signs right when she arrived. RN #6 said a patient reporting chest pain should not have been left alone and someone should have been in the room with Patient #11. RN #6 said RN #5 came back in the room after she arrived and the Patient's vital signs were checked again, which indicated a low blood pressure and high pulse. RN #6 said shortly after this, Patient #11 stopped breathing, became pulseless and Cardiopulmonary Resuscitation (CPR) was initiated by nursing staff. RN #6 said CPR continued until paramedics arrived to take over and transport Patient #11 to an outside hospital. RN #6 said she was unaware of any education completed with staff after this event.

During an interview on 4/11/24 at 12:48 P.M., the Hospital CEO said she was unsure if any education was done with nursing staff after Patient #11's event and was unable to say if any education had been completed for TAs after this event. The CEO acknowledged that Patient #11's abnormal pulse was not communicated to the physician and said she thought that Patient #11 had been left with a TA after reporting chest pain and acknowledged that TAs are unable to perform nursing assessments and acknowledged that an RN did not remain with Patient #11 to monitor the Patient after he/she reported chest pain and difficulty breathing to RN #4.

The Hospital failed to ensure Patient #11's abnormal vital signs were reported to the physician and failed to ensure Patient #11 was monitored by a Registered Nurse (RN) after experiencing an acute change in condition. Patient #11 reported difficulty breathing and chest pain and was left unmonitored by an RN for a period of time after reporting the chest pain and subsequently became apneic and pulseless.

2. Patient #7 was admitted to the Hospital in November 2023 for alcohol dependence/ withdrawal.

Review of Patient #7's Detox Progress Note dated 11/26/23 indicated the Patient had Hypokalemia (low potassium levels that can cause fatigue, muscle cramps and abnormal heart rhythms) and medications were ordered: 40 milliequivalents (meq) Potassium Chloride (KCl) x 1, 1 liter of Normal Saline intravenous (IV) with 40 meq potassium with an additional 40 meq 4 hours later and a repeat potassium level for the next morning.

Review of Patient #7's Detox Progress Note dated 11/27/23 indicated Patient #7 was not seen as they were sent to the hospital for hypokalemia and low blood pressure prior to medical rounds.

Review of Patient #7's Medication Administration Record for 11/26/23- 11/27/23 failed to indicate the Potassium treatments were administered as ordered.

Review of Patient #7's Registered Nurse Daily Progress Note dated 11/27/23 at 5:00 A.M. indicated the treatment noted for Patient #7 in the provider's progress note, intended for treating a Potassium (K+) level of 2.9 (normal range is 3.6-5.2) had not been provided to the Patient. Nursing supervisor notified and the provider was called. Patient #7's blood pressure was 80/55 and an order was given to send the Patient to the Emergency Department (ED) for evaluation and treatment.

Patient #8 was admitted to the Hospital in November 2023 for alcohol dependence/ withdrawal.

Review of Patient #8's Registered Nurse Daily Progress Note dated 11/27/23 at 8:17 A.M. indicated the Patient had received treatment for low potassium including Potassium Chloride (KCl) 40 meq by mouth x 2 doses and a liter of Normal Saline with Potassium 40 meq Intravenous (IV) x 1. The Daily Progress Note further indicated this treatment was intended for a different patient and the nursing supervisor and provider were notified and the Patient was transferred to the ED for evaluation and treatment.

Review of Patient #8's Medication Administration Record indicated that on 11/26/23, Patient #8 received the following medications:
-12:29 P.M., Patient #8 received KCl 40 meq by mouth
-12:57 P.M., an IV was started and Patient #8 received Normal Saline with 40 meq Potassium via IV at a rate of 175 milliliters per hour
-5:23 P.M., Patient #8 received KCL 40 meq by mouth

Review of Patient #8's Detox Progress Note dated 11/27/23 indicated the Patient was sent out for evaluation in the ED after being given IV fluids containing potassium by mistake.

During an interview on 1/25/24 at 12:44 P.M., Nursing Supervisor #1 said she had gotten a report that the medication error had occurred, and that Patient #8 had received the medication intended for Patient #7.

During an interview 1/25/24 at 11:33 A.M., Registered Nurse (RN) #1 said for medication orders and administration, there should be 2 identifiers checked: patient name and date of birth (DOB). RN#1 said he was the nurse who received the critical lab results over the phone and said Patient #7 and #8 had the same first name. RN#1 said he called the provider to report the critical potassium level for Patient #7 and entered the medication order for Patient #8, instead of Patient #7. RN#1 said he put the potassium orders in for the wrong patient and that Patient #8 received the medications intended for Patient #7.

During an interview on 1/25/24 at 12:14 P.M., the Chief Nursing Officer said coaching and counseling was done with RN#1 after the event but was unable to provide any re-education or additional corrective actions performed as a result of the medication error. The Chief Nursing Officer said orders should be entered electronically by the provider directly during weekdays and weekend mornings and outside of those hours, nurses will enter the order as a telephone order. The Chief Nursing Officer said for potassium orders, a second nurse will verify the order and, in this case, the 2nd nurse verifying the order but was unaware that RN #1 had entered the potassium orders for the wrong patient.

The Hospital failed to provide care in a safe setting by failing to administer medications as intended for Patient #7 and instead administering the medications for Patient #8.