HospitalInspections.org

Based on medical record review, review of the facility's occurrence log and policies, facility P&T meeting minutes, and staff interview, it was determined the facility failed to ensure all medication errors were identified and reported. This failure directly impacted 1 patient (Patient # ) and had the potential to impact all patients receiving treatment at the facility by placing them at risk of incorrect medication administration. The findings include:

Facility policy #PH-121R3 Medication Errors, dated 7/07/17, stated "All medication errors will be reported on the Occurrence/Close Call Report.... Chief Compliance Officer and Pharmacist will report to P & T committee quarterly."

Patient #10 was a 10 year old male who was admitted to the ED on 5/31/19 for treatment of injuries received in an MVA.

Patient #10 's medical record documented "Fentanyl 15 mcg IV was order (sic), patient was given 50 mcg IV due to communication error. This was recognized within minutes...patient was placed on cardiac monitoring and pulse ox and respiratory therapy stayed at the bedside throughout the rest of his hospital stay."

Minutes of the P&T committee meeting, held on 6/17/19, documented "May 2019 - no med errors reported."

In an interview on 6/24/19 at 10:00 A.M., the facility pharmacist stated he had not received an occurrence report related to the medication error documented in Patient #10 's medical record.

The facility failed to ensure all medication errors were reported per policy.

Based on medical record review and staff interview, it was determined the facility failed to ensure medical record entries were completed by health care professionals for 8 of 10 patients (Patients #5,#6, #8, #13, #14, #18, #19, and #20) who presented to the ED and whose records were reviewed. This resulted in a lack of clarity regarding triage care and allowed the potential for a lack of continuity of care. Findings include:

a) Patient #5 was a 25 year old male who was admitted to the ED on 5/22/19 following an MVA.

Review of his medical record showed a hand written form, titled "ER Nursing Record," that had been scanned into the record. The form documented triage level, vital signs, pain level, and a systems assessment. The form documented the first name of the nurse assigned to his care. The form was not authenticated by signature and was not dated.

b) Patient #6 was a 56 year old male who was admitted to the ED on 5/29/19 following a Code Blue in the radiology department of the facility.

Review of his medical record showed a hand written form, titled "ER Nursing Record," that had been scanned into the record. The form documented triage level, vital signs, pain level, and a systems assessment. The form documented the first name of the nurse assigned to his care but the form was not authenticated by signature and was not dated or timed.

c) Patient #8 was a 42 year old male who presented to the ED on 5/31/19 complaining of a headache.

Review of his medical record showed a hand written form, titled "ER Nursing Record," that had been scanned into the record. The form documented vital signs. It did not include triage level, pain level, systems assessment, or staff assigned to his care. The form was not authenticated by signature and was not dated or timed.

d) Patient #13 was a 37 year old female who presented to the ED on 4/05/19 for a change in mental status.

Review of her medical record showed a hand written form, titled "ER Nursing Record," that had been scanned into the record. The form documented vital signs only with no triage level, pain level, or system assessment. The form documented the first name of the nurse assigned to her care but the form was not authenticated by signature and was not dated or timed.

e) Patient #14 was a 55 year old female who presented to the ED with the complaint of fever and chills.

Review of her medical record showed a hand written form, titled "ER Nursing Record," that had been scanned into the record. The form documented vital signs, triage level, and pain level. No systems assessment was documented. The form documented the first name of the nurse assigned to her care but the form was not authenticated by signature and was not dated or timed.

f) Patient #18 was a 16 year old male who presented to the ED with the complaint of fever.

Review of his medical record showed a hand written form, titled "ER Nursing Record," that had been scanned into the record. The form documented triage level, vital signs, pain level, and a systems assessment. The form documented the first name of the nurse assigned to his care but the form was not authenticated by signature and was not dated or timed.

g) Patient #20 was a 27 year old female who presented to the ED with the complaint of tongue swelling.

Review of her medical record showed a hand written form, titled "ER Nursing Record," that had been scanned into the record. The form documented vital signs, triage level, pain level and a partial systems assessment. The form documented the first name of the nurse assigned to her care but the form was not authenticated by signature and was not dated or timed.

h) Patient #20 presented to the ED with the complaint of weakness and fatigue.

Review of her medical record showed a hand written form, titled "ER Nursing Record," that had been scanned into the record. The form documented vital signs, triage level, pain level and a systems assessment. The form did not document the name of the nurse assigned to her care, was not authenticated by signature and was not dated or timed.

In an interview on 6/28/19 at 10:00 A.M., the Clinical IT nurse, who was performing CNO duties, confirmed the incomplete ER Nursing Records. She said the form was designed to be a guide for nurses and the expectation was for the nurses to transfer the information to the EMR.

In an interview on 6/27/19 at 9:05 A.M., the Director of Health Information said the hand written forms were scanned into the record when the information was not transferred to the EMR by the nurses.

In an interview on 6/26/19 at 5:05 P.M., the CCO confirmed the lack of complete triage and the lack of signature, date and time.

The facility failed to ensure patient records were complete.

Based on OTPO agreement review, Eye Bank agreement review, and staff interview, it was determined the facility failed to work cooperatively with the designated OTPO and Eye Bank in educating staff on donation issues. This failure had the potential for CAH staff to not identify potential donors, as well as failure to inform potential donor families of their donation options. Findings include:

The CAH/OTPO agreement, dated 10/23/17, stated "With the support of Hospital administration, [name of OTPO] will provide Hospital education for hospital staff by providing educational programs, in-services, and attending skills day when invited by the Hospital. These educational services are available to the Hospital at least annually, but may occur more frequently per hospital needs."

The CAH/Eye Bank agreement, signed 06/2017, stated "[name of Eye Bank] RESPONSIBILITIES: Provide [name of CAH] with periodic education to hospital [sic] medical [sic] and nursing staff members regarding eye donation."

In an interview on 6/26/19 at 5)00 P.M., the CCO stated facility staff had not received education from the OTPO or Eye Bank organizations.

The facility failed to ensure staff received education related to donation issues.

Based on staff interview and admission documentation review, it was determined the facility failed to ensure visitation rights were provided to each patient or his/her representative for 20 of 20 patients (Patients # 1-20) whose records were reviewed. This had the potential to interfere with the patients' choice to receive or not receive specified visitors, as well as patient understanding of the facility's possible need to restrict visitation. Findings include:

Consent forms were reviewed for admission to the facility and to swing bed status.

A pamphlet, available in the facility lobby, titled "Patient Rights and Responsibilities" was reviewed.

A pamphlet, available in the facility lobby, titled "Notice of Privacy Practices" was reviewed.

None of the documents reviewed contained information for patients related to visitation rights.

In an interview on 6/27/19 at 2:50 P.M., the CCO confirmed that patients were not informed of their visitation rights.

The facility failed to ensure patients, or their representatives, did not receive information related to their visitation rights.