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Based on review of medical records, policy and procedure, and staff interviews, it was determined that the facility failed to administer on the orders contained within an electronic standing orders, order sets, and protocols for patient orders of one patient (P)#1 out of six sampled patients by not titrating a blood pressure medication as per order to help manage P#1's blood pressure.

Findings:

A review of Patient (P)#1's medical record revealed that P#1 was admitted to the facility on 10/26/23 at 1:24 p.m. via the emergency department with the chief complaint of Altered Mental Status. P#1's blood pressure on arrival was 197/99 mmHg.

A review of the History and Physical (H&P) revealed that P#1's blood pressure at 1:44 p.m. was 219/99 mmHg, and Hydralazine (medication to treat high blood pressure) was given intravenously (via the vein) at 1:44 p.m. At 1:47 p.m., P#1's blood pressure was 206/94 mmHg. At 1:49 p.m., P#1's blood pressure was 207/102 mmHg.

P#1 had a Computed Tomography (CT) Scan of the head (a procedure to help detect internal bleeding) at 1:10 p.m. and a Neurological consultation, which confirmed that there was no acute bleeding in the brain, and P#1 was diagnosed with Acute Ischemic Stroke (occurs when the blood supply to part of the brain is interrupted or reduced, preventing the brain tissue from getting oxygen and nutrients).

Documentation of the physician orders at 1:42 p.m. revealed an order of Nicardipine (a medication that treats high blood pressure) to be titrated by 2.5 mg/hr with a titration maximum of 15 mg/hr. Documentation revealed that P#1's systolic blood pressure was to be maintained within the range of 160 to 179 mmHg, and the diastolic between 90 to 104 mmHg. Documentation revealed the infusion was to be initiated if the Systolic blood pressure was greater than/equal to 180 mmHg, or if the diastolic was greater than/equal to 105 mmHg.

A review of the physician orders revealed an order for Tissue Plasminogen Activator (tPA, Activase, Alteplase- a medication that facilitates the breakdown of blood clots) on 10/26/23 at 1:52 p.m.

Documentation of the medication administration record (MAR) on 10/26/23 revealed that the Nicardipine infusion was initiated at 1:59 p.m. at the rate of 5 mg/hr. P#1's blood pressure was 198/91 mmHg at 1:58 p.m. At 2:01 p.m., P#1's blood pressure was 174/77 mmHg. At 2:05 p.m., P#1's blood pressure was 174/77 mmHg. At 2:06 p.m., P#1's blood pressure was 156/72 mmHg.

A review of the medication administration record on 10/26/23 revealed that Alteplase bolus was administered at 2:07 p.m. and the Alteplase infusion at 2:08 p.m. P#1's blood pressure at 2:11 p.m. was 181/84 mmHg.

Documentation under the physician progress notes on 10/26/23 revealed that a repeat CT scan was done at 2:49 p.m., which revealed no acute bleeding.

Documentation under the medication administration record revealed that the tPA infusion was stopped at 3:10 p.m.

At 2:20 p.m., P#1's blood pressure was 192/86 mmHg.
At 2:30 p.m., P#1's blood pressure was 197/89 mmHg.
At 2:41 p.m., P#1's blood pressure was 135/73 mmHg.
At 2:55 p.m., P#1's blood pressure was 133/77 mmHg.
At 3:10 p.m., P#1's blood pressure was 160/90 mmHg.
At 3:20 p.m., P#1's blood pressure was 165/77 mmHg.
At 3:25 p.m., P#1's blood pressure was 164/85 mmHg.
At 3:40 p.m., P#1's blood pressure was 185/89 mmHg.
At 4:00 p.m., P#1's blood pressure was 175/80 mmHg.
At 4:08 p.m., P#1's blood pressure was 197/91 mmHg.
At 4:15 p.m., P#1's blood pressure was 198/89 mmHg.

A review of the nursing progress notes revealed that P#1 was transferred to the intensive care unit on 10/26/23 at 4:30 p.m. as per the facility's protocol. P#1's blood pressure was 180/78 mmHg at the time of transfer.

At 4:45 p.m., P#1's blood pressure was 175/85 mmHg.
At 5:00 p.m., P#1's blood pressure was 179/84 mmHg.
At 5:15 p.m., P#1's blood pressure was 169/79 mmHg.
At 5:30 p.m., P#1's blood pressure was 156/74 mmHg.
At 5:45 p.m., P#1's blood pressure was 161/72 mmHg.
At 6:00 p.m., P#1's blood pressure was 173/77 mmHg.
At 6:15 p.m., P#1's blood pressure was 176/81 mmHg.
At 6:33 p.m. and 6:36 p.m., P#1's blood pressure was 178/86 mmHg.
At 6:45 p.m., P#1's blood pressure was 214/101 mmHg.

Documentation failed to reveal that the Nicardipine infusion was titrated as per the physician orders from 1:59 p.m. to 7:00 p.m.

Documentation under the physician progress notes revealed an order for a CT scan on 10/26/23 at 6:22 p.m., however, documentation revealed that P#1's heart rate dropped while being transferred for CT, and had to be taken back to the Intensive Care Unit (ICU) to be intubated (insertion of a tube through the airway so that air can get through) at 6:54 p.m.

Documentation under the medication administration record (MAR) on 10/26/23 revealed that the next titration of the nicardipine was done at 7:00 p.m. at the rate of 10 mg/hr. P#1's blood pressure was 152/101 mmHg.

At 7:05 p.m., the titration was at 12.5mg/hr. P#1's blood pressure was 164/79 mmHg.

At 7:27 p.m., the titration was decreased to 10 mg/hr. P#1's blood pressure was 160/77 mmHg.

At 7:30 p.m., titration was reduced to 7.5 mg/hr. No blood pressure documentation.

At 7:32 p.m., the titration was reduced to 5 mg/hr. P#1's blood pressure was 155/85 mmHg.

At 7:50 p.m., the titration was decreased to 2.5 mg/hr. P#1's blood pressure was 152/73 mmHg.

At 7:55 p.m., the titration was stopped. P#1's blood pressure was 140/74 mmHg.

At 8:32 p.m., P#1's blood pressure dropped to 88/59 mmHg.

At 9:30 p.m., P#1's blood pressure was 163/79 mmHg.

At 10:02 p.m., P#1's blood pressure was 180/88 mmHg.

At 10:15 p.m., P#1's blood pressure was 99/52 mmHg.

At 10:30 p.m., P#1's blood pressure was 184/103 mmHg.

At 11:15 p.m., P#1's blood pressure was 108/61 mmHg.

On 10/27/23 at 6:02 a.m., P#1's blood pressure was 82/50 mmHg.

At 10:02 a.m., P#1's blood pressure was 127/66 mmHg.

At 1:02 p.m., P#1's blood pressure was 121/60 mmHg.

P#1 expired on 10/27/23 at 2:55 p.m. P#1's family notified.

A review of the facility's policy titled "Medical Administration" policy # F-027, last revised 10/17/22, revealed that the professional care nurse was responsible for the administration and documentation of medications.

A review of the facility's policy titled "Medication Order Types" policy # 23763, last revised 10/09/23 revealed that titrating orders were orders in which the dose was progressively increased or decreased in response to the patient's status (Common examples: critical care infusions, dopamine, lorazepam). If a patient required multiple titratable infusions for the same clinical indication and/or clinical endpoint, the most recently ordered infusion would take priority in being titrated unless specifically ordered otherwise by the provider.

A review of the facility's policy titled "Assessment and Documentation of the Emergency Department Patient" policy # 6902-36, last revised 2/2023 revealed it was the policy of Northside Hospital Gwinnett Emergency Services to assess all patients. The assessment began with triage and progressed through the initial assessment, ongoing reassessment and through the patient's final disposition. Further review revealed reassessments would occur if the patient was unstable, defined as having abnormal vital signs, receiving medications titrated for effect, receiving fluid boluses, or by deterioration in condition.

An interview took place in the conference room on 11/13/23 at 4:16 p.m. with Director, Neuroscience (DN) DD who stated that the staff administered the tPA to P#1 once she (P#1) exhibited stroke-like symptoms and the CT head confirmed there was no hemorrhage. DN DD stated that the tPA was administered within the window period to prevent complications from the stroke.

A telephone interview took place in the conference room on 11/14/23 at 10:35 a.m. with Nurse Practitioner (NP) FF who stated that P#1 was admitted to the intensive care unit (ICU) for the post tPA pathway as per protocol. NP FF stated that P#1 declined in mental status while waiting on CT, and she (P#1) became hemodynamically unstable (abnormal or unstable blood pressure). NP FF stated that she reported to the physician and updated P#1's treatment plan.

A telephone interview took place in the conference room on 11/14/23 at 11:00 a.m. with Clinical Supervisor (CS) HH who stated that tPA bolus was usually given at the Emergency department (ED), and the medication is managed by the pharmacy. CS HH stated that patients are received in the intensive care unit (ICU) after the bolus and the physician orders are strictly followed.

A telephone interview took place in the conference room on 11/14/23 at 2 p.m. with Registered Nurse (RN) II who stated that staff always made sure vitals were checked during tPA administration. RN II stated that when she noticed P#1 was coughing up blood, she (RN II) notified the physician who ordered an intravenous dose of Pepcid (medication to treat acid reflux), which was given. RN II stated that she could not recall if P#1 was on a cardiac infusion and if she (P#1) had any other anti-hypertensive medication.

A telephone interview took place in the conference room on 11/14/23 at 2:30 p.m. with Medical Doctor (MD) JJ who stated that any patients on tPA are admitted to the intensive care unit as per the stroke protocol. MD JJ stated that P#1 was on a Nicardipine drip (medication used to treat high blood pressure), and the blood pressure would not go down if the medication was not titrated as per order.

A telephone interview took place on 11/14/23 at 4:30 p.m. with Registered Nurse (RN) BB who stated that she could not recall if P#1 was on an infusion. RN BB stated that if a patient was on a Nicardipine drip, the medication would be titrated off the order parameters. RN BB further stated she could not recall if P#1 was on Nicardipine infusion.