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Based on observation, interview and record review, the facility did not meet the Condition of Participation with regard to Nursing Services as evidenced by:


A.
Facility failure to follow policy and procedure for fall prevention for 2 (two) of 10 (ten) patients (Patient 28 and Patient 31). This deficient practice had the potential for injury if a fall should occur for Patient 28 and Patient 31.
(Refer to A-0398)

B.
Facility failure to:
1. Ensure one (1) of 33 sampled patients would not receive a wrong intravenous medication (Patient 1);

2. Ensure nurses would prepare patient specific labels in preparation for medication administration for 2 of 33 sampled patients (Patient 1 and 3).

These deficient practices had caused, or the potentials of medication errors and/or adverse event that may or may not affect patients' health condition.
(Refer to A-0405)

Based on observation, interview, and record review, facility failed to follow policy and procedure for fall (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level) prevention for 2 (two) of 10 (ten) patients (Patient 28 and Patient 31).

1. On 6/27/2022, at 2:38 pm, Patient 28 was found with bed in a position that required lowering the bed height.

2. On 6/28/2022 12:58 pm, Patient 31 was found with bed in a position that required lowering the bed height.

This deficient practice had the potential for injury if a fall should occur for Patient 28 and Patient 31.

Findings:

1. A review of Patient 28's Patient Information Sheet, printed 6/29/2022, indicated Patient 28's facility Registration Time was 6/17/2022 at 9:19 pm.

A review of Patient 28's History and Physical (H&P), dated 6/17/2022, indicated Patient 28 was found unresponsive and was in respiratory distress (condition that causes low blood oxygen). H&P indicated Patient 28 was admitted for acute respiratory failure (inability of the respiratory system to meet the oxygenation or ventilation [air flow in and out] of the patient) requiring intubation (process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea [airway/windpipe]. The tube keeps the trachea open so that air can get through), and COPD (Chronic obstructive pulmonary disease, refers to a group of diseases that cause airflow blockage and breathing-related problems).

A review of Patient 28's documentation for Falls Information: Fall Risk Scale John Hopkins (tool developed as part of an evidence-based fall safety initiative; Scoring: less than 6 points = Low fall risk, 6 to 13 Total Points = Moderate Fall Risk, more than 13 Total Points = High Fall Risk), dated 6/27/2022, at 7:00 am, indicated Patient 28's fall risk score was more than 13, Fall Risk level: "High".

A review of Patient 28's Fall Risk Care Plan (process that correctly identifies existing needs and recognizes potential needs or risks), initiated 6/18/2022, at 4:39 am, indicated interventions include bed in low position.

During a concurrent observation and interview on 6/27/2022, at 2:35 pm, with Nurse Manager (NM) -03, Patient 28's bed was observed with orange colored light projecting on the floor. Observed NM-03 enter Patient 28's room and adjust the bed height to a lower position. NM-03 stated, bed should have been in the lowest position for fall precaution.

2. A review of Patient 31's Patient Information Sheet, printed 6/29/2022, indicated Patient 31's facility Registration Time was 6/27/2022 at 7:11 p.m.

A review of Patient 31's History and physical (H&P), dated 6/28/2022, indicated Patient 31 was brought in by family for dizziness and syncopal (fainting or passing out) episodes since 6/14/2022. H&P indicated, Patient 31 was admitted for acidosis (condition in which there is too much acid in the body fluids and can cause serious complications), Alzheimer's Disease (type of dementia that affects memory, thinking and behavior), hypertension (high blood pressure), and memory disorder (disorders of cognition, the ability to reason, remember, make decisions and communicate).

A review of Patient 31's documentation for Falls Information: Fall Risk Scale John Hopkins, dated 6/28/2022, at 7:00 a.m., indicated Patient 31's fall risk score was 13, Fall Risk level: "Moderate".

A review of Patient 31's Fall Risk Care Plan, initiated 6/28/2022, at 1:32 p.m., indicated interventions include bed in low position.

During a concurrent observation and interview on 6/28/2022, at 12:58 pm, with Registered Nurse (RN) -09, Patient 31's bed was observed with orange colored light projecting on the floor. Observed RN-09 enter Patient 31's room and adjust the bed height to a lower position. RN-09 stated, bed was not down. RN-09 stated, bed should have been down for safety.

During an interview on 6/28/2022, at 1:00 p.m., with RN-11, RN-11 stated, RN-11 was the primary nurse assigned to Patient 31. RN-11 stated Patient 31 had multiple medical concerns and was on fall precautions.

A review of the facility's Smart Bed Reference Guide, [no date], indicated "A green 'Bed in Lowest Position' icon shows when the bed is not in the lowest position. The icon flashes amber when the bed is not in the lowest position."

A review of facility policy and procedure (P&P), titled "Fall Prevention," effective date 07/25/2017, revised 5/28/2021, indicated a purpose "To establish a program for assessing patients for risk factors, reduction in patient falls, and protecting patients from injury if a fall should occur." Policy indicated "1. Initial Assessment/ Screening: A. Within 4 hours of admission to the unit, an RN will complete the "John Hopkins Fall Risk Assessment Tool" assessment tool." Policy further indicated "4. Plan of Care: A. Strategies to prevent falls for all patients regardless of risk score may include but are not limited to: ... 7. Locked bed in lowest position."

Based on observation, interviews, and record review, the hospital failed to:

1. Ensure one (1) of 33 sampled patients would not receive a wrong intravenous (IV, medication administered through the veins for a faster effect on the body) medication (Patient 1);
2. Ensure that nurses would prepare patient's medication for administration on containers with proper labelling for 2 of 33 sampled patients (Patient 1 and 3)

These deficient practices had the potential for the patients to experience adverse reaction from the medication errors which may affect patients' health condition.

Findings:

1. During an interview on 6/29/2022, at 12:49 p.m., with the director of intensive care unit (DIR 03) in the presence of the registered nurse supervisor (RNS 02), RNS 02 stated Patient 1 was admitted to the intensive care unit from the emergency department on 1/18/202,1 at 10:55 p.m., for septic shock (a life threatening condition that happens when the blood pressure drops to a dangerously low level after an infection) and respiratory failure (a serious condition that happens when the lungs cannot get enough oxygen into the blood). DIR 03 said Patient 1 was a long term ventilator (a machine that helps a patient breathe) dependent resident at a nursing home before admission to the hospital. RNS 02 stated Patient 1 was taking medications including norepinephrine (generic for Levophed, a medication to treat low blood pressure and heart failure). DIR-03 also stated Patient 1 had "do not resuscitate" order (a medical order signed by a physician at a patient's request that instructs health care providers not to do cardiopulmonary resuscitation or CPR, if the patient stop breathing or the heart stop beating) established during the stay in the emergency department.

A review of Patient 1's norepinephrine (also known as Levophed; medication used to treat life threatening low blood pressure) order, dated 1/18/2021, at 2:20 p.m., indicated to titrate (the process of adjusting the dose of a medication for the maximum benefit without adverse effects) by 2 micrograms (mcg a unit of measurement) per minute every 5 minutes to keep systolic blood pressure (the pressure exerted when the heart beats and blood is ejected into the arteries) greater than 90 millimeters of mercury (mmHg, the unit of measuring blood pressure).

During an interview on 6/29/2022, at 12:55 p.m., Director of Pharmacy (DOP) stated the barcode scanning (a process when a nurse scans a barcode on the medication to verify the right medication was being administered) record showed the night shift registered nurse (RN 14) scanned the barcode of norepinephrine for Patient 1 at 6:33 a.m. on 1/19/2021, however, RN 14 hanged (administered) the fentanyl drip (a controlled substance and potent opioid [group of pain relieving drugs] used to treat severe pain) instead of norepinephrine for Patient 1. RNS 02 recalled the event occurred to Patient 1 on 1/19/2021 at around 7 a.m., Patient 1's IV pump (device that delivers fluids and medications at a controlled amount) was sounding alarm which indicated the medication was finished and needed exchange.

During an interview, on 6/29/2022, at 1:15 p.m., DIR 03 stated Patient 1 did not have an order for fentanyl but RN 14's other assigned patient was on fentanyl drip. DIR 03 also stated RN 14 scanned Patient 1's emptied norepinephrine IV bag on 1/19/2022, at 6:33 a.m., instead of the fentanyl bag and then RN 14 "spiked and hang" (administered) the wrong medication, fentanyl drip, to Patient 1.

During an interview on 6/29/2022, at 1:19 p.m., DOP stated the fentanyl drip was a pre-mixed bag that had 100 milliters (ml) in volume, minus the tubing volume at roughly 10 ml and the pharmacy calculated wastage at 36 ml, DOP stated Patient 1 received roughly 54 ml (540 mcg) of fentanyl.

During an interview on 6/29/2022, at 1:23 p.m., RNS-02 stated that on 1/19/2021, at around 7:30 a.m., the day shift nurse (RN-15) reported to her (RNS-02) the discovery of fentanyl being administered in error to Patient 1; the correct medication norepinephrine was scanned as administered at 7:59 a.m. to Patient 1. Then, at 8 a.m. on 1/19/2021, RNS-02 stated Patient 1's blood pressure started to drop, bradycardia (low heart rate) occurred, and the attending physician ordered atropine (medication to increase heart rate) which was administered at 8:05 a.m.; however, Patient 1 was pronounced dead at 8:10 a.m.

During an interview on 6/29/2022, at 1:40 p.m., DIR 03 stated RN 14 failed to perform eight (8) rights (right patient, right medication, right route, right time, right reason, right documentation, right monitoring, right response) of medication administration to check if it was the right medication for the right patient.

A review of the facility's policy and procedure (P&P), titled "Intravenous Therapy," revised on 7/24/2018, indicated " ... Before administration of any drug, the licensed practitioner should review the Eight Rights: Right patient. Right Drug, ..."


2a. During an interview on 6/29/2022, at 12:55 p.m., RNS 02 stated that the event occurred to Patient 1 on 1/19/2021. RNS 02 stated she (RNS 02) saw the emptied fentanyl premix bag that was connected to Patient 1 and the bag did not have a patient specific label on it. RNS 02 stated such label should have at least patient's name, date and time of administration, and the initial of the person who administered the bag.

During an interview on 6/29/2022, at 1:40 p.m., DIR 03 stated RN 14 failed to affix patient specific label to the fentanyl premix bag and that the process of making such label would have probably alerted the nurse to double check the patient's correct name and medication.

A review of the facility policy and procedure (P&P) titled "Intravenous Therapy," revised on 7/24/2018, indicated " ... All IV bags must have the date, time, and initials of nurse "hanging" the solution or medication."

2b. During a medication administration observation on 6/28/2022, at 2:45 p.m., in the intensive care unit (ICU), in the presence of the DOP and the nurse manager of ICU (NM 04), the registered nurse (RN 16) accessed the automated dispensing cabinet (Pyxis) and retrieved 1 vial of fentanyl 100 microgram in 2 milliliters (mcg/ml, a unit of measurement) injection for Patient 3. RN 16 withdrew 0.5 ml into one syringe and wasted the remainder with another nurse. Then RN-16 brought the syringe to Patient 3's room.

A review of Patient 3's physician order for fentanyl, dated 6/28/2022, at 2:33 p.m., indicated Patient 3 was to receive fentanyl 25 mcg (0.5 ml) every 4 hours as needed for severe pain (score 7 to 10).

During an interview on 6/28/2022, at 2:54 p.m., DOP confirmed the aforementioned fentanyl syringe prepared for Patient 3 did not have any label (name of medication, dose, etc.) affixed.

During an interview on 6/30/2022, at 9:56 a.m., the executive administrator of Quality and Patient Safety stated the syringe that contained medication withdrawn from a vial should have a label with at least the patient's name.

A review of the facility policy and procedure (P&P), titled "Automated Dispensing Machine Access and Use," revised 5/18/2021, indicated "... Place the medications removed from the [Automated Unit Dose System] in a clearly labeled, patient specific, container ..."