HospitalInspections.org

Based on observations including video recordings, interviews, review of medical record and incident/event documentation for 29 of 40 patients reviewed (Patients 59, 61, 63, 65, 66, 67, 68, 69, 70, 71, 72, 76, 77, 79, 81, 82, 83, 84, 85, 86, 87, 88, 89, 93, 94, 95, 97, 98 and 99), and review of policies and procedures and other documentation it was determined that nursing services had not been organized and managed by a director of nursing who was responsible to ensure the delivery of safe and appropriate care to patients who experienced skin alterations, changes of condition, falls, medication errors and other incidents that resulted in potential or actual harm.

Findings include:

1. Refer to the findings cited under Tag A395, CFR 482.23(b)(3), CoP Nursing Services - Standard: RN supervision and evaluation of nursing care for each patient.

2. Refer to the findings cited under Tag A396, CFR 482.23(b)(4), CoP Nursing Services - Standard: Development and maintenance of a nursing care plan for each patient.

3. Refer to the findings cited under Tag A405, CFR 482.23(c), CoP Nursing Services - Standard: Preparation and administration of drugs.

4. Refer to the findings cited under Tag A115, CFR 482.13, CoP Patient's Rights.

Based on observations including video recordings, interviews, review of medical record and incident/event documentation for 29 of 40 patients reviewed (Patients 59, 61, 63, 65, 66, 67, 68, 69, 70, 71, 72, 76, 77, 79, 81, 82, 83, 84, 85, 86, 87, 88, 89, 93, 94, 95, 97, 98 and 99), and review of policies and procedures it was determined that nursing services had not been organized and managed to ensure the delivery of safe and appropriate care to patients who experienced skin alterations, changes of condition, falls, medication errors and other incidents that resulted in potential or actual harm.

Findings include:

1. Refer to the findings cited under Tag A395, CFR 482.23(b)(3), CoP Nursing Services - Standard: RN supervision and evaluation of nursing care for each patient.

2. Refer to the findings cited under Tag A396, CFR 482.23(b)(4), CoP Nursing Services - Standard: Development and maintenance of a nursing care plan for each patient.

3. Refer to the findings cited under Tag A405, CFR 482.23(c), CoP Nursing Services - Standard: Preparation and administration of drugs.

4. Refer to the findings cited under Tag A115, CFR 482.13, CoP Patient's Rights.

Based on interviews, review of medical record and incident/event documentation for 8 of 8 patients reviewed for the provision of nursing services (Patients 59, 61, 69, 76, 83, 84, 86 and 97) and review of policies and procedures it was determined that the hospital failed to develop and implement clear and complete nursing services policies and procedures to ensure the development and maintenance of an individualized nursing care plan for each patient based on patient assessment.

Findings include:

1. Refer to the findings cited under Tag A395, CFR 482.23(b)(3), CoP Nursing Services - Standard: RN supervision and evaluation of nursing care for each patient that reflects a lack of individualized nursing care plans.

Based on review of medical record and incident/event documentation for 7 of 9 patients who experienced medication errors (Patients 68, 71, 77, 81, 87, 93 and 95) and review of policies and procedures it was determined that the hospital failed to develop and implement nursing services policies and procedures to ensure the provision of safe and appropriate care to prevent medication errors.

Medication practices did not conform with the "six rights of medication administration" to ensure that patients received care in a safe setting. Recognized standards of practice for the "rights of correct medication administration" are referenced on the Lippincott Nursing Center website on 08/06/2018 and are identified as the "Right patient...Right medication...Right dose...Right route...Right time...Right documentation."

This is a repeat deficiency previously cited at Tag A144 on the original survey completed on 12/13/2018.

Findings include:

1. There were no nursing services policies and procedures related to medication administration. The only related policy and procedure provided was titled "Medication Administration" dated as last revised "01/2019." That policy was identified as a "Pharmacy" policy and the "owner" was the "Pharmacy Manager." This two-page document contained broad language for the following three sections of the policy: Labeling and Dispensing; Controlled (Scheduled) Medications; and Medication Adminsitration Details. The "Medication Administration Details" section of the policy was incomplete and included no specific procedures or directions for how nursing services personnel were to administer medications. Under item "IV. Medication Administration - Nurse must check all 'five rights,'" the only language was "- Right Patient (must use two patient identifiers, ie. picture, DOB, name) - Right Drug - Right Dose - Right Time - Right Route." Other unclear and incomplete language in that section included "VI. When medication bar code is available for unit dose medications, medications will be scanned via HCS system to be documented on the MAR." and "VII. Check to ensure that each patient has swallowed his/her medications."

2. A progress note in the medical record of Patient 68 dated 01/31/2019 by an RN reflected "At 0635 this morning pt received a Zantac that was not ordered." A "Medication Occurrence (sic) Report" was dated and signed by the RN on 01/31/2019 at 0648 and reflected the Zantac 150 mg was administered to Patient 68 and "Staff was pulling morning meds. Had a med cup for a pt to bring to room. This pt walked up asking for things and morning meds. Stimulus on unit. Staff placed this pt (sic) morning med in the same cup as other pt."

The investigation of the error was inaccurate and incomplete. In the "Pharmacy Dispensing" section of the form the documentation inaccurately reflected that the pharmacy dispensed the "Wrong Medication." The "Administering" errors section of the form was blank and reflected there were no errors related to administration of the medication. The "Contributing factors" section was incomplete and although four items were checked such as "Last 2 hours of 12 hour shift" and "Stimulus on Unit," the item "5 rights not done before administering medication" was not checked for this case where the patient received the wrong medication. The "Patient Effect Severity Rating" was inaccurately identified as "0" and was "0-Patient not effected (occurrence did not reach patient - no missed doses or incorrect therapy)." The only "Action Taken" was "Had nurse return to educated (sic) and finish documentation" initialed by an unknown author and dated 01/31/2019 at 1700. Further, an "Incident Investigation Summary" form contained a note dated 01/31/2019 at 1700 that referred to an "override" failure of the "Medispense" machine that did not clearly correspond with the RN's description of how the error occurred.

3. A "Medication Occurrence (sic) Report" was dated and signed by the RN on 02/02/2019 at 1810 and reflected that three nurses had administered excess dosages of Lorazepam to Patient 71 on four occasions on 02/01/2019 and 02/02/2019 as "Four orders of medication given to pt from 2/1 - 2/2 as scheduled without CIWA being greater than 15. 0040, 0553 - [Nurse 1]. 1324, 1807 - [Nurse 2, Nurse 3]."

The "Contributing Factors" section of the form did reflect that the "5 rights not done before administering medication." However, other parts of the investigation of the error were inaccurate and incomplete. For example, in the "Administering" errors section of the form it reflected that the medication was given at the "Wrong Time" versus "Wrong Dose." There was no other evaluation of how three nurses made the same error on four consecutive occasions. The "Incident Investigation Summary" form contained an undated and unsigned note that reflected "Ativan scheduled for Q6 Hours for CIWA [greater than] 15. Pt scoring CIWAs less than 5. Four doses of Ativan given per this order...New order for PRN Ativan. Confusing order D/C'd." The "Investigation Summary / Outcome" section of the form reflected that "explained and educated staff that reading the entire order would've kept the error from happening....Nurse was confused by way that order is written on MAR by HCS (delete order)." The documentation did not clearly reflect that the investigation was adequate to identify all causes that resulted in three nurses making the same error consecutively or how three nurses failed to follow the "5 rights." Review of an attached copy of the MAR on which the medication order was documented reflected the order was clearly written and electronically printed as "Lorazepam tablet...1 mg...every six hours 0600, 1200, 1800, and 2345 for Lorazepam Protocol for CIWA greater than 15."

4. A "Medication Occurrence Report" reflected that Patient 87 received Tramadol 50 mg on 02/13/2019 at 0117 that was not ordered.

The investigation of the error was unclear, incomplete and not timely. The report was dated and signed on 02/17/2019 at 1251, four days after the error. An undated and unsigned "comment" was recorded as "Spoke to [Nurse 4]. [He/she] remembers calling for 1 time order. Told [him/her] to come in and correct the order." The "Administering" section of the form reflected the error was "Unordered Drug given" and "Controlled Substance Discrepancy." There was no "Contributing Factors" section on the report that had been on previously reviewed reports and there were no contributing factors otherwise identified. The "Incident Investigation Summary" form contained an undated and unsigned note that reflected "[Nurse 4] called, [he/she] denied giving any meds that night." However, another entry on that same form reflected "Reviewed cameras noted [Nurse 4] giving the med at time of incident and observed error screen on medispense. F/U call to follow today. Pt did get med. Will educate [Nurse 4] [he/she] is coming in tonight to correct order." Another note on the same form by a different author reflected "...spoke [with Nurse 4] 2/15/19 1915 believes [he/she] called for order." The "Investigation Summary / Outcome" section of the form further reflected a failure to thoroughly investigate this error as the DPI recorded on 02/15/2019 at 1120, prior to completion of the other entries, that "RN did not recall giving the pt the med, but video footage review confirmed that the RN did give the medication to the patient...Cause of error was unable to be determined as RN could not remember giving the med or any details about its administration." This entry was not consistent with the other documentation that reflected the RN "remembers calling for 1 time order" and "[he/she] is coming in tonight to correct order." Those additional concerning pieces of information were not investigated nor was there a final resolution of the error.

5. Medication error, progress note and MAR documentation reflected that Patient 95 received IM Ativan on 02/16/2019 at 0158 and IM Zyprexa on 02/16/2019 at 0159 inconsistent with physician orders that Ativan and Zyprexa were not to be given within one hour of each other.

Investigation documentation reflected that "Unfamiliar with the patients" and "Unit disruption" were the contributing factors but failed to identify the "5 rights not done before administering medication" entry on the medication error form. "Investigation Summary / Outcome" documentation by the DPI on 02/19/2019 at an illegible time reflected 'Pt was administered 2 PRN meds within an hour of each other when they should have been separated by 1 hour. Issue caused when one RN remain logged into HCS, causing the other RN to not recognize one PRN had already been administered." However, this investigation did not clearly explain or resolve how two different nurses could have accessed the medication dispensing machine, removed the IM medication, prepared the IM medication for injection, and administered the IM injection to the same patient within the span of one minute without each other being aware.

6. Medication error and MAR documentation reflected that Patient 93 received an excess dosage of SQ insulin on 02/15/2019 at 1105. Investigation documentation did not identify failure to follow the "5 rights" as a contributing factor and concluded that the error was "just an accident" as stated by the RN who administered the insulin.

7. Medication error and progress note documentation reflected that Patient 77 received a double dose of Oxycodone on 02/09/2019 at 0950 and investigation documentation reflected that "5 rights not done before administering medication."

8. Medication error, progress note and MAR documentation reflected that Patient 81 received Ativan two hours late on 02/10/2019 at 1955, and investigation documentation reflected there were no contributing factors to consider and "it must have been an oversight."