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Based on review of hospital policies and procedures, Patient #4's medical record, other documents, and staff interviews, it was determined the administration failed to require staff to report Level I medication errors to the Quality Assessment and Performance Improvement (QAPI) program.
This deficient practice poses a risk to the patient's health and safety when the quality program fails to identify opportunities for improvement, reduce potential errors, and improve patient care.

Findings include:

The hospital policy titled Patient Complaint/Grievance Process (last revised 2/1/2016) requires: "...Concerns/complaints and grievances are logged for data management and filed by the facility DQRM. The facility DQRM will work with the facility Directors and Managers to facilitate performance improvement activities related to complaints and grievances...."

The hospital policy titled Medication Error Reporting (reviewed 10/3/2017) revealed: "...A medication error is defined as any deviation from established policies and/or procedures during the prescribing, transcribing, dispensing, administering, and monitoring of a drug...Security levels are assigned to each occurrence so that plans for improvement can be effectively and efficiently managed...Level I: The problem was corrected before it reached the patient...Level I is considered a potential error. These should be tabulated and reviewed as part of the hospital's medication use program. Information can be used to identify weak places in the system and improvements can be implemented to reduce the numbers...."

Patient #4's medical record contained a physician's order to discontinue the Ceftriaxone (Rocephin) on 3/11/2019. This medication continued to appear on the MAR on 3/12/2019 and 3/13/2019 with an administration time of 10:00.

Hospital document dated 3/21/2019, identified the following concerns reported by Patient #4: "...4/11/2019...[Dr.'s name] stated that she would make sure that the order for the discontinuation of Rocephin would be written in the chart. We were assured that no further doses of the antibiotic would be administered...antibiotics are only to be used as needed, as our bodies can become resistant to them and not be effective...Tuesday, March 12th, the nurse came in wanting to administer Rocephin again and we told her that this medication was discontinued. We advised her to check the chart so she did. When she came back she admitted that it was discontinued and apologized...The day nurse on Wednesday, March 13th tried to give me Rocephin again...The day shift nurse tried to give it again on Thursday, March 14th the day I was discharged...."

Employee #2 confirmed in an interview conducted on 4/11/2019 that the hospital did not have any incident reports, complaints, grievances or medication administration error reports for Patient #4.

Employee #1 and Employee #13 confirmed in interviews conducted on 4/11/2019 and 4/15/2019 that s/he spoke to the patient, while the patient was hospitalized, regarding patient concerns about nursing staff taking an antibiotic into the patient's room after the physician had discontinued the medication. Employee #1 verified that a written complaint was received from the patient and provided a copy of the complaint on 4/15/2019.

Employee #2 confirmed in an interview conducted on 4/11/2019 that medication error reports were not required when the discontinued medication (Ceftriaxone / Rocephin) was taken into the patient's room after the Physician discontinued the medication on 4/11/2019. The medication continued to appear on the medication administration record until 4/14/2019. Employee #2 did not feel that this was a "near miss" or "Level I" error.

Based on review of facility policies/procedures, hospital documents, Patient #1's medical record, and staff interviews, it was determined the facility failed to:

1. ensure that nursing staff activated the "Rapid Response Team (RRT)" policy, once the patient experienced a change/deterioration in his/her medical condition, and
2. the respiratory therapist completed patient assessments on 4/6/2019 from 11:15 to 4/7/2019 at 06:20.

Findings include:

1. The hospital policy titled "Assessment/Re-Assessment, Interdisciplinary, Approved 4/3/2019" revealed: "...Patients receiving inpatient services will have an initial assessment and appropriate follow-up assessments based upon their individual needs...The assessment process will be a continuous inter-disciplinary function and a collaborative effort with all departments functioning as a care team...Information generated via a patient's assessment by all clinical disciplines will be integrated to identify and prioritize the patient's needs for care and treatment...Re-Assessment...Respiratory Care...Patients are assessed and results documented with each therapy for the following: Appropriateness of ordered therapies...Suggest alternate therapies...Review available x-ray results...Sputum production...Breath sounds before and after therapy...Physical response to treatment...Cough & Sputum production...Work of breathing...Adverse reactions to previous therapies...."

The hospital policy titled "Rapid Response Team (RRT), Reviewed 10/2016" revealed: "...A Rapid Response Team (RRT) shall be activated when a patient...experiences an acute change or deterioration in condition...Protocols...Rapid Response Team Protocols are utilized by the RRT members for the following change in patient's condition: Respiratory Distress...Symptomatic Hypotension...Chest Pain...Change in Mental Status...Changing Cardiac Rhythm...Possible RRT Events...Events that may precipitate a call for the Rapid Response Team (RRT) include but are not limited to: Sudden change in heart rate...New onset of dysrhythmias...Sudden change in systolic blood pressure or any significant changes in blood pressure systolic or diastolic...Sudden change in respiratory rate...Sudden change in oxygen saturation...Sudden change in mental status or Level of Consciousness...Failure to respond to treatment for an acute problem / symptom...."

VITAL SIGNS:

4/5/2019: respiratory rate was 16 - 26, blood pressure was 106/64 to 134/73, pulse 91 to 103, temperature was 98.0 - 99.3, and oxygen saturation was 91% to 97% on 4/5/2019 while on 35% oxygen via trach collar

4/6/2019: respiratory was 18-40, blood pressure 125/64 to 85/49, pulse 94 to 107, temperature 96.8 to 102.7, and oxygen saturation 94% to 96% while on 35% trach collar

4/7/2019: (08:00) Temperature 100.4, pulse 92, Respirations 35, Blood pressure 73/38, Blood glucose 305, O2 Sat 92% on 30% CPAP


VENTILATOR / BIPAP FLOW SHEET:

4/5/2019: The respiratory therapist completed a patient assessment at 07:10, 11:15, 15:20, 20:05, 23:10, and 02:40 on 4/6/2019.

4/6/2019: The respiratory therapist completed a patient assessment at 07:15 and 11:15.

4/7/2019: The respiratory therapist completed a patient assessment at 06:20: "...changed to CPAP...."


SEPSIS SCREEN:

The "Sepsis Screen" is completed every shift and PRN. This screening requires the following: "...If there are 2 or more positive finding or are you suspicious of an infection? If yes, notify physician & implement sepsis protocol/orders...."

The "Sepsis Screen" completed on 4/6/2019 at 20:00 contained the following positive sepsis indicators: "...Positive Finding Indicators: Temperature >101 F or <96.8...Heart Rate >90/min (new onset tachycardia) or significant change from baseline...Respiratory rate >20 respirations per minute...20:00...Temperature 101.9, Heart Rate 112, Respiratory rate 32...24:00...Temperature 102.7...Respiratory rate 40...Blood pressure 85/49...pulse blank...."


NURSING DOCUMENTATION:

4/7/2019 at 06:20: "...TC O2 turned up to 70% RT aware...Pt still de-sating to low 80%...."

4/7/2019: "...07:49: Transfer to ICU pending...MD updated on patient condition by house supervisor...0955: Rapid response called for bradycardia. Unable to palpate pulse. Please see code documentation for details of resuscitation efforts. Time of death 1019...."

Employee #1 confirmed in an interview on 4/15/2019 that "anyone can call a rapid response". Employee #1 was unable to identify why a rapid response was not called during the night of 4/6/2019 and was unable to locate respiratory therapy interventions during the night of 4/6/2019.


2. The "Respiratory Care Practitioner Job Description" requires the following: "...Continues to identify patient problems and initiates plans of care as patient condition dictates...Monitors all ventilator, BiPAP, and CPAP parameters as per established hospital policy...Cardiopulmonary documentation is reflected on the appropriate respiratory care flow sheet...Flow sheets must be accurate, complete and signed according to hospital policy and procedure...Re-assesses each patient per protocol to document progress...

The hospital document: "PROTOCOLS FOR RESPIRATORY THERAPY, (Protocols provided by the American Association for Respiratory Care), requires the following: "...5. During the course of therapy, the physician will be called by the RCP if the patient's clinical status deteriorates, or if an adverse event occurs...."

The medical record did not contain documentation from the respiratory therapist between 4/6/2019 11:15 and 4/7/2019 at 06:20.

Employee #14 confirmed in an interview conducted on 4/15/2019 that respiratory therapist complete assessments every 4 hours when a patient is on a ventilator, being weaned off a ventilator or on "aerosol". Employee #14 confirmed that interventions for a patient with a respiratory rate of 40 would include obtaining a blood gas and depending on results put the patient back on a ventilator or complete an SVN treatment. Employee #14 confirmed that the respiratory therapist did not complete patient assessments on 4/6/2019 from 11:15 to 4/7/2019 at 06:20.

Based on review of medical staff rules and regulations, hospital policies and procedures, medical record documentation and staff interviews, it was determined the administrator failed to ensure that anti-infective medication was stopped after seven (7) days, or re-ordered by the physician as required by the Medical Staff Rules and Regulations, for patient #4. This deficient practice poses a potential risk to the patient's health and safety due to potential side effects from antibiotics and complications from antibiotic resistant organisms.

Findings include:

The "Medical Staff Rules and Regulations, Revised 10/26/2016" revealed: "...Drugs must be discontinued or re-ordered by the physician. Medications have been assigned automatic stop periods as follows:...C-II Medications = 15 days...C-III to V = 30 days...Sedatives = 30 days...Anti-infective = 7 days...Anticoagulants = 15 days...Others = 30 days...."

On 3/1/2019 at 16:00, Physician #1 ordered the following : "...Ceftriaxone (Rocephin) 1 gram IV Q24H...Azitromycin [sic] 500 mg IV Q24H...Continue on Admission...YES...."

The order did not contain a length of time or a stop date for the antibiotics.

The Infectious Disease Physician #3 documented: "...3/7/2019...D/C Zithro...2 more days of Rocephin...3/11/2019 at 15:45...Discontinue ceftriaxone (Rocephin)...."

On 3/7/2019 at 17:26, Physician #1 documented: "...Continue with the antibiotics. S/he needs two more days of IV Rocephin. The Zithromax has been discontinued...3/8/2019 at 15:11...Continue the antibiotics and completed per ID recommendation...3/9/2019 at 15:15...Complete antibiotics per ID recommendation...3/10/2019 at 20:24...Continue antibiotics...3/11/2019 at 19:15...Antibiotics have been discontinued...."

The medical record contained a physician's order to discontinue the Rocephin on 3/11/2019.

The Medication Administration record contained the following:

"...3/11/19 - 0700 - 3/12/19 - 0659...Ceftriaxone Sod 1 GM Vial (ROCEPHIN)...START/STOP...3/2/19 / 3/16/19...1000 (crossed off and initialed by the nurse) D.C. 3/11/19...."

"...3/12/19 - 0700 - 3/13/19 - 0659...Ceftriaxone Sod 1 GM Vial (ROCEPHIN)...START/STOP...3/2/19 / 3/16/19...1000 (entire entry had a line drawn through it with the writing 'D/C 3/12/19')...."

"...3/13/19 - 0700 - 3/14/19 - 0659...Ceftriaxone Sod 1 GM Vial (ROCEPHIN)...START/STOP...3/2/19 / 3/16/19...1000 (line through the entry with the writing 'D/C 3/11/19')...."

Employee #5 confirmed in an interview conducted on 4/11/2019, the pharmacy did not receive the initial order to discontinue the Rocephin on 3/11/2019 due to a problem with the fax machine. Employee #5 demonstrated the "Meditech" program that is utilized by pharmacy staff. The system defaults to discontinue antibiotics after 14 days. Employee #5 confirmed that s/he was not aware of the medical staff rules and regulation that identifies anti-infective medications to be discontinued after 7 days or as re-ordered or stopped by a physician.