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Based on records reviewed and interviews, the Hospital 's Quality Assessment Performance Improvement activities failed for one (Patient #9) of ten medical records sampled to implement preventive actions and mechanisms that include feedback and learning throughout the hospital after Patient #9's adverse patient event.

Findings included:

The policy titled, Patient Event Reporting System, dated 10/2016, indicated that the Hospital used the information gathered from investigations of significant events to identify opportunities for improvement.

The document titled, Report, indicated Patient #9's adverse patient event, a Vancomycin (a powerful life-saving antibiotic) medication error occurred on 8/7/17.

The Laboratory Report, dated 8/8/17, indicated Patient #9's Vancomycin level was 24.3, (high level and potentially harmful).

The Document titled, Pharmacy Adult Vancomycin Dosing and Monitoring Protocol, dated 12/2016, indicated a random drug level goal was 15-20.

The meeting minutes titled, Medication Safety Committee, dated 9/26/17, indicated the Hospital investigated the medication error of Patient #9 that occurred on 8/7/17. The meeting minutes identified that pharmacy staff and registered nurses needed education regarding verification of Vancomycin orders. The meeting minutes indicated the Hospital would implement education through staff meetings, huddles and rounding. The meeting minutes indicated that nurse managers would conduct audits.

The Surveyor interviewed the Clinical Risk Manager at 9:30 A.M. on 9/22/17. The Clinical Risk Manager said she did not recall if Hospital A implemented corrective actions identified by the Medication Safety Committee.

The Hospital provided no clear documentation or information to indicate that the Hospital implemented the corrective actions regarding Patient #9's Vancomycin medication error of 8/7/17, as recommended by the Hospital 's Medication Safety Committee, by the time of the Survey on 9/22/17, more than one (1) month after the medication error. The Hospital provided no documentation to indicate that Nurse Managers conducted audits as identified in the Medication Safety Committee Meeting Minutes dated 9/26/17.

Based on records reviewed and interviews the Nursing Services failed to appropriately define the scope of practice for Diagnostic Technicians working within the Emergency Department Nursing Service and define that starting an intravenous (IV) was within the scope of Nursing Practice in accordance with the Board of Registration in Nursing.

Findings included:

The Board of Registration in Nursing, as authorized by Generals Law of the State, limit the practice of infusion therapy to include the insertion and removal of short and midline peripheral intravenous devices to registered nurses and to licensed practical nurses consistent with organization policy and procedure. Administration of IV medications (Normal Saline was considered a medication) was not within the scope of practice of a Diagnostic Technician and only a licensed nurse or physician/physician assistant may administer IV medications (http://www.mass.gov/eohhs/gov/departments/dph/programs/hcq/dhpl/nursing/nursing-practice/advisory-rulings/iv-therapy.html).

The Hospital's policy titled, Medication and IV Therapy Practice Guidelines, dated 9/21/17, indicated Diagnostic Technicians may perform venipuncture. The policy did not indicate that Hospital A approved Diagnostic Technicians to start IVs.

The Job Description titled Diagnostic Technician, undated, indicated starting an intravenous (IV) was an essential duty and responsibility.

The Surveyor interviewed Registered Nurse #1 at 10:15 A.M. on 9/21/17. Registered Nurse #1 said that Diagnostic Technicians started intravenous (IVs).