HospitalInspections.org

The Hospital was out of compliance for the Condition of Participation for Nursing Services.

Findings included:

Based on record review and interviews, the Hospital failed to ensure physician orders (medication administration) were followed for one Patient (#2) out of a total sample of ten patients.

Cross Reference:
482.23(c) - Standard: Preparation and Administration of Drugs (405)

Based on record review and interview, the Hospital failed to ensure Intravenous (IV) contrast (a substance taken by mouth or injected IV that causes the particular organ or tissue under study to be seen more clearly) was administered in accordance with a physician order for one Patient (#2) out of a total sample of 10 patients.

Findings included:

Review of Patient #2 's medical records indicated that he/she was admitted to the Hospital on 7/30/24 with a history of chronic kidney disease (CKD) and ischemic cardiomyopathy (a disease where the heart muscle becomes weakened, making it harder for the heart to pump blood effectively) now presenting with worsening shortness of breath and fatigue. Patient #2 was ordered for a CT Angiogram (CTA) Chest (imaging to show blood flow through your blood vessels or heart) in preparation for a transcatheter aortic valve replacement (TAVR) procedure.

Review of the medical record indicated that an order was placed on 8/9/24 for a CT Angiogram Chest to evaluate for TAVR.

A Protocol Summary was completed by Radiologist #1 on 8/9/24 at 7:39 A.M., for the CT Angiogram Chest with low dose contrast ordered.

Review of the Resident Cardiology Progress Note dated 8/13/24 at 2:16 P.M., indicated that Patient #2 received excessive contrast during the CT on 8/12/24. Due to this error Cardiology indicated that Patient #2 was to receive 500 cc ' s of Lactated Ringers (IV fluids replacing fluid and electrolytes) and orders to monitor renal function.

Review of the Progress Note documented by the Attending Cardiologist dated 8/14/24 at 6:56 A.M., indicated that Patient #2 ' s acute kidney injury (AKI) is likely due to large contrast dose at CTA and would consult renal.

During an interview on 5/6/25 at 8:52 A.M., Radiologist #1 said Patient #2 had a CT scan of the heart on 8/12/24. He said that Cardiology puts the order in for the scan and the radiologist will review and order the appropriate protocol. He said he ordered low dose protocol for Patient #2 after reviewing the Cardiology note indicating renal function. The radiologist said low dose protocol is 30cc ' s of contrast. He said the expectation would be for the CT technologist to read the comments before each scan.

During an interview on 5/6/25 at 9:45 A.M., the CT technologist said she administered 100cc of contrast for Patient #2 which is the standard protocol for contrast for TAVR imaging. She said after administration she scrolled down on the order which indicated low dose protocol. The CT technologist said low dose protocol is 30cc ' s of contrast. She said the expectation is for the CT technologist to read the comments before administering the contrast and this was an oversight and not done. She further said that the provider as well as the radiologist were made aware of the error and orders for IV hydration were placed in response.

During an interview on 5/6/25 at 11:35 A.M., Risk Manager #1 said this was reviewed during mortality and a case collaborative review (CCR) was scheduled for 5/6/25. She acknowledged Patient #2 did not receive the low dose contrast as specified in the order under comments. The risk manager failed to provide evidence corrective actions were implemented.

The Hospital failed to ensure IV contrast was administered as ordered for Patient #2.