HospitalInspections.org

Based on interview and document review the facility failed to ensure the Pharmacy and Therapeutics Committee (P&T) and Quality Committee (QC) analyzed medication errors and approved corrective action to reduce or eliminate them from re-occurring. This failure may allow the same or similar medication errors to continue, which creates an unsafe patient care environment.

Findings:

P&T minutes (a medical staff committee) from July 2012 to July 2013 were reviewed on September 12, 2013, at 8:45 a.m. There was no evidence in the minutes that medication errors were analyzed and corrective action approved to reduce or eliminate reoccurrence.

The July 26, 2013 minutes under, "Medication Errors-2013" read: "...statistics regard medication error rates April thru July of 2013; all are level 1 errors." Under "Action/Follow Up," the minutes read: "After review and discussion a motion is made and seconded to approve the Medication Error rates report."

There was no evidence of:
a. A description of level 1 errors.
b. What caused the errors.
c. The identification of any re-occurring errors.
d. A discussion of corrective action(s) to reduce or eliminate errors from re-occurring.

During a meeting with MD 1 at 9 a.m., on September 12, 2013, he said the medication error analysis was contained in the QC minutes (a medical staff committee).

A review of the QC minutes from December 2012 to May 2013, revealed there was no evidence of any discussion of medication errors.

During a meeting with the Director of Pharmacy (DOP), on September 12, 2013, at 11:15 a.m., he acknowledged the P&T and QC minutes did not contain any analysis of medication errors.

Based on interview and record review, the facility failed to ensure a patient (Patient 12) was provided an effective and safe discharge plan including an evaluation of the patient's capacity for self-care, and the likelihood of the patient's need for post-hospital services. This had the potential to result in the patient's needs not being met.

Findings:

The medical record for Patient 12 was reviewed. Patient 12 was admitted to the facility on May 23, 2013, with diagnoses that included urosepsis and cellulitis (an infection of the skin and deep underlying tissues).

The nurse documentation, dated May 23, 2013, at 3:57 a.m., "Arrives with malodorous (foul smelling) purulent drainage from the right calf wound."

Physician orders dated, May 23, 2013, indicated to keep right leg elevated, place a Kerlix 4 X 4 (a gauze bandage) on right leg and ace wrap it from foot up. Clinical documentation indicated wound care was done twice a day. The last assessment prior to discharge on May 26, 2013, at 9 a.m., indicated dressing applied or changed, "Red granulation noted on wound bed, with small amount of bleeding. Removed old dressing. Applied 44 gauze with Kerlix and ace wrap."

A case management note, dated May 24, 2013, at 2:03 p.m., indicated, "Discharge Plan... I anticipated this patient needed dressing changes at discharge, pt (patient) unable to come in for out pt wound care due to no car. Possible home health might be able to see pt..." An additional note by the case manager (CM) on May 24, 2013, at 3:09 p.m., indicated, "I spoke with [Staff 41] RN regarding this pt and her dressing of her wound. Nurse [Staff 41] does not think the pt is capable of doing her own dressing changes. I spoke to her about talking to MD regarding home health to see this pt."

On September 12, 2013, at 8:05 a.m., Staff 41 was interviewed. Staff 41 stated she did not remember Patient 12. Staff 41 stated it was case management's responsibility to notify the physician about the need for home health. However, she stated, if the CM told her to notify the physician then she probably did. Staff 41 was unable to find documentation to indicate if the physician was notified of the need for a home health referral. Staff 41 stated, the physician did not order a home health referral, so she does not know if he knew about the recommendation by the CM.

On September 12, 2013, at 8:15 a.m., the CM staff was interviewed. The CM stated her usual process was to notify the physician herself if a patient was evaluated as needing a home health referral. She stated she can not remember if she ever personally talked with the physician regarding this patient. The CM stated, according to her notes, she saw Patient 12 on May 24, 2013, which was a Friday, and the patient was discharged on May 26, 2013, which was her day off. The CM stated, again according to her notes, she spoke with Staff 41 on the 24th, and maybe Staff 41 notified the physician. The CM was unable to find any documentation that the physician was notified, either by her or Staff 41, regarding Patient 12's need for home health. The CM stated this patient, "Fell through the cracks."

The policy and procedure titled, "Discharge Planning," dated April 16, 2013, was reviewed. The policy indicated, "The RN in conjunction with the case manager will continuously evaluate the patient for post-hospital needs... Clinical Case Managers are responsible for assisting patients and families with coordination of all home care services... Case manager or Nursing staff should document any referrals that have been made... "