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Based on interview and record review, the facility failed to ensure nursing staff conducted pain level reassessments after administering pain medication for 2 of 67 patients (300 and 601).

Findings:

1. Patient 300 was admitted to the facility on 1/3/13. According to the history and physical (H&P), dated 1/3/13, the patient sustained a right hip fracture after falling at home. The plan was to admit the patient and treat conservatively with pain control and physical therapy. The H&P also indicated that the patient had a history of chronic pain and was on high dose Norco (a narcotic pain medication).

On 1/8/13 at 11:30 A.M. the Electronic Medication Administration Record (EMAR) was jointly reviewed with Unit Manager 3. According to the EMAR, the patient was given Morphine 4 mg (milligrams) IV (intravenously) on 1/3/13 at 6:01 P.M. for pain level of 6/10 (a numeric rating scale where 0 is no pain and 10 is worst possible pain). The patient was given a second dose at 7:04 P.M. for pain level of 7/10. There was no documentation that nursing staff reassessed the patient's pain level for medication effectiveness after administering the Morphine.

Per further review of the EMAR, the patient was given 2 tablets of Norco on 1/3/13 at 11:21 P.M. and on 1/5/13 at 11:57 A.M. for a pain level of 8/10. There was no documentation that nursing staff reassessed the patient's pain level for medication effectiveness after administering the Norco.

Review of the facility's policy and procedure (P&P) Pain Assessment and Management, dated 2/14/11, directed nursing staff to perform a reassessment of pain intensity within 15-30 minutes after an IV medication, or within 30-60 minutes after an oral, Intramuscular or subcutaneous medication. In addition, nursing staff were to document the reassessment of pain intensity on the PRN (as needed) Medication Effectiveness screen in the EMAR.

When interviewed on 1/8/13 at 11:30 A.M., Unit Manager 3 acknowledged there was no documentation that nursing staff reassessed the patient's pain level for medication effectiveness after administering the doses of morphine and Norco.

2. On 1/9/13 at 10:45 A.M. the record of Patient 602 was jointly reviewed with the Pharmacist (RPh 601). Patient 602 had been receiving treatment for a ruptured abdominal aortic aneurysm (bleeding from a ruptured artery inside the abdomen).

The prescriber, Physician (MD) 601, ordered Morphine 4 mg (milligrams - an opioid narcotic for pain) q 1 h (every 1 hour) prn (as needed for) pain, severe 7-10, and the order appeared in the electronic Medication Administration Record (eMAR).

The eMAR was jointly reviewed by RPh 601 and Registered Nurse (RN) 603, and indicated that Morphine had been administered 9 times between 1/5/13 and 1/9/13. There were no pain reassessments recorded in the eMAR as required by the facility Policy and Procedure (P&P).

The Facility P&P titled Pain Assessment and Management, approved 7/21/10, included,
"II,H. Pain Reassessment - PRN pain assessment within a specific period of time following the implementation of pain management intervention to assess intervention effectiveness based on the type, onset, and action of the intervention.
1. Reassessment of the symptom being treated should be performed:
a. Within 15-30 minutes for an IV medication.

IV,E. Reassessment of pain intensity level will be documented on the PRN Medication Effectiveness Screen of the eMAR.
1. Reassessment of pain intensity level and sedation level will be within 15-30
minutes after IV opioid medication."

RPh 601 and RN 603 acknowledged that a pain reassessment level was not recorded on the eMAR as required by the P&P.

Based on observation, interview, and record review, the facility failed to ensure that written care plans were developed for 11 of 67 sampled patients related to high fall risk status (203, 207, 208, 302, 304, 305, and 310), constipation and infection (206), risk for injury to self and others (303), decreased cardiac output (310), and risk for aspiration (505).

Findings:

1. The facility admitted Patient 203 on 12/29/12 with a diagnosis of biliary colic (biliary pain most frequently caused by obstruction of the common bile duct) according to the facesheet. Per the History and Physical (H&P) dated 12/28/13, Patient 203 also had multiple medical problems to include Stage IV metastatic endometrial cancer, nausea and vomiting, general malaise, and abdominal pain.

When interviewed on 1/7/13 at 11:28 A.M., Registered Nurse (RN) 2 stated that Patient 203 was a "hospice patient," and that the patient was "weak and regularly receives pain and antianxiety medication." RN 2 stated that the patient was at high risk for falling and she assessed the patient to have a Morse Fall Risk Scale [MFRS] (a method of assessing a patient's risk for falling) score of 45 that morning. According to RN 2, when a patient had a score of 45 or greater, the patient was at high risk for falling and a care plan should be initiated.

Joint review of the electronic medical record (EMR) at 11:47 A.M. indicated that Patient 203 was assessed on admission to have a fall risk score of 45. The plan of care was initiated on 1/3/13.

Review of the facility's policy and procedure, entitled Fall Prevention and Management, dated 4/11/12, directed nursing staff to complete the MFRS assessment upon patient admission, every shift, and post-fall, and to initiate appropriate interventions in the plan of care for Morse Scale scores of 45 or greater. In addition, the Standards of Patient Care for the Adult Inpatient Policy and Procedure (P&P), dated 4/11/12, directed nursing staff to develop, document, and initiate the plan of care within 8 hours of admission.

When interviewed on 1/7/13 at 12:10 P.M., Unit Manager 1 acknowledged that the plan of care was not initiated until 1/3/13, 5 days after Patient 203 was admitted and assessed to have a MFRS score of 45.

2. The facility admitted Patient 207 on 12/31/12 with a diagnosis of altered level of consciousness (ALOC) according to the facesheet. Per the neurology and critical care consult reports dated 1/1/13, the patient also had a sudden onset of speech arrest and significant left-sided neurologic deficit. A CT (Computed Tomography) scan (a radiology exam using X-rays to make detailed pictures of structures inside the body) of the patient's head showed that the patient had a right cerebrovascular accident (stroke - when blood flow to a part of the brain stops.)

Patient 207 had an embolectomy (emergency removal of clotted blood) on 1/1/13 and was taken to the Intensive Care Unit (ICU) after the procedure. According to the first MFRS assessment on 1/1/13, nursing staff assessed the patient to have a score of 45. The scores for the following shifts in the ICU were 75 on 1/2/13 A.M. and P.M., and 60 on 1/3/13 A.M. The patient was transferred to the Medical-Surgical unit at 3:54 P.M. on 1/3/13. The nursing staff gave Patient 207 a MFRS score of 60 during the admission assessment to the unit.

When interviewed on 1/7/13 at 3:10 P.M., RN 6 stated that Patient 207 had left-sided weakness and that there was high potential for the patient to fall. Joint review of the EMR at 3:17 P.M. indicated that the patient's plan of care for fall prevention was not initiated until 1/4/13 at 4:00 A.M. RN 6 stated that the care plan should have been initiated whenever the patient's fall risk score was 45 or greater. She stated the plan of care should have been initiated on 1/1/13.

Review of the facility's policy and procedure, entitled Fall Prevention and Management, dated 4/11/12, directed nursing staff to initiate appropriate interventions in the plan of care for Morse Scale scores 45 or greater. In addition, the Standards of Patient Care for the Adult Inpatient P&P, dated 4/11/12, directed nursing staff to develop, document, and initiate the plan of care within 8 hours of admission.

When interviewed on 1/8/13 at 3:22 P.M., Unit Manager 2 acknowledged that nursing staff had not initiated the plan of care for Patient 207 until 1/4/13, 3 days after the patient was admitted and assessed to have a MFRS score of 45.

3. The facility admitted Patient 208 on 1/4/13 with a diagnosis of lumbosacral spondylosis (a painful degenerative spinal condition) according to the facesheet.

When interviewed on 1/7/13 at 3:35 P.M., RN 7 stated that the patient had "minimally invasive surgery" on his lumbar spine and was admitted to the orthopedic unit after the procedure. He stated that Patient 208 was unsteady when he ambulated with a walker and that the patient continued to receive scheduled, and as needed medication for back pain.

Joint review of the EMR and MFRS scores at 3:42 P.M. showed that nursing staff assessed Patient 208 to have MFRS scores greater than or equal to 45, beginning the morning of 1/5/13. These scores indicated that the patient was at high risk for a fall. RN 7 stated that when a patient had a MFRS score of 45 or greater, a care plan had to be initiated and interventions put into place.

Review of the facility's policy and procedure, entitled Fall Prevention and Management, dated 4/11/12, directed nursing staff to initiate appropriate interventions in the plan of care for Morse Scale scores 45 or greater. In addition, the Standards of Patient Care for the Adult Inpatient P&P, dated 4/11/12, directed nursing staff to develop, document, and initiate the plan of care within 8 hours of admission.

When interviewed on 1/8/13 at 3:22 P.M., Unit Manager 2 acknowledged that nursing staff had not initiated the plan of care for Patient 208 on 1/7/13, 2 days after the patient was assessed to have a MFRS score of 45 or greater.



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4. Patient 302 was admitted to the facility on 1/6/13 with a diagnosis of hepatic encephalopathy (decrease in brain function as a result of liver failure) according to the Admission H&P. Per the H&P, the patient fell at home after trying to get out of bed and was brought in by paramedics with a decreased level of consciousness.

The EMR was jointly reviewed with Unit Manager 3 on 1/8/13 at 3:40 P.M. The patient was initially assessed on 1/6/13 at 1 P.M. as a high fall risk, with a MFRS score of 75. However, nursing staff did not initiate the Fall Prevention and Management Care Plan until 1/7/13 at 12:17 A.M.

Review of the facility's policy and procedure entitled, Fall Prevention and Management, dated 4/11/12, directed nursing staff to complete the MFRS assessment upon patient admission, every shift, and post-fall, and to initiate appropriate interventions in the plan of care for Morse Scale scores 45 or greater. In addition, the Standards of Patient Care for the Adult Inpatient P&P, dated 4/11/12, directed nursing staff to develop, document, and initiate the plan of care within 8 hours of admission.

When interviewed on 1/8/13 at 4 P.M., Unit Manager 3 stated that nursing staff should initiate a fall risk care plan "right away" if a patient was assessed as a high fall risk. She acknowledged that nursing staff did not initiate a care plan related to fall risk until 1/7/13, 12 hours after Patient 302 was admitted and assessed to have a MFRS score of 75.

5. Patient 304 was admitted to the facility on 1/4/13 with diagnoses that included fever and altered mental status, per the Admission H&P. According to the H&P, the patient had a history of Alzheimer's disease with severe dementia and was brought in by her daughter for decreased mental status.

The EMR was jointly reviewed with Unit Manager 3 on 1/8/13 at 11:20 A.M. The patient was initially assessed on 1/4/13 at 10 P.M. as a high fall risk, with a MFRS score of 50. However, nursing staff did not initiate the Fall Prevention and Management Care Plan until 1/5/13 at 7:39 P.M.

Review of the facility's policy and procedure, entitled Fall Prevention and Management, dated 4/11/12, directed nursing staff to complete the MFRS assessment upon patient admission, every shift, and post-fall, and to initiate appropriate interventions in the plan of care for Morse Scale scores 45 or greater. In addition, the Standards of Patient Care for the Adult Inpatient P&P, dated 4/11/12, directed nursing staff to develop, document, and initiate the plan of care within 8 hours of admission.

When interviewed on 1/8/13 at 11:30 A.M., Unit Manager 3 stated that nursing staff should initiate a fall risk care plan "right away" if a patient was assessed as a high fall risk. She acknowledged that nursing staff did not initiate a care plan related to fall risk until 21 hours after Patient 304 was admitted and assessed to have a MFRS score of 50.

6. Patient 305 was admitted to the facility on 1/6/13 with diagnoses that included brain tumor and seizure episode, per the Admission H&P. According to the H&P, the patient was brought in by paramedics after a loss of consciousness and fall at home.

On 1/8/13 at 2:30 P.M., the EMR was jointly reviewed with Unit Manager 4. The patient was initially assessed on 1/6/13 at 1:25 P.M. as a high fall risk, with a MFRS score of 45. However, nursing staff did not initiate the Fall Prevention and Management Care Plan until the next day on 1/7/13 at 11 A.M.

Review of the facility's policy and procedure, entitled Fall Prevention and Management, dated 4/11/12, directed nursing staff to complete the MFRS assessment upon patient admission, every shift, and post-fall, and to initiate appropriate interventions in the plan of care for Morse Scale scores 45 or greater. In addition, the Standards of Patient Care for the Adult Inpatient P&P, dated 4/11/12, directed nursing staff to develop, document, and initiate the plan of care within 8 hours of admission.

When interviewed on 1/8/13 at 2:40 P.M., Unit Manager 4 stated that nursing staff should initiate care plans within their shift. She acknowledged that nursing staff did not initiate a care plan related to fall risk until 22 hours after Patient 305 was admitted and assessed to have a MFRS score of 45.

7. Patient 310 was admitted to the facility on 1/5/13 with diagnoses of syncope (fainting) and right ankle fracture, according to the Admission H&P. Per the H&P, the patient lost consciousness while in the shower and then woke up on the floor with right ankle pain. The plan was to admit the patient for observation and treatment of a right ankle fracture.

On 1/7/13 at 2 P.M. the EMR was jointly reviewed with the patient's assigned nurse, RN 10. She stated that the patient was assessed as a high fall risk, but was unable to find a care plan in place related to fall risk. RN 10 acknowledged, "The patient should have one."

On 1/8/13 at 3:05 P.M. the EMR was jointly reviewed with Supervisor 1. The patient was initially assessed on 1/5/13 at 7 P.M. as a high fall risk, with a MFRS score of 55. Nursing staff continued to assess the patient as a high fall risk from 1/5/13 to 1/7/13 without a fall risk care plan in place. The care plan Fall Prevention and Management was not initiated until 1/7/13 at 7 P.M.

Review of the facility's policy and procedure, entitled Fall Prevention and Management, dated 4/11/12, directed nursing staff to complete the MFRS assessment upon patient admission, every shift, and post-fall, and to initiate appropriate interventions in the plan of care for Morse Scale scores 45 or greater. In addition, the Standards of Patient Care for the Adult Inpatient P&P, dated 4/11/12, directed nursing staff to develop, document, and initiate the plan of care within 8 hours of admission.

When interviewed on 1/8/13 at 3:10 P.M., Supervisor 1 stated that nursing staff should initiate care plans within their shift. She acknowledged that nursing staff did not initiate a care plan related to fall risk until 2 days after Patient 310 was admitted and assessed to have a MFRS score of 55.

8. The facility admitted Patient 206 on 1/4/13 for abdominal distention, nausea, vomiting, and fever according to the Admission H&P. In addition, the patient had a history of multiple sclerosis (an autoimmune disease that affects the brain and spinal cord), was wheelchair bound, and had a chronic urinary catheter (thin, sterile tube inserted into the bladder to drain urine) with evidence of a urinary tract infection (UTI).

When interviewed on 1/7/13 at 2:38 P.M., RN 5 stated the patient was admitted for "constipation and a UTI." She also stated that Patient 206 was "basically a paraplegic (paralysis of the lower half of the body including both legs, usually caused by damage to the spinal cord) and could not really move much on her own."

Joint review of the EMR at 2:55 P.M. showed that there were no plans of care related to the prevention of constipation or infection. RN 7 stated that the facility's policy is to initiate a care plan for identified problems within 24 hours.

Review of the facility's policy and procedure entitled, Standards of Patient Care for the Adult Inpatient, dated 4/11/12, directed nursing staff to develop, document, and initiate the plan of care within 8 hours of admission.

When interviewed on 1/8/13 at 2:55 P.M., Unit Manager 2 acknowledged that nursing staff failed to initiate plans of care as per the facility's policy and procedure. She stated that the care plans should have been initiated on 1/4/13 when Patient 206 was admitted.

9. Patient 303 was admitted to the facility on 1/6/13 on a 5150 hold (involuntary psychiatric hold on a person deemed to be a danger to himself or others) after ingesting bleach as a suicide attempt, per the Admission H&P. The H&P also indicated that the patient had a history of several suicide attempts, with the last one on 8/27/12.

On 1/7/13 at 3:30 P.M. the EMR was jointly reviewed with the patient's assigned nurse,
RN 9. He was unable to find a care plan in place related to patient safety. RN 9 stated that the care plan, Danger to Self and Others, was, "Probably one I should initiate" and then proceeded to initiate it in the EMR.

The EMR was jointly reviewed with Unit Manager 3 on 1/8/13 at 3:40 P.M. According to the nurses notes, Patient 303 was admitted to the unit on 1/6/13 at 10 P.M. However, the care plan, Danger to Self and Others, was not initiated until 1/7/13 at 3:37 P.M.

Review of the facility's P&P, Standards of Patient Care for the Adult Inpatient, dated 4/11/12, directed nursing staff to develop, document, and initiate the plan of care within 8 hours of admission.

During an interview on 1/8/13 at 3:45 P.M., Unit Manager 3 acknowledged that nursing staff did not initiate the care plan Danger to Self and Others until 17 hours after Patient 303 was admitted to the hospital.

10. Patient 301 was admitted to the facility on 1/6/13 with diagnoses of chest pain and irregular heart rate, according to the Admission H&P. Per the H&P, the patient was feeling chest pressure and missed heart beats and was admitted for observation.

On 1/8/13 at 3:05 P.M. the EMR was jointly reviewed with Supervisor 1. The patient was admitted to the telemetry unit on 1/6/13 at 8:30 P.M. According to the patient's care plans, nursing staff did not initiate the Standard Care Plan or the Cardiac Output care plan until the next day, on 1/7/13 at 2:36 P.M. The patient was subsequently discharged less than 4 hours later, at 6 P.M.

Review of the facility's policy and procedure, Standards of Patient Care for the Adult Inpatient, dated 4/11/12, directed nursing staff to develop, document, and initiate the plan of care within 8 hours of admission.

When interviewed on 1/8/13 at 3:10 P.M., Supervisor 1 stated that nursing staff should initiate care plans within their shift. She acknowledged that nursing staff did not initiate care plans until 1/7/13, 18 hours after Patient 301 was admitted, and less than 4 hours before the patient was discharged.



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11. On 1/7/13 at 2:49 P.M., Patient 505's medical record was reviewed. According to Patient 505's history and physical, dated 1/4/13, the patient's diagnoses included dementia and altered mental status.

According to the Adult History form, that was completed by a nurse on 1/5/13, a family member who accompanied the patient reported that the patient was not eating and was "not closing her mouth," prior to admission. The family member reported that she had, "To cut food up into small pieces, pt [patient] taking roughly 1 hour to eat a meal." She reported that the patient had significant weight loss for several months prior to admission. The Adult History form included documentation of "Pneumonia: self, aspiration." On the same form, under the category of Nutritional Screen there was a section under eating difficulties, in which the options were all left blank by the nurse. Had the swallow box been marked "yes" by the nursing staff, based on the patient's information that was being obtained, an automatic consult to nutritional services would have occurred, per the hospital system.

The physician progress notes, dated 1/5/13, under Nutrition indicated, "Questionable aspiration risk. NPO (nothing by mouth) for now, speech/sw consult."

According to the Nutrition Assessment, dated 1/5/13, which was triggered by the patients weight loss prior to admission, was completed by a registered dietitian for Patient 505 and included, "Swallow evaluation pending." There was a note that the diet was NPO [nothing by mouth] as of 1/5/13.

On 1/6/13, the physician ordered a mechanical soft with ground meats diet, and ordered aspiration precautions on the same day.

On 1/7/13 at 3:30 P.M., LN 510 stated that she was taking care of Patient 505. She stated that Patient 505 had not had a care plan developed for the physician order for aspiration precautions. She stated that aspiration precautions entailed the head of bed (HOB) to be elevated at 30-40 degrees. She stated that nursing was responsible to ensure that there was a care plan for aspiration precautions, and "there should've been one."

On 1/7/13 at 3:35 P.M., LN 512 reviewed Patient 505's medical record and stated that since the history and physical indicated dementia and altered mental status, in addition to the nursing admission form (or the Adult History form), a bedside swallow should have been done. LN 512 verified that a bedside swallow was not implemented for Patient 505.

On 1/7/13 at 3:43 P.M., the nursing supervisor for the unit (LN 511), reviewed Patient 505's medical record and confirmed that a swallow evaluation was never completed, nor ordered by the physician. LN 511 was unaware of the physician's progress notes, that were written on 1/5/13, for a swallow consult. LN 511 stated it was not part of the daily nursing practice to look at physician progress notes. LN 511 verified that there was not a nursing care plan developed for the physician's order of aspiration precautions. LN 511 stated that the HOB should be elevated "45 degrees to 90 degrees during feeding", when aspiration precautions were in place.

According to the medical record under Safety ADLs (activities for daily living), Patient 505's HOB was elevated at 30 degrees on 1/6/13 and 1/7/13.

On 1/8/13 at 3:46 P.M., the Clinical Specialist (LN 513) stated that aspiration precautions entailed oxygen at bedside and suction available, but that HOB elevation was not a factor for aspiration precautions and there was not a standard for HOB elevation for the hospital. LN 513 further stated that nurse's do not perform bedside swallow screens. Only speech therapy can perform swallow screens in their hospital. LN 513 added that nurse's were not expected to develop a care plan for aspiration precautions.

At that time, LN 513 in the presence of the Chief Nursing Officer (CNO), went to the hospital's on-line system, where hospital approved policies were located, and provided a policy on Aspiration Precautions.

According to the document that was provided entitled, Aspiration Precautions, which was a current policy per the CNO, "6. Position patient upright in bed or sitting at a 90-degree angle in a chair, 7. Perform the nurse swallow screen ..., 10. Document the procedure in the patient's record."

LN 514 provided a document entitled, Swallowing/Dysphagia- Adult Care Plan, that she stated was the hospital's care plan for aspiration precautions, that should have been in place for Patient 505. The document included guidance of, "Position to sit at 90 degrees."

On 1/8/13 at 3:55 P.M., the CNO verified that there was confusion among nursing on the hospital's expected policy and procedures for aspiration precautions, and that staff needed to be trained. The CNO acknowledged that there should have been a care plan developed for Patient 505 for aspiration precautions, that would have provided clearer communication to the nurse's caring for Patient 505.

Based on observation, interview and record review at Facility A, pain medications were administered for levels of pain outside the range ordered by the prescriber for 2 of 67 sampled patients (601, 602); and a nurse administered propofol at a rate sufficient to reach a Sedation Agitation Scale (SAS) value of "3", even though the prescriber's order required an SAS of "2" for 1 of 67 sampled patients (601).

Findings:

1. On 1/8/13 at 2:10 P.M. the record of Patient 601, was jointly reviewed with Pharmacist (RPh) 601. Patient 601 was hospitalized following surgery to remove part of his large intestine. Medications ordered included Norco 5/325 [5 mg (milligrams) hydrocodone (a narcotic for pain) plus 325 mg acetaminophen (a non-narcotic pain reliever)] one tablet q 4 h (every 4 hours) prn (as needed) for mild pain 1-3 (pain level of 1 to 3 on a scale of 0 to 10, with 10 being most severe) and Norco 5/325 two tablets q 4 h prn for moderate pain 4-6 (pain level of 4 to 6 on a scale of 0 to 10). In addition, Morphine 4 mg IVP (given by direct injection into a vein) 4 mg q 3 h prn severe pain 7-10 (pain level of 7 to 10).

The approved Facility Policy and Procedure (P&P), revised 7/21/2010 indicated, "The purpose of Pain Assessment and Management was to... provide guidelines for pain assessment and management to enhance patient comfort, function, and facilitate patient/.family satisfaction." The "Numerical Rating Scale (NRS) is a scale using 0-10 numerals to assess pain intensity." The following terms were assigned to various levels of pain as follows:

"no pain - correlates with a pain rating of '0'
mild pain - correlates with a pain rating of '1-3'
moderate pain - correlates to a pain rating of '4-6'
severe pain - correlates to a pain rating of '7-10'"

The electronic Medication Administration Record (eMAR) for Patient 601 was jointly reviewed by RPh 601 and Registered Nurse (RN) 602. The eMAR indicated that Norco had been administered as follows:

1/4/13 at 11:54 A.M., Norco 5/325, two tablets for pain intensity of "8"
1/5/13 at 4:19 P.M., Norco 5/325 two tablets for pain intensity of "7"
1/6/13 at 2:56 P.M., Norco 5/325, two tablets for pain intensity of "9"

According to the orders written by Physician (MD) 602, pain intensities of 7, 8, or 9 should have been treated with Morphine 4 mg IVP rather than Norco.

RPh 601 and RN 602 acknowledged that the doses of Norco administered to Patient 601 did not match the pain levels in the orders prescribed by MD 602.

The failure to follow the prescriber's orders for analgesia could have resulted in the Patient 601 being inadequately treated for pain.


2. On 1/9/13 at 10:45 A.M. the record of Patient 602 was jointly reviewed with RPh 601. Patient 602 had been receiving treatment for a ruptured abdominal aortic aneurysm (bleeding from a ruptured artery inside the abdomen).

The prescriber, MD 601, ordered Morphine 4 mg (milligrams - an opioid narcotic for pain) q 1 h (every 1 hour) prn (as needed for) pain, severe 7-10, and the order appeared in the electronic Medication Administration Record (eMAR).

The eMAR was jointly reviewed by RPh 601 and RN 603, and indicated that Morphine had been administered as follows:

1/5/13 at 2:43 P.M. Morphine 4 mg. IVP for pain intensity of "7"
1/5/13 at 8:27 P.M. Morphine 4 mg. IVP for pain intensity of "7"
1/6/13 at 12:41 A.M. Morphine 4 mg. IVP for pain intensity of "5"
1/6/13 at 9:46 A.M. Morphine 4 mg. IVP for pain intensity of "3"
1/7/13 at 1:20 A.M. Morphine 4 mg. IVP for pain intensity of "5"
1/7/13 at 3:40 A.M. Morphine 4 mg. IVP for pain intensity of "5"
1/8/13 at 8:17 P.M. Morphine 4 mg, IVP for pain intensity of "5"
1/8/13 at 10:47 P.M. Morphine 4 mg. IVP for pain intensity of "5"
1/9/13 at 10:15 A.M. Morphine 4 mg. IVP for pain intensity of "0"

RPh 601 and RN 603 acknowledged that the pain intensity for which the morphine was administered was lower than the pain intensity required by the order of MD 601.

The administration of a narcotic analgesic, such as Morphine for pain levels of less severity than those prescribed by the physician, could lead to overmedication of the patient and could potentially result in serious adverse drug reactions.


3. On 1/19/13 at 11:00 A.M., the record of Patient 601 was reviewed jointly with RPh 601. Patient 601 was in the intensive care unit and was being treated for a ruptured abdominal aortic aneurysm (a leaking artery in the abdomen). Patient 601 was intubated (had a breathing tube placed in his wind pipe), and breathing was assisted with a respirator (breathing machine).

The Sedation Agitation Scale (SAS) used by the facility was the following:

"1" = Unarousable. Does not communicate.
"2" = Very sedated. Arouses to physical stimuli. Does not communicate or follow
commands.
"3" = Sedated: Follows simple commands.
"4" = Calm and Cooperative

In order to maintain the patient free of agitation and comfortably on the respirator, MD 601 ordered propofol 1000 mg (milligrams) per 100 ml (milliliters) to be titrated (rate of administration gradually adjusted) to keep Patient 601 at a Sedation Agitation Scale (SAS) of "2".

RN 603 acknowledged that she adjusted (titrated) the propofol infusion rate to keep the patient at a level she thought was appropriate. The Sedation Agitation Scale levels, as recorded hourly in the eMAR, were as follows:

1/9/13 at 12:00 A.M. = 3
1/8/13 at 10:00 P.M. = 3
1/8/13 at 8:00 P.M. = 3
1/8/13 at 7:00 P.M. = 3
1/8/13 at 5:00 P.M. = 3
1/8/13 at 4:00 P.M. = 3

RN 603 stated, "I didn't realize propofol was ordered to be titrated to a SAS of "2". That was my mistake. I titrated to a "3".

The failure to administer the propofol as ordered by MD 601 created the potential for under-sedating Patient 601. Under-sedation could have potentially resulted in an adverse event related to the management of Patient 602's respirations (breathing).

Based on observation, interview, and record review, the temperature of the refrigerator located in Labor and Delivery at Facility B was outside the required temperature range, for 1 of 27 sampled refrigerators.

Findings:

On 1/8/13 at 9:50 A.M. the medication refrigerator, located in the Labor and Delivery unit at Facility B, was observed. The refrigerator temperature was 50 degrees F (Fahrenheit).

The refrigerator was connected to a centralized temperature monitor, which continuously recorded refrigerator temperatures throughout the facility. The centralized temperature monitor, located in the pharmacy, was observed. An alert was displayed for the Labor and Delivery refrigerator. The alert indicated the Labor and Delivery refrigerator temperature had been out of range since 8:57 A.M. on 1/8/13. The refrigerator contained a variety of injectable medications such as oxytocin, which required storage between 36 and 46 degrees Fahrenheit.

The FDA approved package literature for oxytocin injection, required that it be stored in the refrigerator at temperatures between 2 and 8 degrees C (Centigrade), equivalent to 36 to 46 degrees F.

Facility Policy and Procedure titled, Medications Storage and Safety, revised 4/23/12, included,

"I. Medications requiring special conditions for storage to ensure stability will be properly stored.
1. Refrigerator ...temperatures shall be maintained in the proper range (2.2 - 7.7 degrees Celsius/ 36 - 46 degrees Fahrenheit for Refrigerators) to ensure the integrity of medications that require refrigeration ..."

It is well known that medications stored outside the manufacturer's recommended temperature range may undergo diminished potency over time.

RPh 601 acknowledged that the refrigerator had been out of range for nearly 1 hour before the temperature variation was discovered.

Based on observation, interview, and record review at Facility A, two different medications were ordered for the same patient (603) and for the same indication, nausea and vomiting, without specifying when one or the other medication should be used first or second for 1 of 67 sampled patients (603).

Findings:

On 1/9/13 at 1:20 P.M. the record of Patient 603 was reviewed. The electronic Medication Administration Record (eMAR) listed two drugs for nausea and vomiting. The drugs were: promethazine (Phenergan) 6.25 mg (milligrams) IV Push (administered directly into a vein) q 6 h (every 6 hours) prn (as needed) for nausea/vomiting; and, ondansatron (Zofran) 4 mg IV Push q 6 h prn nausea.

RN 604 was observed at 1:27 P.M. as RN 604 administered ondansatron (Zofran) 4 mg. by IVP (directly into a vein).

On 1/9/13 at 1:45 P.M., RPh 602 was interviewed. When asked if she had reviewed and validated the orders for ondansatron and promethazine, she said she had reviewed the orders. However, there had been an additional issue, which came up at the same time and had diverted her attention. She said that she would normally have added an "exploding comment" ("popup window" on the eMAR), which would direct the nurse to use ondansatron first and promethazine only if ondansetron did not provide adequate relief from nausea. RPh 602 said that she was distracted by the other issue and didn't remember to go back and add the "exploding comment" on the eMAR.

Based on observation, interview and record review, the Food Service Director failed to ensure that one cook was knowledgeable on internal cooking temperature of poultry, and that the wash water temperature of the 3-compartment sink was at least at 110 degrees Fahrenheit.

1. On 1/7/13 at 9:30 A.M., Cook 500 said that a turkey was in the oven cooking. Cook 500 was asked how he knew when the turkey would be done and cooked thoroughly. Cook 500 stated that he would check the internal temperature of the turkey using a thermometer. Cook 500 stated that he knew the turkey was cooked thoroughly if the internal temperature reached 145 degrees Fahrenheit (F?).

The Food Service Director was present during the above interview with Cook 500 and verified that Cook 500 was unable to state accurate internal cooking temperatures.

The hospital's policy and procedure entitled Infection Control Overview in FANS (last revised 10/29/12) indicated that poultry was to be cooked to an internal temperature of 165 F?.

2. On 1/7/13 at 10:03 A.M., the 3- compartment sink was in use to clean and sanitize food service utensils. There was an external digital temperature reading on the 3-compartment sink that indicated 102 F?. The dietary employee (DE 501), who was washing the utensils, stated that the 102 F? temperature was the temperature of the wash water.

The dietary supervisor (DS 502) placed a thermometer into the wash water and it was 102 F?. DS 502 stated that the wash water was to be at least at 115 F?. in accordance with guidance provided to dietary staff located on the temperature recording log for the 3-compartment sink.

The hospital's policy and procedure entitled Infection Control Overview in FANS (last revised 10/29/12) indicated, "Compartment Sink: c. Wash. Wash items in the first sink in a detergent solution ...the water temperature in the first compartment should be at least 110 F? (use a thermometer to check the water temperature)."

Based on observation, interview and record review, the hospital failed to ensure that the nutritional needs for 2 of 67 sampled patients were met when: 1) One patient's nutritional needs were not adequately addressed when a stage III pressure ulcer was identified (Patient 503), and 2) The therapeutic diet prescribed had not met the assessed nutritional needs for one patient (Patient 504).

Findings:

1. On 1/8/13 at 11:06 A.M., Patient 503's medical record was reviewed. Patient was admitted to the hospital on 1/5/13. On 1/5/13, Patient 503 was prescribed a regular diet and a consult order for a registered dietitian (RD) was placed, due to Patient 503 having a pressure ulcer.

On 1/5/13, a registered dietitian (RD 507) documented the following in the medical record, "Assessed due to Stage 3 pressure ulcer right hip, poor po [by mouth] intake. Diet - Regular. Po intake 0 - 10%. Meds and labs noted. Pt at mildly compromised nutritional risk. Provide Ensure [an oral nutrition supplement] TID [three times a day]. RD to f/u [follow up] per dept [department] procedure."

Patient 503's medical record was reviewed with RD 506. RD 506 stated that since the patient was assessed as only mildly compromised, an RD would not assess Patient 503's nutritional intake again until 6 - 7 days later, per department procedure.

RD 506 reviewed Patient 503's medical record and stated that the food and nutrition department was providing a nutrition supplement, three times a day with meals. RD 506 stated that the nutrition supplement provided 39 grams of protein and 1050 calories a day, in addition to the regular diet prescribed.

RD 506 reviewed Patient 503's documented oral intake that included the regular diet prescribed and the nutrition supplement. RD 506 verified that the majority of the documentation was blank, under the nursing area section where there was a line item for oral intake, meal percent, and supplement consumed.

RD 506 verified that RD 507's initial nutrition note was the only time that a registered dietitian assessed nutrition intake for Patient 503, which was documented as 0 - 10%. RD 506 verified that a clinical status of a stage III pressure ulcer resulted in altered nutrition status, in which calorie and protein needs would be increased. RD 506 acknowledged that Patient 503 had not had a comprehensive nutrition assessment, in which Patient 503's individualized estimated nutrition needs would be determined in order to determine if the patient's needs were met.

RD 506 verified that Patient 503 remained with poor po (oral) intake, and that Patient 503's nutritional needs had not been met since admission.

On 1/8/13 at 1:24 P.M., the Clinical Nutrition Specialist stated that RD 507 "could have and should have" completed a comprehensive nutrition assessment for Patient 503, in order to evaluate individualized nutrition needs for meaningful and appropriate nutrition intervention recommendations and re-assessments.

According to the hospital's policy and procedure entitled, Assessing Nutritional Requirements in Adults, last revised 6/5/12, "Purpose: To establish standardized guidelines for the dietitian to use when assessing the nutrient requirements of an adult in the acute care setting." According to the policy, a person with a Stage III pressure ulcer would need 1.25 - 1.5 grams of protein per kilogram of body weight, and would need 30 - 35 calories per kilogram of body weight.

2. On 1/9/13 at 12:42 P.M., Patient 504's medical record was reviewed. According to Patient 504's history and physical, dated 1/5/13, the diagnosis included diabetes type II and severe morbid obesity with the "importance of weight loss."

On 1/5/13, the physician ordered a consistent carbohydrate diet, without specifying a specific caloric level. The hospital's consistent carbohydrate diet provided 2,000 calories a day per the hospital's Diet Guidelines policy, last revised 9/17/12.

On 1/8/13, Registered Dietitian (RD 508) completed a nutrition assessment for Patient 504. According to the nutrition assessment, Patient 504 told RD 508 that she, "Eats bigger portions than hospital meals" provide. RD 508 noted the physician and patient's goal for weight loss. RD 508 assessed the patient's individualized nutrition needs, based on the patient's daily weight of 189.8 kilograms (kg), to be 2,500 calories per day for weight loss. RD 508 further documented that the current therapeutic diet order of consistent carbohydrate, that provided 2,000 calories per day, met the patient's nutritional needs, despite assessing the patient's nutritional needs at 2,500 calories per day.

ON 1/9/12 at 12:55 P.M., RD 509 reviewed Patient 504's medical record. RD 509 verified that the therapeutic diet ordered did not meet the patient's assessed nutritional needs, as assessed by RD 508. RD 509 stated that the patient was eating 100% of the meals. RD 509 acknowledged that RD 508 should have provided recommendations to the physician for a 2,500 calorie, consistent carbohydrate, diet per the patient's individualized assessed nutritional needs.

RD 509 verified that the hospital's approved policy and procedure to promote weight loss once identified by a physician, was to decrease a patient's caloric intake by 250 to 500 calories per day. RD 508's assessment for 2,500 calories per day was in accordance with hospital policy, however the RD failed to make recommendations to modify the therapeutic diet order to ensure the patient's nutritional needs were met, in accordance with hospital policy.

According to the hospital's policy and procedure entitled, Nutritional Intervention: Screening/Assessment/Documentation - Acute, last revised 9/17/12, patient's with an admission weight of < (greater than) 60 kg or > (less than) 85 kg, who had been prescribed a consistent carbohydrate diet, would have an individualized nutrition assessment completed to determine the default consistent carbohydrate diet needed to be modified, in order to meet those patient's nutritional needs.

The hospital's policy and procedure entitled, Assessing Nutritional Requirements in Adults, last revised 6/5/12, indicated, "A. To establish standardized guidelines for the dietitian to use when assessing the nutrient requirements of an adult in the acute care setting. B. To provide standards for evaluating weight status and ensure the methods of calculations are consistent among clinical staff members." The policy indicated that for weight loss the method was to assess estimated nutritional needs and then minus 250 - 500 calories per day.