HospitalInspections.org

The Governing Body Condition of Participation was found out of compliance.

Findings included:

Based on records reviewed and interviews, the Governing Body failed for four (4) patients sampled (Patients #1, #2, #3 & #10) to ensure that the Medical Staff was accountable to the Governing Body for the quality of care provided to patients regarding antibiotics that were not administered, antibiotics documented as omitted and two (2) medication events where patients received an over intended dose of Propofol (an anesthesia medication), in error.

Refer to TAG: A-0049, Medical Staff Accountability

The Governing Body failed for three (3) patients sampled (Patients #1, #2 & #3) to ensure that the Chief Executive Officer was responsible for managing the entire Hospital specifically the Hospital's Quality Assessment & Performance Improvement (QAPI) Program and processes after adverse patient events. The Governing Body failed to ensure the QAPI processes of thorough analysis of patient adverse events, thorough implementation of corrective actions and implementation of monitoring (auditing) corrective actions for effectives and prevention of adverse patient events.

Refer to TAG: A-0057, Chief Executive Officer

The Governing Body failed for one contracted service to ensure assessment of services furnished to the Hospital, through the Hospital's QAPI program activities, were safe and effective.

Refer to TAG: A-0083, Contracted Services

The Governing Body failed to ensure responsibility for the Hospital's compliance with all of the Conditions of Participation. The Patient Rights Condition of Participation and the QAPI Condition of Participation were found out of compliance.

Refer to TAG: A-0115, Patient Rights & TAG: A-0263, QAPI

Based on records reviewed and interviews, the Governing Body failed for four (4) patients (Patients #1, #2, #3 & #10) to ensure that the Medical Staff was accountable to the Governing Body for the quality of care provided to patients regarding antibiotics that were not administered, antibiotics documented as omitted and two medication events where patients received an over intended dose of Propofol (an anesthesia medication), in error.

Findings included:

1.) Patient #1's Discharge Summary, dated at 1:52 P.M. on 3/12/17, indicated the Hospital admitted Patient #1 with a diagnosis of respiratory insufficiency. The Medical Record indicated Patient #1 had a history of End Stage Renal (kidney) Disease. The Record indicated Patient #1's hospitalization included Peritoneal (abdominal) Dialysis (process to remove waste products from blood by a machine for kidney disease patients), intubation (breathing machine) and Extracorporeal Membrane Oxygenation (ECMO, treatment that uses a pump to circulate blood through an artificial lung back into the bloodstream of a critically ill patient). The Medical Record, dated at 11:21 A.M. on 3/10/17 indicated an order for the antibiotic, Zosyn, was ordered to start at 12:00 P.M. and a Registered Nurse administered the antibiotic at 1:44 A.M. on 3/11/17, (approximately 14 hours later). The Medical Record indicated Patient #1 was diagnosed with multi organ systems failure at the time of death and died on 3/12/17, two (2) days after the antibiotic was ordered.

The document titled Hospital Report, dated 3/29/17, indicated Zosyn (an antibiotic) was ordered but not given; a verbal order was given to hold the antibiotic however the Medical Record indicated a Registered Nurse administered the antibiotic Zosyn.

The Surveyor interviewed Patient Safety Staff #1 and Patient Safety Staff #2 at 11:00 A.M. on 11/28/17. Patient Safety Staff #1 and Patient Safety Staff #2 said the Hospital was notified of Patient #1's death through the Hospitals event reporting system on 3/12/17 and of Patient #1's positive blood culture (blood infected with bacteria) through the Hospitals event reporting system on 3/17/17. They said the Hospital conducted an Internal Investigation and identified the following corrective actions:

A.) To include the Children's Hospital Early Warning Score (CHEWS) into the Sepsis Protocol and educate Providers and staff of the Sepsis Protocol and CHEWS,

B.) Communication about verbal orders through a Practice Alert (e-mail),

C.) Re-educate the Nursing Staff on the use of Medication Administration Record (MAR) Safety View (computer view that summarized medications not administered) in the Electronic Medical Record (EMR), and

D.) Update the Dialysis Nurse's Note to improve communication.

The Hospital provided no indication that they fully implemented the corrective action plan. The Hospital provided no documentation to indicate Providers (physicians, nurse practitioners) were educated that the CHEWS were included into the Sepsis Protocol nor that Providers were educated of verbal orders through a Practice Alert.

Document Review of the Hospital Report titled Antibiotic Use, dated 8/1/17-11/28/17, indicated Patient #10 had an antibiotic omitted on 11/22/17. The Hospital provided no documentation to indicate monitoring of antibiotic administration as delayed or antibiotics documented as omitted.

The Hospital provided no documentation to indicate the Medical Staff was responsible to the Governing Body for the quality of care and services provided to patients regarding antibiotic administration errors.




39257


The following is regarding Patients #2 & #3:

The Hospital Report, dated 01/12/2017, indicated that a physician in training administered 50 milligram (mg) of Propofol instead of the intended dose range of 15 to 30mg on 01/12/17 to Patient #3 (first Propofol event). The Hospital Report indicated a nurse prepared the syringe containing the Propofol with more than the dose of Propofol ordered by the physician in training and the physician in training did not know that the syringe contained more than the dose ordered.

The Pharmacy and Therapeutics Committee Meeting Minutes, dated 04/2017, indicated a recommendation to update the Medication Administration Policy to utilize only weight-based doses (doses calculated on a patient's weight) to be prepared by Registered Nurses (RN) for sedation procedures, with a single weight-based dose in each syringe.

The policy titled Adverse Drug Event (ADE) Reporting, dated 06/04/17, indicated Hospital staff document significant ADEs in the patient's medical record. Review of Patient #3's medical record indicated that no documentation of a significant ADE was recorded regarding Patient #3's over the intended dose of Propofol.

The Hospital Report, dated 10/31/17, indicated Physician #3 administered 60mg of Propofol instead of 10mg of Propofol to Patient #2 on 10/30/17 (the second Propofol event within 10 months). The error resulted in Patient #2 becoming hypotensive (low blood pressure) and apneic (not breathing) requiring interventions that included Bag Mask Ventilator Support (artificial breathing) and Fluid Resuscitation (administration of intravenous (IV) fluids).

The Surveyor interviewed Physician #1 (supervisor of physician in training) on 11/29/17 who said that Physician #3 (physician in training) was unaware that the nurses were preparing in one syringe more than one dose of Propofol. Physician #3 administered 5 to 6 milliliters (mL) of Propofol to Patient #2 (equivalent to 50 to 60 mg of Propofol instead of the intended 10 mg dose). The error resulted in Patient #2 becoming hypotensive and apneic requiring interventions that included Bag Mask Ventilator Support and Fluid Resuscitation.

The Corrective Action Plan, dated 11/07/17, included education & training for providers who administer Propofol in the Intensive Care Unit (ICU)-A of the Hospital. The Hospital provided no documentation to indicate a corrective action plan was given to all providers in other areas of the Hospital that have the credentials to administer Propofol. These other areas include, but are not limited to, the Operating Room (OR), Interventional Radiology (IR), Gastroenterology (GI), Emergency Department (ED), Hospital satellite locations etc.

The Surveyor interviewed Pharmacist #2 on 11/30/17. Pharmacist #2 said that Propofol was administered in other areas besides ICU-A, at the following locations: ED, GI, OR, IR, Neonatal Intensive Care Unit (NICU).

An email, dated 11/24/17, from Pharmacist #1, indicated that the Medication Administration Policy needed to be updated to reflect that only weight-based doses should be prepared. The email from Pharmacist #1 indicated that recommendations were identified and remained open (required follow-up and implementation).

The Surveyor interviewed Pharmacist #1 on 11/30/17. Pharmacist #1 said that corrective recommendations were identified as a result of the first Propofol event that occurred on 01/2017. Pharmacist #1 said these recommendations did not materialize (not implemented). Pharmacist #1 said that the policy titled "Authorized Medication Administration" was last modified 10/19/16, and was not updated to reflect only weight-based doses in accordance with the identified recommendations.

Based on records reviewed and interview the Governing Body failed for three (3) patients sampled (Patients #1, #2 & #3) to ensure that the Chief Executive Officer was responsible for managing the entire Hospital specifically the Hospital's Quality Assessment & Performance Improvement Program and processes (QAPI) after adverse patient events. The Governing Body failed to ensure the QAPI processes of thorough analysis of patient adverse events, thorough implementation of corrective actions and implementation of monitoring (auditing) corrective actions for effectives and prevention of adverse patient events.

Findings included:

Patient #1's Medical Record, dated at 11:21 A.M. on 3/10/17 indicated an order for the antibiotic, Zosyn, was ordered to start at 12:00 P.M. and a Registered Nurse administered the antibiotic at 1:44 A.M. on 3/11/17, (approximately 14 hours later).

The document titled Hospital Report, dated 3/29/17, indicated Zosyn (an antibiotic) was ordered but not given; a verbal order was given to hold the antibiotic; however, the Medical Record indicated a Registered Nurse administered the antibiotic Zosyn. The document titled Hospital Report indicated corrective actions regarding Sepsis Huddles (meetings), e-mail Practice Alert to Providers regarding verbal orders, Intensive Care Unit-A nurses' education regarding the use of the Medication Administration Record Safety View (a computerized summary of medications not administered) use and revision of a Dialysis Nurse's Note regarding communication.

The Surveyor interviewed Patient Safety Staff #1 and Patient Safety Staff #2 at 11:00 A.M. on 11/28/17. Patient Safety Staff #1 and Patient Safety Staff #2 said the Hospital conducted an Internal Investigation regarding Patient #1.

The Surveyor interviewed the Intensive Care Unit Medical Director at 12:00 P.M. on 12/4/17. The Medical Director said the Hospital did not monitor staff compliance with the corrective actions regarding sepsis, did not monitor staff compliance with the corrective action regarding usage of the Medication Administration Record and did not know the effectiveness of the corrective action regarding the Dialysis Nurse's Note.

The Hospital provided no documentation to indicate corrective actions were thoroughly implemented or monitored (audited) as effective and preventative.

Based on records reviewed the Governing Body failed for one contracted service to ensure assessment of services furnished to the Hospital through the Hospital's Quality Assessment & Performance Improvement (QAPI) program activities, were safe and effective.

Findings included:

The document titled Arion Waters, dated 2017, indicated a contract between the Hospital and Arion Waters [a company for dialysis (process to remove waste products from blood by a machine for kidney disease patients] services.

The Hospital provided no documentation to indicate QAPI Program activities assessed the Arion Waters contracted dialysis service as safe and effective and reported to the Governing Body for review.

The Hospital provided no documentation to indicate the Governing Body was informed for review that QAPI Program activities assessed the Arion Waters contracted dialysis service for safety and effectiveness.



13092

Two clinical contracts were randomly selected for review from a list provided to the Surveyor on 12/20/17.

The Manager of Corporate Compliance & Regulatory Affairs was interviewed at approximately 2:00 P.M. on 12/20/27. The Manager of Corporate Compliance & Regulatory Affairs said that one of the two clinical services was not utilized by the Hospital so there was no evaluation of the service. The Manager of Corporate Compliance & Regulatory Affairs said the other contracted clinical service had been reviewed by the Medical Director of Dialysis and the Director of Clinical Services for Nephrology; however, the Hospital provided no documentation to indicate the Governing Body's actions to ensure the service was provided in a safe manner.

Based on records reviewed and interviews the Hospital failed for four of ten patients sampled, (Patient #1, #2, #3 & #10) to ensure care in a safe setting. Patient #1 did not receive an antibiotic per a Nurse Practitioner's order. Patient #3 received an over intended dose of Propofol (an anesthesia drug) in January of 2017, in error. Patient #2 received an over intended dose of Propofol in October of 2017, in error, ten (10) months later and a dose of Patient #10's antibiotic was reported as omitted.

Findings included:

1.) Patient #1's Medical Record, Discharge Summary, dated at 1:52 P.M. on 3/12/17, indicated the Hospital admitted Patient #1 with a diagnosis of respiratory insufficiency. The Medical Record indicated Patient #1 with a history of End Stage Renal (kidney) Disease. The Medical Record indicated Patient #1's hospitalization included Peritoneal (abdominal) Dialysis (process to remove waste products from blood by a machine for kidney disease patients), intubation (breathing machine) and Extracorporeal Membrane Oxygenation (ECMO, treatment that uses a pump to circulate blood through an artificial lung back into the bloodstream of a critically sick patient). The Medical Record indicated Patient #1 with a diagnosis of multi-organ systems failure at the time of death. The Medical Record, dated at 11:21 A.M. on 3/10/17 indicated an order for the antibiotic, Zosyn, was ordered to start at 12:00 P.M. and a Registered Nurse administered the antibiotic at 1:44 A.M. on 3/11/17, (approximately 14 hours later).

The Patient Safety Staffs #1 & #2 said it was their understanding that there was a verbal order, from ICU-A team that included a Nurse Practitioner and a Renal (kidney specialist) Physician, to hold Patient #1's antibiotic (Zosyn) until staff obtained a sample of Patient #1's peritoneal fluid for cell-count (laboratory test) at approximately 12:00 P.M. (on 3/11/17).

The Surveyor interviewed Registered Nurse (RN) #1 at 4:00 P.M. on 11/29/17. RN #1 said that the ICU-A team huddle (meeting at approximately 11:00 A.M. on 3/10/17) developed the plan to hold the antibiotic. RN #1 said that he/she was waiting for a member of ICU-A team to tell him/her to start the antibiotic. RN #1 said that he/she did not recall a conversation regarding medication orders with RN #3 (the next RN caregiver for Patient #1) at the change of the shift report, at 7:00 P.M. on 3/10/17.

The Surveyor interviewed the Attending (ICU -A) Physician at 9:30 A.M. on 12/4/17. The Attending Physician said that he did not know of an order to hold the antibiotic.

Review of Patient #1's medical record indicated no documentation to indicate RN #1 was given a verbal order to hold the antibiotic.

The Surveyor interviewed Nurse Practitioner #1 at 2:00 P.M. on 12/4/17. Nurse Practitioner #1 said she did not provide the verbal order to hold Patient #1's antibiotic until obtaining the (peritoneal fluid) cell-count. Nurse Practitioner #1 said the (communication) process was different for every patient and every nurse.

2.) The Hospital Report titled Intravenous (IV) Antibiotic, dated 3/1/17-11/30/17, indicated 3%-7% of antibiotics were not administered 60 minutes (one hour) to 480 minutes (eight hours) after the physician ordered the antibiotic to start.

The Hospital Report titled Antibiotic Use, dated 8/1/17-11/28/17, indicated Patient #10 had an antibiotic omitted on 11/22/17.

The Hospital Medication Report, dated 8/11/17-11/2/17 indicated 14 medication omissions. The report titled Antibiotic Use, dated 8/1/17-11/28/17, indicated two omissions.

The Hospital provided no documentation to indicate the Hospital reviewed QAPI data to identify problems and patterns, evaluate those problems and patterns and take steps to ensure a safe patient environment regarding antibiotic administration after Patient #1's death.

Based on records reviewed and interviews the Hospital failed to ensure for four of ten patients sampled, (Patient #1, #2, #3 & #10) care in a safe setting when Patient #1 did not receive an antibiotic per physician order, Patient #2 & #3 received an over intended dose of Propofol and when a dose of Patient #10's antibiotic was reported as omitted. The Hospital failed to provide adequate training and education on the proper administration of Propofol (an anesthesia drug) resulting in Patient #2 and Patient #3 receiving an over the intended dose of Propofol, in error.

Findings included:

1.) Patient #1's Medical Record, Discharge Summary, dated at 1:52 P.M. on 3/12/17, indicated the Hospital admitted Patient #1 with a diagnosis of respiratory insufficiency. The Medical Record indicated Patient #1 with a history of End Stage Renal (kidney) Disease. The Medical Record indicated Patient #1's hospitalization included Peritoneal (abdominal) Dialysis (process to remove waste products from blood by a machine for kidney disease patients), intubation (breathing machine) and Extracorporeal Membrane Oxygenation (ECMO, treatment that uses a pump to circulate blood through an artificial lung back into the bloodstream of a critically sick patient). The Medical Record indicated Patient #1 with a diagnosis of multi-organ systems failure at the time of death. The Medical Record, dated at 11:21 A.M. on 3/10/17 indicated an order for the antibiotic, Zosyn, was ordered to start at 12:00 P.M. and a Registered Nurse administered the antibiotic at 1:44 A.M. on 3/11/17, (approximately 14 hours later).

Patient #1's Medical Record indicated a Provider order for Zosyn (an antibiotic), dated at 11:21 A.M. on 3/10/17, to start at 12:00 P.M.

Review of Patient #1's medical record indicated no documentation to indicate RN #1 was given a verbal order to hold or discontinue the antibiotic.

Document Review of the Hospital Report titled Antibiotic Use, dated 8/1/17-11/28/17, indicated Patient #10 had an antibiotic omitted on 11/22/17. The Hospital provided no documentation to indicate monitoring of antibiotic administration as delayed or antibiotics documented as omitted.

2.) The Hospital Report titled Intravenous (IV) Antibiotic, dated 3/1/17-11/30/17, indicated 3%-7% of antibiotics were not administered 60 minutes (one hour) to 480 minutes (eight hours) after the physician ordered the antibiotic to start.

The Hospital Medication Report, dated 8/11/17-11/2/17 indicated 14 medication omissions. The report titled Antibiotic Use, dated 8/1/17-11/28/17, indicated two omissions.

The Hospital provided no documentation to indicate the Hospital reviewed QAPI data to identify problems and patterns, evaluate those problems and patterns and take steps to ensure a safe patient environment regarding antibiotic administration after Patient #1's death.


39257


The following is regarding Patients #2 & #3:

The Hospital Report, dated 01/12/2017, indicated that a physician in training administered 50 milligram (mg) of Propofol instead of the intended dose range of 15 to 30mg on 01/12/17 to Patient #3 (first Propofol event). The Hospital Report indicated that the physician in training was unaware that the nursing staff did not prepare single doses of Propofol.

The Pharmacy and Therapeutics Committee Meeting Minutes, dated 04/2017, indicated a recommendation to update the Medication Administration Policy to utilize only weight-based doses (doses calculated on a patient's weight) to be prepared by Registered Nurses (RN) for sedation procedures, with a single weight-based dose in each syringe.

The policy titled Adverse Drug Event (ADE) Reporting, dated 06/04/17, indicated Hospital staff document significant ADEs in the patient's medical record. Review of Patient #3's medical record indicated that no documentation of a significant ADE was recorded regarding Patient #3's over the intended dose of Propofol.

The Hospital Report, dated 10/31/17, indicated Physician #3 administered 60mg of Propofol instead of 10mg of Propofol to Patient #2 on 10/30/17 (the second Propofol event within 10 months). The error resulted in Patient #2 becoming hypotensive (low blood pressure) and apneic (not breathing) requiring interventions that included Bag Mask Ventilator Support (artificial breathing) and Fluid Resuscitation (administration of intravenous (IV) fluids).

The Surveyor interviewed Physician #1 on 11/29/17 who said that Physician #3 was unaware that the nurses were preparing in one syringe more than one dose of Propofol. Physician #3 administered 5 to 6 milliliters (mL) of Propofol to Patient #2 (equivalent to 50 to 60 mg of Propofol instead of the intended 10 mg dose). The error resulted in Patient #2 becoming hypotensive and apneic requiring interventions that included Bag Mask Ventilator Support and Fluid Resuscitation.

The Corrective Action Plan, dated 11/07/17, included education & training for providers who administer Propofol in the Intensive Care Unit (ICU)-A of the Hospital. The Hospital provided no documentation to indicate a corrective action plan was given to all providers in other areas of the Hospital that have the credentials to administer Propofol. These other areas include, but are not limited to, the Operating Room (OR), Interventional Radiology (IR), Gastroenterology (GI), Emergency Department (ED), Hospital satellite locations etc.

The Surveyor interviewed Pharmacist #2 on 11/30/17. Pharmacist #2 said that Propofol was administered in other areas besides ICU-A, at the following locations: ED, GI, OR, IR, Neonatal Intensive Care Unit (NICU).

An email, dated 11/24/17, from Pharmacist #1, indicated that the Medication Administration Policy needed to be updated to reflect that only weight-based doses should be prepared. The email from Pharmacist #1 indicated that several issues related to the recommendations were identified, remained open and needed follow up.

The Surveyor interviewed Pharmacist #1 on 11/30/17. Pharmacist #1 said that corrective recommendations were identified as a result of the first Propofol event that occurred on 01/2017. Pharmacist #1 said these recommendations did not materialize (not implemented). Pharmacist #1 said that the policy titled "Authorized Medication Administration" was last modified 10/19/16, and was not updated to reflect only weight-based doses in accordance with the identified recommendations.

The Condition of Participation for Quality Assessment and Performance Improvement (QAPI) was found out of compliance

Findings included:

The Hospital failed for four of ten patients sampled (Patients #1, #2, #3 & #10) to ensure that QAPI activities were data-driven, including analysis and preventative corrective actions to reduce medical errors, 8 months, after Patient #1's death and Patient #2 and Patient #3's medication errors where Patient #3's medication error occurred in January of 2017 and 10 (10) months later Patient #2's medication error occurred in October of 2017.

Refer to TAG: A-0273

The Hospital failed to ensure for four of ten patients sampled (Patients #1, #2, #3 & #10), that QAPI activities monitored (audited) corrective actions to ensure that the corrective actions were effective.

Refer to TAG: A-0283

The Hospital failed to ensure for three of ten patients sampled (Patients #1, #2 and #3), that QAPI activities included feedback and learning throughout the Hospital.

Refer to TAG: A-0286

The Governing Body failed to ensure, for four of ten patients sampled (Patients #1, #2, #3 & #10), an effective quality improvement and patient safety program that thoroughly defined, implemented and maintained (monitored, evaluated) quality improvement activities following medical errors.

Refer to TAG: A-0309

Based on records reviewed and interviews the Hospital failed for four of ten patients sampled (Patients #1, #2, #3 & #10) to ensure that Quality Assessment and Performance Improvement (QAPI) activities were data-driven, included thorough analysis and preventative corrective actions to reduce medical errors, 8 months, after Patient #1's death and Patient #2 &Patient #3's medication errors and Patient #10's medication event.

Findings included:

The following regarding Patient #1:

Patient #1's Discharge Summary, dated at 1:52 P.M. on 3/12/17, indicated the Hospital admitted Patient #1 with a diagnosis of respiratory insufficiency. The Medical Record indicated Patient #1 with a history of End Stage Renal Disease. The Medical Record indicated Patient #1's hospitalization included Peritoneal (abdominal) Dialysis (process to remove waste products from blood by a machine for kidney disease patients), intubation (breathing machine) and Extracorporeal Membrane Oxygenation (ECMO, treatment that uses a pump to circulate blood through an artificial lung back into the bloodstream of a critically sick patient). The Medical Record indicated Physicians diagnosed Patient #1 with multi organ systems failure at the time of death. The Medical Record, dated at 11:21 A.M. on 3/10/17 indicated an order for the antibiotic, Zosyn, was ordered to start at 12:00 P.M. and a Registered Nurse administered the antibiotic at 1:44 A.M. on 3/11/17, (approximately 14 hours later).

Patient #1's Medical Record indicated a Provider order for Zosyn (an antibiotic), dated at 11:21 A.M. on 3/10/17, to start at 12:00 P.M.

The document titled Summary Report, dated 3/29/17, indicated Zosyn was ordered but not given; a verbal order was given to hold the antibiotic (however, the Medical Record indicated a Registered Nurse administered the antibiotic Zosyn).

The Surveyor interviewed Patient Safety Staff #1 and Patient Safety Staff #2 at 11:00 A.M. on 11/28/17. Patient Safety Staff #1 and Patient Safety Staff #2 said the Hospital Internal Investigation regarding Patient #1 discovered that:

A.) The Sepsis (infection) Tool was not designed for children with chronic (long lasting) conditions,

B.) A verbal order, from ICU-A team that included a Nurse Practitioner and a Renal (kidney specialist) Physician, to hold Patient #1's antibiotic (Zosyn) until staff obtained a sample of Patient #1's peritoneal fluid for cell-count (laboratory test) at approximately 12:00 P.M. (on 3/11/17) was not written and there should not have been a verbal order to hold the antibiotic.

C.) There was approximately a 12-hour delay in administering an antibiotic.

The Medical Record, dated at 11:21 A.M. on 3/10/17 indicated an order for the antibiotic, Zosyn, was ordered to start at 12:00 P.M. and a Registered Nurse administered the antibiotic at 1:44 A.M. on 3/11/17, (approximately 14 hours later).

D.) There was little communication between the Dialysis Nurse and RN #1, and

E.) The laboratory notified the Emergency Department physician of Patient #1's positive blood culture result.

Patient Safety Staff #1 and Patient Safety Staff #2 said that the Hospital Internal Investigation identified the following corrective actions:

A.) To include the Children's Hospital Early Warning Score (CHEWS) into the Sepsis Protocol and educate Providers and staff of the Sepsis Protocol and CHEWS,

B.) Communication about verbal orders through a Practice Alert (e-mail).

C.) Re-educate the Nursing Staff on the use of Medication Administration Record (MAR) Safety View (computer view that summarized medications not administered) in the Electronic Medical Record (EMR), and

D.) Update the Dialysis Nurse's Note to improve communication.

The document titled Summary Report indicated the following corrective actions:

A.) Incorporate the Sepsis Huddles (meetings, Sepsis Protocol) into the Children's Hospital Early Warning Score (CHEWS) algorithm. Patient Safety Staff #1 and Patient Safety Staff #2 said that the Hospital Internal Investigation identified a corrective action consisted of Provider education of the Sepsis Protocol and CHEWS. The document titled Children's Hospital Early Warning Score (CHEWS), dated 2017, did not indicate that the Sepsis Huddles (meetings) were incorporated into CHEWS algorithm. The Hospital provided no documentation to indicate Providers were educated about verbal orders through the Practice Alert (e-mail).

B.) Communicate to all Intensive Care Unit (ICU) -A Physicians (doctors) and Nurse Practitioners regarding verbal orders (to hold, do not administer).

The policy titled Authorized Medication Prescribing Guidelines, dated 3/6/15, and the policy titled Verbal orders, dated 10/20/16, indicated orders Providers communicated verbally to clinical staff were indicated only when the Provider was physically unable to write the order.

The e-mail titled Practice Alert, dated 3/27/17, indicated changes in written orders, including delaying an already ordered therapy should be done in the Electronic Medical Record and not verbally. The Practice Alert indicated no indication of a recommendation specifically regarding holding a medication, antibiotic.

The Surveyor interviewed Registered Nurse (RN) #1 at 4:00 P.M. on 11/29/17. RN #1 said Intensive Care Unit -A Team discussed holding Patient #1's antibiotic until obtaining the (peritoneal fluid) cell-count as part of Patient #1 plan of care and the ICU -A Team members were a Nurse Practitioner and an Attending (ICU -A) Physician. RN #1 said that the Provider responsible to write a verbal order depended on the circumstances (case by case). RN #1 said that the ICU-A team huddle (meeting) developed the plan to hold the antibiotic. RN #1 said that he/she was waiting for a member of ICU-A team to tell him/her to start the antibiotic.

The Surveyor interviewed the Attending Physician at 9:30 A.M. on 12/4/17. The Attending Physician said that he did not know of an order to hold the antibiotic.

The Surveyor interviewed Nurse Practitioner #1 at 2:00 P.M. on 12/4/17. Nurse Practitioner #1 said she did not provide the verbal order to hold Patient #1's antibiotic until obtaining the (peritoneal fluid) cell-count. Nurse Practitioner #1 said she did not review medications ordered at the end of her shift with the covering physician (in accordance with Medical Staff Bylaws).

The Hospital Medical Staff Bylaws, dated 7/19/16, indicated the Intensive Care Unit Attending Physician was responsible for all decisions concerning patients. The Hospital Medical Staff Bylaws, dated 7/19/16, indicated medication orders were reviewed by the authorized practitioner (physician, nurse practitioner) upon clinical handoff or transfer of care.

The Hospital provided no indication that the Hospital Internal Investigation identified that their discovery of a 12 hour delay in antibiotic administration was actually approximately a 14 hour delay.

The Medical Record, dated at 11:21 A.M. on 3/10/17 indicated an order for the antibiotic, Zosyn, was ordered to start at 12:00 P.M. and a Registered Nurse administered the antibiotic at 1:44 A.M. on 3/11/17, (approximately 14 hours later).

The Hospital provided no indication that the Hospital Internal Investigation identified conflicting information regarding the Provider (Nurse Practitioner, Physician) that possibly provided the verbal order. The Hospital provided no indication that the Hospital identified or responded to inconsistencies in the accounts between the Hospital Internal Investigation, RN #1 and Nurse Practitioner #1. The Hospital provided no documentation to indicate that the Hospital Internal Investigation was aware and analyzed that RN #1 was waiting for a member of the ICU-A team to communicate when to discontinue holding the antibiotic according to the verbal order and to start the antibiotic. The Hospital provided no documentation to indicate that the Hospital Internal Investigation developed corrective action(s), a communication process or a policy regarding this communication when to start the antibiotic.

C.) ICU-A nurse education about the use of the Medication Administration Record Safety View use at the change of shift report and auditing for compliance.

D.) Develop a Dialysis Nurse's Note to include communication about when the Dialysis Nurse sent specimens for cultures (testing) to the laboratory with the patient's physician responsible for hospital care.

The Surveyor interviewed Patient Safety Staff #1 and Patient Safety Staff #2 at 11:00 A.M. on 11/28/17. Patient Safety Staff #1 and Patient Safety Staff #2 said the Hospital Internal Investigation discovered there was little communication between the Dialysis Nurse and RN #1. Patient Safety Staff #1 and Patient Safety Staff #2 said the Dialysis Nurse had the information about the peritoneal fluid and communicated this information with the Renal Physician. Patient Safety Staff #1 and Patient Safety Staff #2 said that RN #1 and ICU-A covering physician were not aware that the peritoneal fluid was obtained and sent for cell-count. Patient Safety Staff #1 and Patient Safety Staff #2 said that the Hospital Internal Investigation identified a corrective action to update the Dialysis Nurse's Note to improve communication.

The Surveyor interviewed Dialysis Nurse #1 at 9:00 A.M. on 11/30/17. Dialysis Nurse #1 said she told RN #1 that the peritoneal fluid cell-count test was negative. Dialysis Nurse #1 said that the Hospital did not interview her.

The Hospital provided no documentation to indicate that the Hospital Internal Investigation developed a corrective action that clearly described the communication process.

The following regarding Patient #10:

Review of Patient #10's Medial Record indicated a physician order, dated at 2:53 P.M. on 11/21/17, to administer Cefazolin (an antibiotic) three times after surgery with an end-state (stop date) at 7:00 A.M. on 11/22/17.

The Surveyor interviewed Medical Record Review Nurse Navigator #1, at 11:00 A.M. on 12/4/17. The Medical Record Review Nurse Navigator #1 said when a medication order was re-timed (schedule change) and a dose was pending, the medication order stop-time discontinued the medication and the medication computer system generated a notice as medication dose as not done.

The Hospital provided no documentation to indicate tracking and analysis of medications delayed or omitted related to the medication computer system generated notice of a medication dose as not done.

The following regarding medication administration analysis:

The Hospital Report titled Intravenous (IV) Antibiotic, dated 3/1/17-11/30/17, indicated 3%-7% of antibiotics were not administered 60 minutes (one hour) to 480 minutes (eight hours ) after the physician ordered the antibiotic to start.

The Hospital Medication Report, dated 8/11/17-11/2/17 indicated 14 medication omissions. The Report titled Antibiotic Use, dated 8/1/17-11/29/17, indicated two omissions. The Hospital provided no documentation to indicate medication omissions were analyzed.

The Hospital Report titled Antibiotic Use, dated 8/1/17-1/28/18, indicated Patient #10 as an antibiotic omitted on 11/22/17 and the Hospital Report, dated 11/22/17, indicated one dose as not done.

The Surveyor interviewed Pharmacist #1 at 1:20 P.M. on 11/30/17. Pharmacist #1 said that the Hospital did not track delays in the administration of all antibiotics.

The Surveyor interviewed Pharmacist #2 at 8:30 A.M. on 12/4/17. Pharmacist #2 said not everyone (nursing staff) used the Medication Administration Safety View, monitoring the Mediation Administration Record safety view usage was not a corrective action in response to and after Patient #1's death. Pharmacist #2 said that the Hospital relied on the Hospital's Event Reporting System to identify delays in antibiotic administration.

The Hospital Intravenous (IV) Antibiotic, Antibiotic Use, and Medication Reports, indicated the Hospital did not track or analyze data to indicate that medications and antibiotics were administered according to Hospital policy and physician orders.

The Hospital provided no documentation to indicate the Hospital reviewed QAPI data to identify problems and patterns, evaluating those problems and patterns and taking steps to ensure effective QAPI processes regarding antibiotic administration, 8 months, after Patient #1's adverse event and death.

The following regarding event reporting:

The policy titled Authorized Medication Administration, dated 11/6/15, indicated the Hospital scheduled medication times based on individual patient needs and clinical indication (severity of patient illness). The policy indicated time-critical (must be administered timely) medications required timely administration to meet patient need or clinical situation (severity of patient illness).

The policy titled Adverse Event Reporting, dated 6/24/16, indicated a reportable adverse event is an event that placed a patient at risk for injury. The policy indicated if staff was uncertain if an event was reportable, the staff should report the event to the Hospital within 24 hours of recognition of the event. The policy indicated first time dose of intravenous antibiotic for patients with fever as administered as soon as available or 30 minutes before or after obtaining the medication.

Patient Safety Staff #1 and Patient Safety Staff #2 said that RN #3 (the RN caring for Patient #1 on 3/11/17 at 2:00 A.M.), discovered the antibiotic was not administered, administered the antibiotic and did not notify the (ICU-A) team and did not notify the Quality Department of the approximately 12 hour delay in administering the antibiotic. However, The Medical Record indicated a Registered Nurse administered the antibiotic Zosyn at 1:44 A.M. on 3/11/17.

The Hospital provided no documentation to indicate that the Hospital Internal Investigation, eight (8) months after Patient #1's death, reviewed for what reason (why) RN #3, on 3/11/17, did not notify the Quality Department of the antibiotic delay in administration.

The Hospital provided no documentation to indicate that the Hospital Internal Investigation thoroughly analyzed and implemented corrective actions in accordance with their Adverse Event Reporting policy.

The following regarding culture reporting:

Patient Safety Staff #1 and Patient Safety Staff #2 said the Hospital Internal Investigation regarding Patient #1 discovered blood cultures were reported as positive for Enterobacter (bacteremia, sepsis) on 3/16/17 from the cultures obtained in the Emergency Department on 3/9/17. They said that the Hospital laboratory notified the Emergency Department Physician of Patient #1's positive blood culture and notified the Quality Department on 3/17/17. They said Patient #1 died on 3/12/17.

The Hospital provided to documentation to indicate that the Hospital Internal Investigation analyzed or implemented necessary corrective actions after discovering that the laboratory reported Patient #1's positive blood culture results to the Emergency Department Physician and not to the physician teams that cared for Patient #1.



39257


The following is regarding Patients #2 & #3:

The Hospital Report, dated 01/12/2017, indicated that a physician in training administered 50 milligram (mg) of Propofol instead of the intended dose range of 15 to 30mg on 01/12/17 to Patient #3 (first Propofol event). The Hospital Report indicated a nurse prepared the syringe containing the Propofol with more than the dose of Propofol ordered by the physician in training and the physician in training did not know that the syringe contained more than the dose ordered.

The Pharmacy and Therapeutics Committee Meeting Minutes, dated 04/2017, indicated a recommendation to update the Medication Administration Policy to utilize only weight-based doses (doses calculated on a patient's weight) to be prepared by Registered Nurses (RN) for sedation procedures, with a single weight-based dose in each syringe.

The policy titled Adverse Drug Event (ADE) Reporting, dated 06/04/17, indicated Hospital staff document significant ADEs in the patient's medical record. Review of Patient #3's medical record indicated that no documentation of a significant ADE was recorded regarding Patient #3's over the intended dose of Propofol.

The Hospital Report, dated 10/31/17, indicated Physician #3 administered 60mg of Propofol instead of 10mg of Propofol to Patient #2 on 10/30/17 (the second Propofol event within 10 months). The error resulted in Patient #2 becoming hypotensive (low blood pressure) and apneic (not breathing) requiring interventions that included Bag Mask Ventilator Support (artificial breathing) and Fluid Resuscitation (administration of intravenous (IV) fluids).

The Surveyor interviewed Physician #1 (supervisor of physician in training) on 11/29/17 who said that Physician #3 (physician in training) was unaware that the nurses were preparing in one syringe more than one dose of Propofol. Physician #3 administered 5 to 6 milliliters (mL) of Propofol to Patient #2 (equivalent to 50 to 60 mg of Propofol instead of the intended 10 mg dose). The error resulted in Patient #2 becoming hypotensive and apneic requiring interventions that included Bag Mask Ventilator Support and Fluid Resuscitation.

The Corrective Action Plan, dated 11/07/17, included education & training for providers who administer Propofol in the Intensive Care Unit (ICU)-A of the Hospital. The Hospital provided no documentation to indicate a corrective action plan was given to all providers in other areas of the Hospital that have the credentials to administer Propofol. These other areas include, but are not limited to, the Operating Room (OR), Interventional Radiology (IR), Gastroenterology (GI), Emergency Department (ED), Hospital satellite locations etc.

The Surveyor interviewed Pharmacist #2 on 11/30/17. Pharmacist #2 said that Propofol was administered in other areas besides ICU-A, at the following locations: ED, GI, OR, IR, Neonatal Intensive Care Unit (NICU).

An email, dated 11/24/17, from Pharmacist #1, indicated that the Medication Administration Policy needed to be updated to reflect that only weight-based doses should be prepared. The email from Pharmacist #1 indicated recommendations and remained open (required follow up and implementation).

The Surveyor interviewed Pharmacist #1 on 11/30/17. Pharmacist #1 said that corrective recommendations were identified as a result of the first Propofol event that occurred on 01/2017. Pharmacist #1 said these recommendations did not materialize (not implemented). Pharmacist #1 said that the policy titled "Authorized Medication Administration" was last modified 10/19/16, and was not updated to reflect only weight-based doses in accordance with the identified recommendations.

Based on records reviewed and interviews the Hospital failed for two of ten patients sampled (Patients #1 & #10) to ensure that Quality Assessment and Performance Improvement (QAPI) activities monitored (audited) corrective actions to measure its success.

Findings included:

The following regarding the Verbal Order corrective action:

The document titled Summary Report, dated 3/29/17, indicated an immediate corrective action included that a Practice Alert (e-mail) was sent to the Intensive Care Unit (ICU) -A Providers that verbal orders should be avoided except in emergencies.

The Surveyor interviewed Nurse Director #2, at 12:00 P.M. on 12/4/17. Nurse Director #2 said that the corrective action plans included a Practice Alert for Providers regarding verbal orders.

The Hospital provided no documentation to indicate the Hospital monitored the effectiveness of the verbal order corrective action through the education using the e-mailed Practice Alert.

The following regarding the Medication Administration Record Safety View Note corrective action:

The document titled Summary Report indicated a corrective action included ICU-A Nurse education about the use of the Medication Administration Record Safety View and auditing for compliance.

The document titled People Completions, undated, indicated 100% of ICU-A Nurse staff completed the education.

The Surveyor interviewed Registered Nurse (RN) #1 at 4:00 P.M. on 11/29/17. RN #1 said that the Hospital was not doing anything differently (implemented corrective actions regarding the Medication Administration Record Safety View to review medication orders), education or changes in nursing practice, after the death of Patient #1.

The Surveyor interviewed Pharmacist #2 at 8:30 A.M. on 12/4/17. Pharmacist #2 said the Hospital was not auditing the usage of the Medication Administration Record Safety View.

The Hospital provided no documentation to indicate ICU-A nurse education regarding the use of the Medication Administration Record Safety View was effective. The Hospital provided no documentation to indicate monitoring (auditing) that all Nurses responsible for medication administration (as appropriate) throughout the Hospital used the Medication Safety View in practice at the change of shift report to ensure all medications were administered as ordered. The Hospital provided no documentation to indicate the revised Dialysis Nurse's Note was effective.

The following regarding the Dialysis (process to remove waste products from blood by a machine for kidney disease patients) Nurses Note corrective action:

The document titled Summary Report indicated a corrective action included the development of a Dialysis Nurse's Note to include communication about when the Dialysis Nurse sent specimens for cultures (testing) to the laboratory with the patient's physician responsible for hospital care.

The Hospital provided no documentation to indicate monitoring the effectiveness of the updated Dialysis Nurses Note regarding communication.

Based on records reviewed and interviews the Hospital failed for three of ten patients sampled (Patients #1, #2 and 3) to ensure that Quality Assessment and Performance Improvement (QAPI) activities included feedback and learning throughout the Hospital.

Findings included:

The following regarding Patient #1:

The following regarding the Verbal Order corrective action:

The document titled Summary Report, dated 3/29/17, indicated an immediate corrective action included that a Practice Alert (e-mail) was sent to the Intensive Care Unit (ICU-A) Providers (physicians and nurse practitioners) that verbal orders should be avoided except in emergencies.

The Surveyor interviewed Nurse Director #2, at 12:00 P.M. on 12/4/17. Nurse Director #2 said that the corrective action plans included a Practice Alert for Providers regarding verbal orders. Nurse Director #2 provided no indication that the Hospital implemented this corrective action in all areas of the Hospital.

The document titled Summary did not indicate that the Hospital sent the Practice Alert to all appropriate Providers of other Intensive Care Units and areas of the Hospital.

The following regarding the Medication Administration Record Safety View corrective action:

Patient Safety Staff #1 and Patient Safety Staff #2 said that RN #3 did not know that antibiotic orders were written.

The document titled Summary indicated a corrective action regarding ICU-A Nurse education about the use of the Medication Administration Record Safety View.

Patient Safety Staff #1 and Patient Safety Staff #2 said that the Hospital Internal Investigation identified the corrective action to re-educate the Nursing Staff on the use of Medication Administration Record Safety View (MAR, computerized view of medications not administers) in the Electronic Medical Record (EMR).

Nurse Director #2 said that the corrective action plans included education/re-education in the use of the Medication Administration Safety View was for ICU-A. Nurse Director #2 provided no indication that these corrective actions were implemented in all areas of the Hospital that administered intravenous antibiotics.

The Hospital provided no documentation to indicate all Nurses responsible for medication administration (as appropriate) throughout the Hospital were required to complete the education.


































39257


The following is regarding Patients #2 & #3:

The Hospital Report, dated 01/12/2017, indicated that a physician in training administered 50 milligram (mg) of Propofol instead of the intended dose range of 15 to 30mg on 01/12/17 to Patient #3 (first Propofol event). The Hospital Report indicated a nurse prepared the syringe containing the Propofol with more than the dose of Propofol ordered by the physician in training and the physician in training did not know that the syringe contained more than the dose ordered.

The Pharmacy and Therapeutics Committee Meeting Minutes, dated 04/2017, indicated a recommendation to update the Medication Administration Policy to utilize only weight-based doses (doses calculated on a patient's weight) to be prepared by Registered Nurses (RN) for sedation procedures, with a single weight-based dose in each syringe.

The policy titled Adverse Drug Event (ADE) Reporting, dated 06/04/17, indicated Hospital staff document significant ADEs in the patient's medical record. Review of Patient #3's medical record indicated that no documentation of a significant ADE was recorded regarding Patient #3's over the intended dose of Propofol.

The Hospital Report, dated 10/31/17, indicated Physician #3 administered 60mg of Propofol instead of 10mg of Propofol to Patient #2 on 10/30/17 (the second Propofol event within 10 months). The error resulted in Patient #2 becoming hypotensive (low blood pressure) and apneic (not breathing) requiring interventions that included Bag Mask Ventilator Support (artificial breathing) and Fluid Resuscitation (administration of intravenous (IV) fluids).

The Surveyor interviewed Physician #1 (physician in training's supervisor) on 11/29/17 who said that Physician #3 (physician in training) was unaware that the nurses were preparing in one syringe more than one dose of Propofol. Physician #3 administered 5 to 6 milliliters (mL) of Propofol to Patient #2 (equivalent to 50 to 60 mg of Propofol instead of the intended 10 mg dose). The error resulted in Patient #2 becoming hypotensive and apneic requiring interventions that included Bag Mask Ventilator Support and Fluid Resuscitation.

The Corrective Action Plan, dated 11/07/17, included education & training for providers who administer Propofol in the Intensive Care Unit (ICU)-A of the Hospital. The Hospital provided no documentation to indicate a corrective action plan was given to all providers in other areas of the Hospital that have the credentials to administer Propofol. These other areas include, but are not limited to, the Operating Room (OR), Interventional Radiology (IR), Gastroenterology (GI), Emergency Department (ED), Hospital satellite locations etc.

The Surveyor interviewed Pharmacist #2 on 11/30/17. Pharmacist #2 said that Propofol was administered in other areas besides ICU-A, at the following locations: ED, GI, OR, IR, Neonatal Intensive Care Unit (NICU).

An email, dated 11/24/17, from Pharmacist #1, indicated that the Medication Administration Policy needed to be updated to reflect that only weight-based doses should be prepared. The email from Pharmacist #1 indicated recommendations and required follow up (implementation).

The Surveyor interviewed Pharmacist #1 on 11/30/17. Pharmacist #1 said that corrective recommendations were identified as a result of the first Propofol event that occurred on 01/2017. Pharmacist #1 said these recommendations did not materialize (not implemented). Pharmacist #1 said that the policy titled "Authorized Medication Administration" was last modified 10/19/16, and was not updated to reflect only weight-based doses in accordance with the identified recommendations.

Based on records reviewed and interviews the Governing Body failed for three of ten patients sampled (Patients #1, #2 & #3) to ensure a quality improvement and patient safety program that thoroughly defined, implemented and maintained (monitored, evaluated) quality improvement activities following medical errors.

Findings included:

The following regarding Patient #1:

The document titled Summary Report, dated 3/29/17, indicated corrective actions included that a Practice Alert (e-mail) was sent to the Intensive Care Unit (ICU) -A Providers (Physicians, Nurse Practitioners) that verbal orders should be avoided except in emergencies and ICU-A Nurse education about the use of the Medication Administration Record Safety View and auditing for compliance.

The Hospital provided no documentation to indicate the Hospital monitored (audited):

1.) The effectiveness of the verbal order corrective action through the education using the e-mailed Practice Alert,

2.) Nurses responsible for medication administration (as appropriate) throughout the Hospital used the Medication Safety View in practice at the change of shift report to ensure all medications administered as ordered, nor

3.) The effectiveness of the updated Dialysis Nurses Note regarding communication.

The Hospital provided no documentation to indicate Quality Assessment and Performance Improvement (QAPI) activities included feedback and learning beyond the ICU-A of Patient #1's hospitalization and throughout the Hospital.


39257


The following is regarding Patient #2 and Patient #3:

The Hospital Report, dated 01/12/2017, indicated that a physician in training administered 50 milligram (mg) of Propofol instead of the intended dose range of 15 to 30mg on 01/12/17 to Patient #3 (first Propofol event). The Hospital Report indicated that the physician in training was unaware that the nursing staff did not prepare single doses of Propofol.

The Pharmacy and Therapeutics Committee Meeting Minutes, dated 04/2017, indicated a recommendation to update the Medication Administration Policy to utilize only weight-based doses (doses calculated on a patient's weight) to be prepared by Registered Nurses (RN) for sedation procedures, with a single weight-based dose in each syringe.

The policy titled Adverse Drug Event (ADE) Reporting, dated 06/04/17, indicated Hospital staff document significant ADEs in the patient's medical record. Review of Patient #3's medical record indicated that no documentation of a significant ADE was recorded regarding Patient #3's over the intended dose of Propofol.

The Hospital Report, dated 10/31/17, indicated Physician #3 administered 60mg of Propofol instead of 10mg of Propofol to Patient #2 on 10/30/17 (the second Propofol event within 10 months). The error resulted in Patient #2 becoming hypotensive (low blood pressure) and apneic (not breathing) requiring interventions that included Bag Mask Ventilator Support (artificial breathing) and Fluid Resuscitation (administration of intravenous (IV) fluids).

The Surveyor interviewed Physician #1 on 11/29/17 who said that Physician #3 was unaware that the nurses were preparing in one syringe more than one dose of Propofol. Physician #3 administered 5 to 6 milliliters (mL) of Propofol to Patient #2 (equivalent to 50 to 60 mg of Propofol instead of the intended 10 mg dose). The error resulted in Patient #2 becoming hypotensive and apneic requiring interventions that included Bag Mask Ventilator Support and Fluid Resuscitation.

The Corrective Action Plan, dated 11/07/17, included education & training for providers who administer Propofol in the Intensive Care Unit (ICU)-A of the Hospital. The Hospital provided no documentation to indicate a corrective action plan was given to all providers in other areas of the Hospital that have the credentials to administer Propofol. These other areas include, but are not limited to, the Operating Room (OR), Interventional Radiology (IR), Gastroenterology (GI), Emergency Department (ED), Hospital satellite locations etc.

The Surveyor interviewed Pharmacist #2 on 11/30/17. Pharmacist #2 said that Propofol was administered in other areas besides ICU-A, at the following locations: ED, GI, OR, IR, Neonatal Intensive Care Unit (NICU).

An email, dated 11/24/17, from Pharmacist #1, indicated that the Medication Administration Policy needed to be updated to reflect that only weight-based doses should be prepared. The email from Pharmacist #1 indicated that several issues related to the recommendations were identified, remained open and needed follow up.

The Surveyor interviewed Pharmacist #1 on 11/30/17. Pharmacist #1 said that corrective recommendations were identified as a result of the first Propofol event that occurred on 01/2017. Pharmacist #1 said these recommendations did not materialize (not implemented). Pharmacist #1 said that the policy titled "Authorized Medication Administration" was last modified 10/19/16, and was not updated to reflect only weight-based doses in accordance with the identified recommendations.