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Based on observation, interview and record review, the facility failed to ensure that the drugs contained in an adult crash cart were accurately reflected on the drug inventory list. This failure had the potential to contribute in staff not being aware of the medications that were readily available to treat emergent medical conditions of all patients that presented to the Emergency Department (ED).

Findings:

An observation was made of the adult crash cart in the ED on 8/15/12 at 9:35 AM. The drug tray in the crash cart contained an inventory list of the drugs available for use in the adult crash cart.

A review of the drug inventory list, indicted that there should be two containers with "Vasopressin (a drug used to increase arterial blood pressure) 50 mg (milligrams)/2 ml(milliliters)" available in the drug tray (This is not an available manufactured dose for Vasopressin).

Observation of the drugs within the drug tray indicated that Vasopressin 20 units/1 ml, times two doses, was available for use in the drug tray.

During an interview with Pharmacist 1, on 8/15/12 at 9:40 AM, Pharmacist 1 verified that Vasopressin 20 units/1 ml, times 2, was available in the crash cart, not Vasopressin 50 mg/2 ml, as indicated on the drug inventory. Pharmacist 1 stated that there was a "misprint" of the dosage on the drug inventory list, and that the list did not accurately reflect the available Vasopressin in the adult crash cart. During the interview Pharmacist 1 verified that it was his responsibility to ensure that the drug inventory list accurately reflected the available drugs and their doses contained in the crash cart.




26500

Based on interview and record review, the facility failed to ensure that drug orders for 3 of 7 sampled patients (Patient 3, 2 and 5), were written in accordance to the facility's policy and procedure. For Patients 3, 2 and 5 the facility failed to ensure that drug orders for Demerol (a narcotic pain medication used for the relief of mild to moderate pain) and Phenergan (a drug classified as an anti-nausea and antihistamine) included a time, the route and specific dose for each drug. This failure had the potential to result in the drugs being administered to Patient 3, 2 and 5 in a manner not intended by the physician.

Finding:

1. The clinical record for Patient 3 was reviewed on 8/15/12. The clinical record indicated that Patient 3 was admitted to the facility on 8/12/12 with diagnoses that included cellulitis (an inflammation to the layers of the skin caused by an infection) to a lower extremity (leg).

A review of the physician's orders on 8/15/12 revealed the following Demerol (a narcotic pain medication used for the relief of mild to moderate pain) and Phenergan (A drug classified as an anti-nausea and antihistamine) order.

Demerol 25
> IV(intravenous) Q(every) 3?(hours)
Phenergan 12.5

A review of the facility's policy and procedure titled, "Orders: Drugs" dated 01/12 indicated the following:

"Each drug order shall include:"
"Time and date of order"
"Specific dose ..."
"Route of administration"

A review of the medication order indicated that there was no time documented on the order sheet that indicated the time that the medication orders had been written. There was no documented unit (such as milligrams or milliliters) of the dosage of Demerol or Phenergan that was to be administered. There was not a route of administration included in the order for each drug, therefore the drugs were not ordered in accordance with the facility's policy and procedure.

During an interview with the facility's Chief Nursing Officer (CNO) on 8/15/12 at 12:35 PM, the CNO verified that the Demerol and Phenergan drug orders for Patient 3 were not in accordance to facility's policy.





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2. The clinical record for Patient 2 was reviewed on 8/15/12. The clinical record indicated that Patient 2 was admitted to the facility on 8/13/12 with diagnoses that included diabetes mellitus (a metabolic disorder characterized by an increased level of sugar in the blood) and diabetic ketoacidosis (an acute life threatening complication of diabetes).

A review of the physician's orders dated 8/14/12 revealed the following Demerol (a narcotic pain medication used for the relief of mild to moderate pain) and Phenergan (A drug classified as an anti-nausea and antihistamine) order.

Demerol 25
> IV(intravenous) Q(every) 3?(hours)
Phenergan 12.5

A review of the facility's policy and procedure titled, "Orders: Drugs" dated 01/12 indicated the following:

"Each drug order shall include:"
"Time and date of order"
"Specific dose ..."
"Route of administration"

A review of the medication order indicated that there was no time documented on the order sheet that indicated the time that the medication orders had been written. There was no documented unit (such as milligrams or milliliters) of the dosage of Demerol or Phenergan that was to be administered. There was no route of administration included in the order for each drug, therefore the drugs were not ordered in accordance with the facility's policy and procedure.

During an interview with the facility's Chief Nursing Officer (CNO) on 8/15/12 at 12:35 PM, the CNO verified that the Demerol and Phenergan drug orders for were not in accordance to the facility's policy.

3. The clinical record for Patient 5 was reviewed on 8/15/12. The clinical record indicated that Patient 5 was admitted to the facility on 7/5/12 with diagnoses that included small bowel obstruction and ileus (the reduced motility of the gastro-intestinal tract).

A review of the physician's orders dated 7/6/12 revealed the following Demerol (a narcotic pain medication used for the relief of mild to moderate pain) and Phenergan (A drug classified as an anti-nausea and antihistamine) order.

Demerol 25
> IV(intravenous) Q(every) 3?(hours)
Phenergan 12.5

A review of the facility's policy and procedure titled, "Orders: Drugs" dated 01/12 indicated the following:

"Each drug order shall include:"
"Time and date of order"
"Specific dose ..."
"Route of administration"

A review of the medication order indicated that there was no time documented on the order sheet which indicated the time that the medication orders had been written. There was no documented unit (such as milligrams or milliliters) of the dosage of Demerol or Phenergan that was to be administered. There was no route of administration included in the order for each drug, therefore the drugs were not ordered in accordance with the facility's policy and procedure.

During an interview with the facility's Chief Nursing Officer (CNO) on 8/15/12 at 12:35 PM, the CNO verified that the Demerol and Phenergan drug orders for were not in accordance to facility's policy.





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26500

Based on record review and interview the facility failed to ensure that licensed nurses and Radiological Technicians documented the disposition for 1 of 7 sampled patients (Patient 5), when the patient was sent to radiology on 2 different occasions.

This failure contributed in information which was not included in the patient's medical record that other health care staff involved in the patients direct care could access in order to monitor the patients condition and provide appropriate care.

Findings:

a. A closed record review for Patient 5 revealed that the patient presented to the Emergency Department (ED) on 7/4/12 with diagnosis which included abdominal pain and vomiting.

A review of the ED physician orders dated 7/4/12, revealed Patient 5 was to receive a computerized tomography (CT) of the abdomen and pelvis.

A review of the "Emergency Department Ongoing Nursing Assessment" notes dated 7/4/12 at 2 AM, revealed "To CT Scan." No further documentation could be located which documented the patients disposition (alert, confused).

A review of the "Ticket to Ride," form used to document "patient status for internal transport," dated 7/4/12 revealed the form was incomplete with the following items that were left unanswered:

"Monitoring: no or yes
Fall Risk: no or yes
Return Status: unchanged or changes (describe)"

A review of the facility's policy "Patient Status-Transportation to Radiology," Policy: RAD A-4.2 established: 4/12, under the policy section documentation stated:

"It is the policy of Colorado River Medical Center, department of radiology....Patient status shall be monitored when leaving nursing care for radiology studies and marked before departure and upon arrival to the patient's room."

Under the procedure section, documentation states:

"The nursing staff shall be responsible for checking patient physiological status before the radiology department takes the patient for the imaging study and then again when the radiology department returns the patient to their room.

The nurse shall document ........ For an exam from the emergency room, the nurse shall write the patient's physiological status and time of departure/arrival under the written CT order.

The radiology staff shall be responsible for documenting into the inpatients chart (under the blue inter-disciplinary notes) the exam name, time of departure/arrival, transportation mode (ex. W/C, ST, AMB), and performing technologist initials."

During an interview with the facility's Chief Nursing Officer (CNO) conducted on 8/14/12 at approximately 3:10 PM, the CNO confirmed that the "Ticket to Ride," form was incomplete and the facility's policy was not followed.

b. A closed record review for Patient 5 revealed that the patient returned to the Emergency Department (ED) on 7/5/12 with a diagnosis of ileus.

A review of the ED physician orders dated 7/5/12, revealed Patient 5 was to receive a CT of the abdomen and pelvis.

A review of the "Emergency Department Ongoing Nursing Assessment" notes dated 7/5/12 at 11:55 AM, revealed "To CT." No further documentation could be located which documented the patients disposition.

A review of the "Ticket to Ride," form used to document "patient status for internal transport," dated 7/5/12 revealed the form was incomplete with the following items left unanswered:

"Return Status: unchanged or changes (describe)
Transporter:
Mode of Transportation (W/C, ST, AMB)"

A review of the facility's policy "Patient Status-Transportation to Radiology," Policy: RAD A-4.2 established: 4/12, under the policy section documentation stated:

"It is the policy of Colorado River Medical Center, department of radiology....Patient status shall be monitored when leaving nursing care for radiology studies and marked before departure and upon arrival to the patient's room."

Under the procedure section, documentation states:

"The nursing staff shall be responsible for checking patient physiological status before the radiology department takes the patient for the imaging study and then again when the radiology department returns the patient to their room.

The nurse shall document ........ For an exam from the emergency room, the nurse shall write the patient's physiological status and time of departure/arrival under the written CT order.

The radiology staff shall be responsible for documenting into the inpatients chart (under the blue inter-disciplinary notes) the exam name, time of departure/arrival, transportation mode (ex. W/C, ST, AMB), and performing technologist initials."

During an interview with the facility's Chief Nursing Officer (CNO) conducted on 8/14/12 at approximately 3:10 PM, the CNO confirmed that the "Ticket to Ride," form was incomplete and the facility's policy was not followed.




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