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Based on clinical record review, interview and review of the Risk Management and Safety Plan, it was determined, the facility failed to implement appropriate corrective actions and mechanism to minimize risk of injury to patients. The deficient practice is evidenced by failure to develop facility wide corrective action plans addressing the root cause of 1 of 1 adverse incident reviewed involving Patient #1. The event resulted in delay in care and services and subsequent patient's death. The facility failed to develop and implement facility wide monitoring tools to minimize reoccurrence.

The findings included:

Review of the investigation of the adverse event involving Patient #1 was conducted on 04/18/24 and 04/19/24. The investigation indicates multiple failures that may have contributed to the patient's death.

The facility investigated and reported the adverse event.

Interview with The Assistant Chief Nursing Officer and The Director of Patient Safety conducted on 04/18/24 at approximately 9:55 AM revealed the facility offers centralized telemetry monitoring. Telemetry beds are assigned throughout the hospital units.

Review of the facility corrective actions implemented after the event, failed to include facility wide staff education and the development of facility wide monitoring tools to sustain compliance.

Interview conducted on 04/19/24 at approximately 1:36 PM with The Vice President of Quality and The Director of Patient Safety revealed the facility corrective actions provided to the surveyor only addressed staff education for the telemetry monitoring technicians and 3rd floor clinical staff. In addition, the audit tool developed to monitor compliance documents the tool captures the 3 North and 3 North West units. The Director of Patient Safety stated the plan was to start with the 3rd floor (where the event took place) and later expand the corrective actions to the rest of the hospital.

Patient Safety and Risk Management Plan, last revised 01/2024 documents:
Goals
The goal of the Patient Safety and Risk Management Plan is to reduce medical errors and hazardous conditions by utilizing a systematic, coordinated and continuous approach to the improvement of patient safety. This approach centers on the establishment of mechanisms that support effective responses to actual occurrences and hazardous conditions; ongoing proactive reductions in medical/health care errors; and integration of patient safety priorities in the design and redesign of all relevant organizational processes, functions and services.
A proactive ongoing systematic approach for the detection and resolution of events which may or do impact patient safety will be supported through:
Recognition and acknowledgement of the potential for medical/health errors and/or injuries and risks to patient safety;
Initiation of actions to reduce these risks;
Internal reporting of what has been found and the actions taken
Process and system focused corrections to reduce related failures including thorough and credible Serious Event Analysis and routine Failure Mode and Effects/Criticality Analysis (FMEA/FMECA)
Minimization of individual blame or retribution for involvement in a medical/health care error;
Organizational learning about medical/health care error; and,
The support of sharing of lessons learned to effect behavioral changes organizational wide and across other health care organizations.

Based on policy review, clinical record review and interview, it was determined, the nursing staff failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5). This failure affected 2 of 5 sampled patients (Patient #7 and #8) as evidenced by failure to follow physician's orders for insulin administration.


The findings included:

1) Clinical record review conducted on 04/18/24 and 04/19/24 revealed Patient #7 has physician's orders for Lispro insulin moderate sliding scale before meals and at bedtime.
If Blood Sugar (BS) 71-150 No coverage
BS 151-200 Give 4 units
BS 201-250 Give 8 units
BS 251-300 Give 10 units
BS 301-350 Give 12 units
BS 351-400 Give 16 units
BS greater than 400 give 18 units and call physician.

Medication administration records dated 04/18/24 documents Patient #7 had blood sugar reading of 155 at 12:54 PM. The record indicates the patient received the wrong insulin dose, 2 units. According to the scale the patient should have received 4 units.

2) Clinical record review conducted on 04/18/24 and 04/19/24 revealed Patient #8 has physician's orders for Lispro insulin mild sliding scale before meals and at bedtime.
If Blood Sugar (BS) 71-150 No coverage
BS 151-200 Give 2 units
BS 201-250 Give 4 units
BS 251-300 Give 6 units
BS 301-350 Give 8 units
BS 351-400 Give 10 units
BS greater than 400 give 12 units and call physician.

Medication administration records dated 04/02/24 documents Patient #8 had blood sugar reading of 243 at 8:30 PM and received the incorrect dose of insulin 2 units. According to the sliding scale the patient should have received 4 units.

Medication administration records dated 03/28/24 documents Patient #8 had blood sugar reading of 157 at 2:35 PM and received the incorrect dose of insulin 0 units. According to the sliding scale the patient should have received 2 units. The record validates the prior blood sugar reading was obtained at 9:21 AM and there is no clinical justification for the omission.

Medication administration records dated 03/27/24 documents Patient #8 had blood sugar reading of 352 at 12:59 PM and received the incorrect dose of insulin 8 units. According to the sliding scale the patient should have received 10 units.

Medication administration records dated 03/27/24 documents Patient #8 had blood sugar reading of 393 at 9:41 AM and received the incorrect dose of insulin 15 units. According to the sliding scale the patient should have received 10 units. The record provides no evidence of additional insulin orders.

Interview with The Assistant Chief Nursing Officer/Informatics, who navigated the electronic clinical record, verified there are no written physician's orders to validate the deviation from the insulin sliding scale documented above.

Facility policy titled "Medication Administration" last revised 01/2024 documents as follows:
PURPOSE:
To promote safety by ensuring to Provide Parameters and General Guidelines for Proper and Safe Medication Administration.
Implementation is successful within a culture that promotes teamwork and where all individuals feel empowered to ensure patient safety.
POLICY:
Drugs shall be administered only upon order of a member of the Medical Staff, an authorized member of the house staff, or other individual who has been granted privileges to write such orders. Medications or routes of administration not addressed in this policy will be assessed based on the clinical needs of the patient and skills required for safe administration and monitoring.
GENERAL GUIDELINES:
1. Drugs should be administered as soon as possible after the dose is prepared, particularly medications for parenteral administration. I. Never leave medication unattended.
J. Remember medication principles:
i. Right Patient: Check identification band and ask patient his name. Use 2 identifiers.
ii. Right time
iii. Right medication
iv. Right dose
v. Right mode of administration
vi. Right education
vii. Right documentation
3. Before administration, the individual administering the medication does the following.
A. Verifies that the medication selected matches the medication order and product label.
B. Visually inspects that the medication for particulates, discoloration, or other loss of integrity.
C. Verifies that the medication has not expired.
D. Verifies no contraindications exist.
E. Verifies the medication is being administered at the proper time, in the prescribed dose, and by the correct route.
4. Any unresolved concerns about the medication are discussed with the patient's LIP, prescriber and/or staff that is involved with the patient's care, treatment, and services.
Before administering a new medication, the patient or family is informed about any potential clinically significant adverse drug reactions or other concerns regarding administration of a new medication.

Based on policy review, clinical record review and interview, it was determined, the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) for 1 of 1, out of 5 sampled patients reviewed for nursing services, (Patient #11) as evidenced by failure to reassess patient's condition during a blood transfusion as specified per facility protocols.


The findings included:

Facility policy titled "Blood Products Administration" revised 11/2023 documents:
SCOPE:
To provide guidelines for safe administration of blood and blood products within the facility.
PURPOSE:
1. To promote safety by ensuring to inform nursing personnel of hospital policy regarding the guidelines for the safe administration and refusal of blood and blood products
2. Provide guidelines to rapidly identify and appropriately respond to suspected transfusion reactions.
Implementation is successful within a culture that promotes teamwork and where all individuals feel empowered to ensure patient safety.
POLICY:
9. PROCEDURE FOR MONITORING AND DOCUMENTATION
A. The RN will stay with the patient and continuously assess for signs and symptoms of blood transfusion reaction for the first 1 5 minutes for each transfused product. For patient areas utilizing the vital sign neuron capsule the RN will document assessment and vital signs in the BCTA desktop by clicking the "capture" button. All other patient areas will document assessment and vital signs by clicking "document" the button. All patient areas will document vitals and any potential transfusion reactions at the following intervals:
i. 5 minutes after initiation of transfusion and as patient condition required.
ii. 1 5 minutes after initiation of transfusion and as patient condition requires iii. 30 minutes after initiation of transfusion and as patient condition requires.
iv. 1 hour after initiation of transfusion and as patient condition requires.
v. Every hour thereafter until transfusion is complete.
B. Upon documentation of final vital signs click: END on BCTA Desktop.
C. A final set of vital signs should be documented 30 minutes after END time in BCTA.
D. Repeat above steps to verify and transfuse subsequent units.
E. Enter through to populate date and time fields and record volume of blood product and NS infused.

Clinical record review conducted on 04/19/24 revealed Patient #11 was prescribed a blood transfusion on 04/05/24.
The record indicates the staff obtained pre transfusion vital signs at 7:52 AM; the transfusion started at 8 AM. The staff monitored the patient at 8:06 AM and 8:30 AM. The transfusion ended at 11:21 AM and the next monitoring was documented at 11:23 AM.
The nurse failed to follow the facility policies and procedures for blood transfusion monitoring, as evidenced by lack of monitoring hourly and 30 minutes after the completion of the blood transfusion.

Interview with the Assistant Chief Nursing Officer/Informatics (ACNO), who navigated the electronic record, was conducted on 04/19/24 at 12:05 PM. The ACNO stated she will research the record for further documentation. At approximately 2:01 PM, the ACNO provided copies of the blood transfusion monitoring, validating the staff did not follow the blood transfusion protocols.