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Based on observation, interview and record review the facility failed to have an organized nursing service that provided complete nursing assessments, associated nursing interventions, and nursing competencies as demonstrated by the following:

1. Failed to implement an appropriate plan of care related to the monitoring of 1 of 30 sampled patients (305) related to an unobserved fall in the ICU. [See ?CFR 482.23 (b) (4)]

2. Failed to ensure a registered nurse correctly programmed a medication delivery pump to deliver morphine to 1 of 30 sampled patients (306). As a result, the patient received 100 mg of morphine in one hour. [See ?CFR 482.23 (c)]

The cumulative effect of these systemic problems resulted in the facility's failure to deliver nursing care in compliance with the Condition of Participation for Nursing Services.

Based on interview and record review the facility failed to assess, intervene and implement an appropriate plan of care as it related to monitoring the safety of 1 of 30 patients (305), who had an unobserved fall in the facility's intensive care unit [ICU].

Findings:

Patient 305 was admitted to the facility on 12/25/09 with diagnoses that included sepsis, pneumonia and colitis according to the Patient Information Sheet. According to the physician notes, Patient A had bilateral lower lobe lung infiltrates and a clinical suspicion of H1N1. According to the emergency room notes, Patient A was noted to have some confusion with decreased level of consciousness. Patient 305 was admitted to an isolation room on a medical floor.

According to the Rapid Response Team record, on 12/26/09 at 6:12 p.m., Patient 305 was transferred to the Intensive Care Unit (ICU) for closer observation due to severe respiratory distress. While in the ICU, Patient 305 was placed on cardiac and pulse oximetry monitoring (a non-invasive optical measurement system to determine oxygen levels) all connected to alarms. Patient 305 was also connected to an intravenous [IV] pump which was infusing Levophed (a vasoactive medication used for blood pressure control) and an intermittent BiPaP oxygen system. (bi-level positive airway pressure, a noninvasive means of assisting oxygen and ventilation) The IV line and the BiPaP system were also connected to alarms.

Patient 305 was identified as high risk for falls, per the facility's computerized nursing documentation dated 12/26/09 and 12/27/09. On 12/27 and 12/28, the physician ordered soft wrist restraints. The reason for the order of the wrist restraints was documented as due to the patient attempting to pull / remove lines / tubes / equipment / dressings, and attempting to get out of bed.

On 12/29/09 Patient 305 fell on the floor in front of her bed. The patient became disconnected from the cardiac monitor, her intravenous line with the levophed medication, the BiPaP oxygen delivery system, and pulse oximetry. The patient was found by a respiratory therapist [ RT 1] in complete arrest at 6:01 p.m., according to the Code Blue record. The last documented set of vital signs taken by Registered Nurse 1 [RN 1] were recorded on the nursing flow sheet at 4:30 p.m. on 12/29/09.

On 3/1/10 at 10:00 a.m., the ICU area was observed with administrative staff. The staff confirmed that while the facility sometimes used a "baby alarm" (a dual monitoring system, one monitor placed in the patients room and the other monitor placed at the nurses station, in order to hear what was happening inside a patients room, particularly a room with a closed door, this type of alarm was not used for Patient 305 during her stay in the ICU. The staff further confirmed that the privacy curtain had been pulled, and the door had been closed to Patient 305's room. This hampered the facility staff from being able to visually see and audibly hear what was going on inside Patient 305's room.

According to the Code Blue Record, on 12/29/09 facility staff started resuscitative measures on Patient 305 at 6:01 p.m. Per the same record, twenty-two [ 22 ] minutes of resuscitative measures elapsed before staff could recover a pulse in Patient 305. According to the physician note from Physician X, who responded to the code, Patient 305 was lying on the floor, incontinent, all leads were off, line[s] pulled out, and she was unresponsive. When monitor leads were reapplied Patient 305 was noted to be in asystole (no visible or palpable pulse).

On 12/30/09, Physician X requested a critical care consult by Physician Y. Physician Y's consult was reviewed. According to Physician Y's consult dated 12/30/09: "The patient has developed progressive organ dysfunction, and now has respiratory failure, anuric renal failure, evidence of an acute myocardial infarction, hemodynamic embarrassment, and severe metabolic acidosis. In addition, she suffered a cardiac arrest last evening (12/29/09) with a prolonged resuscitation effort. She now has evidence of severe anoxic injury if not outright brain death." According to the note, Physician Y indicated the family had been informed that Patient 305 had "probably suffered irretrievable damage, and it was unlikely she would have any meaningful recovery on any level."

Patient A was disconnected from life support on 12/30/09 and expired the same day.

Patients are admitted to the intensive care units in order to ensure that the patients' conditions are closely monitored by facility staff. Patient 305 was in isolation with the door closed. Furthermore, the privacy curtain was pulled. Patient 305 was not visible to staff in the immediate area. Staffs' ability to hear alarms sounding was diminished because the door to the patient's room was closed.

The facility failed to ensure ongoing assessment and safety monitoring of Patient 305, who was not only in a state of respiratory compromise with external monitors of her cardiac and respiratory status, but also a documented high fall risk.

Based on interview and record review, the facility failed to ensure that a Registered Nurse, [RN 2] correctly programmed a medication delivery pump to deliver morphine to Patient 306 at 3 mg [milligrams]/hour. As a result, the patient received 100 mg of morphine in one hour. Patient 306 expired an hour after the infusion was delivered.

Findings:

Patient 306, a 62 year old female was admitted to the facility on 1/27/10. According to the Admission History and Physical, the patient presented to the Emergency Department with shortness of breath and significant vaginal bleeding. Patient 306 was diagnosed with a uterine malignancy and metastatic disease to the lungs.

Patient A underwent a total abdominal hysterectomy on 2/2/10. The clinical summary on the surgical pathology report, dated 2/4/10, read, uterine carcinoma. On 2/6/10, the hospitalist documented that the patient was having increased respiratory difficulty. The plan for the patient was to have palliative chemotherapy.

On 2/7/10, the physician documented that the patient had deteriorated to the point where palliative chemotherapy would be very difficult. On 2/8/10, the physician discussed the plan with the patient who elected hospice care and changed her code status to, "No Code." The physician wrote an order for a "morphine drip titrate to comfort."

Patient A transferred from the Critical Care Unit (CCU) to the medical oncology floor on 2/9/10. According to RN 2's documentation at 5:10 P.M., (the same day) Patient 306 had no measurable vital signs and her pupils were fixed and dilated.

On 3/2/10 at 1:00 P.M., the Department and Administrative staff reviewed the printout of the activity history for the medication pump used to deliver Patient 306's medications. According to the pump printout dated 2/9/10 at 3:08 p.m., when RN 2 hung a new bottle of morphine for Patient 306, the RN programmed the pump to deliver 100 mg/hour instead of 3 mg/hour, which the patient had been receiving. The morphine was provided in a concentration of 1 mg /ml [milliliter].

Continued review of the printout activity history indicated that the pump used to deliver the patient's morphine was a 3 channel pump. That type of pump had the capability to deliver three separate primary line medications, each through a different channel that was programmed individually. Patient 306 had an order for Normal Saline (NS) and morphine. The NS was ordered to run at 10 cc/hour to keep the intravenous (IV) line open. The morphine was running at 3 ml/hour when RN 2 hung the new bottle. The NS was running through Channel A and the morphine through Channel C.

According to the pump printout, on 2/8/10 at 11:40 A.M., a registered nurse in the CCU programmed the pump to deliver morphine at 3 ml/hour through Channel C as a primary line. On 2/9/10 at 3:08 P.M., RN 2 hung a new bottle of morphine. RN 2 programmed the morphine to run through Channel C as a piggyback line and not a primary line. (A piggyback IV is connected to the primary line and the medication is delivered through the primary IV as an adjunct. The piggyback IV can be set to run at a different rate. When the piggyback fluid is finished, the pump automatically returns to the rate of delivery programmed for the primary line.) The pump printout showed that RN 2 mistakenly set the rate of delivery for the piggyback to 100 ml/hour instead of 3 ml/hour.

At 4:11 P.M., on 2/9/10, the IV piggyback had infused 99.8 ml of morphine per the printout and the pump reverted to delivering the morphine at 3 ml/hour as a primary line through Channel C. The delivery was stopped at 4:44 P.M.

The policy and procedure entitled, "Pain: Analgesia Infusion" with an effective date of 1/3/08, was reviewed. According to the policy under,"III. Text/Standards Of Practice: E. Analgesia infusions will be administered via specialized or single channel volume controlled devices. Exception:CCU may use multichannel pumps to infuse IV drip analgesia."

When Patient 306 was transferred from the CCU to the medical oncology floor, the patient was receiving morphine delivered at 3 ml/ hour via a multichannel pump. Nursing failed to transfer the infusion to a single channel pump. Nursing also failed to program the pump correctly and as a result, administered 100 mg of morphine to Patient 306 in one hour instead of 3 mg as intended. Patient 306 died one hour after the infusion was stopped.

Based on interview and record review, the hospital pharmacy failed to provide oversight and clarification of physician orders when morphine was being administered via a continuous intravenous route. This resulted in the administration of morphine that was inconsistent with hospital policy and procedure (#17064) for 7 of 30 sampled patients (202, 100, 109, 110, 111, 305, 306).

Findings:

1a. Patient 202 was observed at 11:00 A.M. on 3/1/10 to have a continuous intravenous morphine solution infusion at 3 milligrams [mg] of morphine per hour. The current applicable physician order was written on 2/27/10 as "morphine 1 -5 mg" via the intravenous route every hour "titrate for comfort".

1b. Patient 100 had an order dated 3/1/10 for "morphine drip 1-5 mg/hr."

1c. Patient 109 had an order written 3/1/10 for morphine drip at 1 mg/hr increase up to 4 mg/hr as needed for respiratory rate (RR) greater than 24 or uncontrolled pain.

1d. Patient 110 had an order written 3/1/10 for morphine continuous drip at 1 mg /hr titrate to comfort for signs and symptoms of pain/respiratory distress.

1e. Patient 111 had an order written 2/24/10 for morphine drip titrate to deep RR greater than 24 or to prevent labored respiratory efforts.

1f. Patient 305 had an order written 12/30/10 for a morphine drip at 2 mg/hr titrate to comfort or RR less than 20.

1g. Patient 306 had an order written 2/8/10 for morphine drip titrate to comfort.

The hospital policy and procedure (P&P) titled Medication Orders with Dosing and Frequency Ranges (#17064) was reviewed. Section 3.B. item #2 "The maximum allowable dose range is a 2 fold range."

Interviews with the hospital's Pharmacist's 1 and 2 were done on 3/2/10 at 3:00 P.M. Pharmacist 1 and 2 confirmed that the order's written were in excess of the 2 fold limit and not consistent with the written policy.

Pharmacist 1 and 2 both concluded that the above practice of ordering the continuous morphine infusion's was inconsistent with the aforementioned policy and exceeded the 2 fold dosing range.

Pharmacist 1 and 2 stated that many of the morphine infusions are used on end of life/palliative care/hospice patients who have a Do Not Resuscitate (DNR) order, and therefore the physician orders were not scrutinized more closely. Pharmacists 1 and 2 were unable to offer any policy/procedure that would address the end of life/palliative care/hospice patients.