HospitalInspections.org

Based on record review, staff interview, and policy review, the hospital failed to ensure that a practitioner issued an order permitting self-administration of a patient's home medication which was to be brought into the hospital. This affected one (Patient #4) of 26 medical records reviewed. The hospital census was 180 patients.


Findings include:

Review of the medical record for Patient #4 revealed he arrived to an outlying emergency department (ED) on 02/05/25 at 12:32 P.M. with a chief complaint of shortness of breath. His visit diagnoses were influenza, hypoxia, immunocompromised state, and acute hypoxic respiratory failure. The resident was admitted for acute hypoxia respiratory failure which required high flow oxygen via nasal cannula and was transferred on 02/05/25 at 5:52 P.M. to the main hospital for further care.

Review of Patient #4's medication list reviewed in the ED by Registered Nurse (RN) (Staff #S) revealed Patient #4 received dolutegravir (Tivicay) 50 milligrams (mg) by mouth daily.

Review of Patient #4's History and Physical (H and P) completed by admitting Physician #R, dated 02/05/25, revealed the patient had the diagnosis of Human Immunodeficiency Virus (HIV). He was to continue his home regimen when able to get it from his spouse the following day. His antiviral home medications included emtricitabine-tenofovir (Truvada) 200-300 mg one tablet by mouth daily and dolutegravir (Tivicay) 50 mg one tablet by mouth daily.

Review of Patient #4's medication administration record (MAR) revealed he was administered emtricitabine-tenofovir (Truvada) 200-300 mg one tablet daily during his hospitalization, 02/06/25 through 02/13/25. There were no doses of dolutegravir (Tivicay) 50 mg administered or received during Patient #4's hospitalization.

During an interview on 04/21/25 at 12:29 P.M., Pharmacy Director #J confirmed Patient #4 did not receive his antiviral medication dolutegravir (Tivicay) during his hospitalization. Pharmacy Director #J stated he believed the issue was that the medication was listed as "non-formulary" and possibly the admitting physician, Physician #R, assumed it wasn't available and did not order it. Pharmacy Director #J confirmed that although a medication may be listed as "non-formulary" the pharmacy would have been able to obtain and provide this medication to the patient. Pharmacy Director #J stated if Patient #4's spouse had brought in his home medication, the physician would have put an order in for the medication and pharmacy would verified the medication.

During subsequent interview on 04/25/25 at 2:16 P.M. with Pharmacy Director #J revealed the definition of non-formulary in the inpatient hospital setting means that a medication may not be stocked, however, that does not mean that the medication cannot be obtained. Pharmacy Director #J stated the use of the word "non-formulary" is what he thinks started the entire situation and why the medication was not ordered, as the admitting physician may have assumed the medication was not available. Pharmacy Director #J confirmed there were no notes in the medical record indicating that Patient #4's spouse ever brought in his home medications to the hospital.

During an interview on 04/24/25 at 12:13 P.M.. Registered Nurse (RN) (Staff #Q) revealed she did not recall Patient #4's spouse bringing in his home medications during his hospitalization, but if she had, the process prior to administering those medications would have required both pharmacy and physician verification.

During an interview on 04/24/25 at 2:35 P.M., RN/Director of Acute Care Services (Staff #K) revealed Patient #4's medical record did not reveal he received dolutegravir (Tivicay) 50 mg during his hospitalization, nor that his spouse brought in his home medications. Staff #K stated there was no documentation of any follow-up with the patient's spouse regarding his home medications.

During an interview on 04/24/24 at 12:50 P.M., Regulation Program Specialist/RN (Staff #A) stated her expectation was that there should have been a follow-up with Patient #4's spouse regarding his home medications.

During an interview on 04/24/25 at 2:58 A.M. with the Medical Director of Hospital Medicine/Physician #T revealed admitting Physician #R was currently working and was unable to be interviewed, however, he had reviewed Patient #4's medical record could answer any questions. Physician #R stated that the admitting physician reviews all medications upon admission and it was charted by Physician #R that Patient #4's home HIV medications would be brought to the hospital by his spouse. Medical Director of Hospital Medicine/Physician #T confirmed there was no evidence that Patient #4's spouse brought in his home medications or that he received Tivicay 50 mg once per day.

Review of the facility's policy titled, "Medications: Use of a Patient's Home Supply," dated 08/01/24, revealed Genesis HealthCare Systems strongly discourages the use of the patient's home supply of medication. In the event that a patient's home medication supply is to be utilized during the patient's hospital stay, an order must be obtained to utilize the patient's medication supply. Prior to administration, all medications for home use must be verified by the pharmacist and labeled to ensure barcode scanning and patient safety. The medications cannot be provided to the patient until verified by Pharmacy.

Based on record review, staff interview, and policy review, the hospital failed to ensure Patient #4's medical record contained complete information/documentation of patient care. This affected one (Patient #4) of three medical records reviewed for discharge. The hospital census was 180 patients.

Findings include:

Review of the medical record for Patient #4 revealed he arrived to an outlying emergency department (ED) on 02/05/25 at 12:32 P.M. with a chief complaint of shortness of breath. His visit diagnoses were influenza, hypoxia, immunocompromised state, and acute hypoxic respiratory failure. The resident was admitted for acute hypoxia respiratory failure which required high flow oxygen via nasal cannula and was transferred on 02/05/25 at 5:52 P.M. to the main hospital for further care.

Review of a Patient Feedback form, dated 02/14/25, revealed Patient #4 called the Nurseline and left a voicemail with a complaint alleging that his spouse waited outside for almost two hours prior to his discharge and that he was not offered a wheelchair and had to walk out of the hospital on his own while wearing oxygen. There were no discharge notes documented so patient safety was unable to determine how the patient left the facility or if he was required to set up his portable oxygen. Nurse Manager RN (Staff #N) reviewed the concern and stated that he witnessed Patient #4 attempting to leave and did not want to wait on staff to remove his intravenous (IV) line. Staff #N stated he clearly overheard the bedside RN offer the patient a wheelchair on discharge and spoke with staff who informed him the patient left as soon as his discharge was ready.

Review of Patient #4's After Visit Summary (AVS), dated 02/13/25, revealed durable medical equipment (DME) was ordered for continuous oxygen to be infused at 4 liters per minute per nasal cannula. Supplies ordered included a portable and stationary oxygen system with nasal cannula, tubing, and humidification. The resident was educated on his medications and follow-up appointments. Review of the AVS form revealed it was not signed by Patient #4.

During an interview on 04/24/25 at 2:35 P.M. with RN/Director of Acute Care Services (Staff #K) revealed Patient #4's medical record did not contain documentation of his refusal of a wheelchair, of the removal of his IV, or of the set-up of his portable oxygen. Staff #K stated the medical record should have contained all of this information. Staff #K confirmed Patient #4 did not sign his discharge/After Visit Summary.

Review of the facility's policy titled, "Discharge Planning and After Visit Summary Requirements," dated 05/01/24, revealed all after visit summary or discharge instructions provided to patients and/or families will require a signature prior to the patient leaving the facility.

Based on record review, interview and policy review, the hospital failed to ensure a medical screening exam was completed in a timely manner to determine if a medical emergency existed.

See A2406.

Based on record review, interview and policy review, the hospital failed to ensure a medical screening exam was completed in a timely manner to determine if a medical emergency existed. This affected one (Patient #3) of 20 records reviewed.

Findings include:
Medical record review revealed Patient #3 arrived at the Emergency Department (ED) on 02/25/25 at 11:56 P.M. via personal vehicle. Patient #3 complained of lower severe abdominal pain, nausea and vomiting, with the pain radiating into the chest. Patient #3 stated he had gallbladder surgery two days ago. He reported feeling the need to have a bowel movement but was unable to do so and had some liquid stool. Patient #3 arrived via personal vehicle. Triage was completed on 02/26/25 at 12:09 AM. Patient #3 was classed as a II on the emergency screen index (ESI) indicating life/organ threat. Initial vital signs were blood pressure 143/83, heart rate 71, respirations 18, temperature 98.5 degrees Fahrenheit (F) orally and oxygen saturation of 99 percent on room air. Patient #3 rated the pate an eight on a one to ten scale. An electrocardiogram (EKG) was obtained. Patient #3 was then put in the "results pending" room in a chair.

At 12:27 AM., nursing protocol orders were placed. Registration was completed at 1:46 AM. At 4:04 AM, an intravenous saline lock was placed. At 4:11 AM, a computed tomography (CT) scan was ordered for the abdomen and pelvis with IV contrast. No further vital signs were obtained until 4:25 AM and at that time blood pressure was 109/54. heart rate 83, respirations 22, temperature 97.6 degrees F orally and oxygen saturation was 100 percent on room air. Patient #3 rated his pain a ten on a one to ten scale. Laboratory orders were not placed until 4:26 AM and the specimens were collected at 4:27 AM. A physician assistant was assigned to Patient #3 at 4:27 AM. At 4:42 AM, Patient #3 was medicated for pain with Dilaudid one milligram IV push. The CT scan was done at 4:54 AM. At 5:46 AM, Patient #3 was finally moved from the "results pending" room to an ED room for examination and treatment. A physical examination was completed by the physician assistant at 5:52 AM. At 6:09 AM, Patient #3 was seen by a physician. Patient #3 was given a rectal enema of mineral oil at 11:58 AM. At 4:31 PM, Patient #3 was discharged home in stable condition.

During an interview on 04/17/25 at 9:15 AM, Emergency Department (ED) Chief Medical Director AA stated the ED was very busy this day with 50 patients present in the ED and 24 in the waiting area. At 12:09 AM, the nurse screened Patient #3 and put him in the "results pending" room and the on duty ED physician was notified.

During an interview on 04/17/25 at 9:15 AM, ED Physician BB stated she signed on for her shift on 02/26/25 at 6:00 AM and signed onto Patient #3's case at 6:08 AM. She treated him and admitted him and the Hospitalist became his physician of record. He was discharged later that day.

Review of the policy titled "Triage and Triage Acuity Classification", dated 06/09/22, stated an ESI II patient was a patient presenting with high risk situations, or confused or lethargic, or sever pain or distress. ESI Level II may include but is not limited to: Threatened with possible life/organ threat. Needs physician within approximately ten minutes and requires high resource intensity. Multiple diagnostic studies or procedures needed.

Record review of the policy titled "Assessment and Reassessment of the ED Patient", dated 09/12/24, stated the primary assessment will be performed by a RN and all patients are continually reassessed at continual intervals, or more frequently as condition dictates. Assessments and reassessments will be documented in the Electronic Charting Record (ECR) and will be completed with the following guidelines: ESI II reassessments every 5-15 minutes with vital signs every 30 minutes for one hour or until stable every one hour. ESI levels are assigned on admission to the ED. The levels may be adjusted upwards as acuity warrants but are not adjusted downward due to potential deterioration of the patient's condition. Vital sign intervals may be changed up to every four hours as the condition may improve. Nursing documentation needs to support the patient's reassessments and status changes.