HospitalInspections.org

Based on interview and record review, the facility failed to ensure 5 (staff members C, D, E, F, and G), who were providing services in the ER, had a current ACLS certification. This deficient practice had the potential to affect all patients who received care in the ER. Findings include:

During a review of the facility's personnel files, the following staff member had an expired ACLS certification:

- Staff member C had an ACLS certification which expired on 9/2018.
- Staff member D had an ACLS certification which expired on 11/2018.
- Staff member G had an ACLS certification which expired on 9/2018.

During a review of the facility's personnel files, the following staff were new employees who had not been ACLS certified:

- Staff member E was hired on 1/17/19 to work in the ER, she did not have an ACLS certification on file.

- Staff member F was hired on 11/7/18 to work in the ER, she did not have an ACLS certification on file.

During an interview on 5/30/19 at 10:00 a.m., staff member J stated RNs who worked in the ER should be ACLS certified. She stated staff members C, D, E, F, and G were the RNs who worked in the ER.

During an interview on 5/30/19 at 10:20 a.m., staff member C stated it was the expectation the nursing staff in the ER were ACLS certified. She stated staff members F and E were in training, and were scheduled in June (2019) to take the full two-day class to complete their initial ACLS certification. She stated the newly hired RNs worked in the ER under the supervision of other RNs. Staff member C stated staff members C, D, and G, who provided supervision of staff members E and F, needed their ACLS recertification. She stated staff members C, D, and E were scheduled in August (2019) to complete their ACLS recertification. She stated due to the rural nature of the facility, it was difficult to get the ACLS training arranged.

A review of the facility's policy and procedure titled, General Operating Policies: Licensure, Certification or Registration of Personnel and Medical Staff, showed, "In order to provide the highest quality medical care, and to be in compliance with applicable statutes and regulations, [Hospital] shall maintain a staff of professionals who are appropriately trained, and who maintain the appropriate licenses, certifications, or registrations... A. Under the authority granted by the Board of Trustees, the Administrator shall ensure that the following staff personnel hold and maintain in good standing, the appropriate licenses, certifications, or registrations. 1. Registered Nurses... B... Further, the Human Resources Department shall see that proof of current licensure, certification, or registration is supplied by each staff member required to hold such licensure, certification, or registration. A copy of such current license, certificate, or registration shall be kept as part of the employee's permanent file. The Human Resources Department shall additionally maintain a mechanism by which she/he may determine the expiration date of licenses, certifications, or registrations, and thereby require the affected employees to submit copies of renewed certificates, as they are obtained... ."

Based on observation, interview, and record review, facility staff failed to review the "five rights" of the medication administration prior to administering fentanyl, a scheduled II controlled substance, which resulted in 1 (#20) of 20 sampled patients receiving double the ordered dose of fentanyl intravenously. Findings include:

During an observation on 5/28/19 at 2:03 p.m., staff member E started an intravenous line to patient #20's right antecubital arm. Patient #20 complained of pain to her left anterior shoulder, which was mildly deformed.

During an observation on 5/28/19 at 2:09 p.m., staff member L entered the ED, assessed patient #20, and gave a verbal order to staff member D for "fentanyl 200 micrograms with some Versed." At 2:17 p.m., staff member D returned from the pharmacy with two 100 microgram [mcg] ampules of fentanyl, one 5 ml vial of Versed, and one vial of "Zofran." Staff member D set the medications on the counter, next to some documents, retrieved a bedside computer, and began typing some notes.

During an observation on 5/28/19 at 2:19 p.m., staff member L stated, "Give [patient 20] 50 mcgs of fentanyl, IV."

During an observation on 5/28/19 at 2:27 p.m., staff member E picked up one fentanyl ampule and drew up the medications in a 5 ml syringe. The syringe contained 2 mls of fentanyl; a total of 100 mcgs. At 2:30 p.m., staff member E administered the 100 mcgs of fentanyl to patient #20. The patient complained of being, "Extremely dizzy."

During an observation and interview on 5/28/19 at 2:35 p.m., staff member E informed staff member D she had given fentanyl 100 mcgs instead of 50 mcgs to patient #20. Staff member D stated orders for patient #20 were, "fentanyl 50 micrograms, not 100 [mcgs]." Staff member E immediately informed staff member L and the patient. Staff member L stated, "That's ok. We will keep her on the monitor." At 2:37 p.m., patient #20 complained again of being, "Very dizzy." Patient #20's vital signs, including an oxygen saturation, were monitored by the ED staff and the patient was discharged from the ED at 3:40 p.m.

During an interview on 5/28/19 at 3:55 p.m., staff member D stated patient #20's medication rights should have been reviewed prior to being administered medications to, "Avoid accidents." Staff member D stated she would assist staff member E with filing an incident report and informing proper staff of the incident.

During an interview on 5/28/19 at 4:20 p.m., staff member E stated patient #20 had received the wrong dose of fentanyl. Staff member E stated, in the future, she would verify all medication orders prior to administering, would review patient medication rights, and would ensure she signed out medications from the narcotic log to avoid errors. Staff member E stated she "usually" reviewed the medication orders, with the medication in hand, to ensure the correct medication was administered. Staff member E stated she had deviated from her "usual" process resulting in the wrong dose of fentanyl being administered to patient #20.

A review of patient #20's Medication Administration Record, dated 5/28/19 at 2:30 p.m., read, "fentaNYL (PF) IV 50 mcg IV Push once..." This was followed up by a second order dated 5/28/19 at 4:56 p.m.

A review of patient #20's Nursing Notes, dated 5/28/19 at 2:35 p.m., read, "Administered 100 mcg of fentanyl in error, provider ordered 50 mcg of fentanyl. Provider bedside. Provider and pt aware of error. VSS. Pt. alert and oriented x 4. Pt reports feeling dizzy..."

A review of the facility policy, Medication Administration, revised 5/19, read, "1. Medications shall be administered only upon the specific written order of a provider. Medications shall be ordered for a specific patient giving the name of the drug, dosage, mode of administration and time frequency...3. Administration of medications...b. Medications will be administered by the nurse who prepares them... ."

Based on interview and record review, the facility failed to ensure the OPO was integrated into their QA program. This deficient practice had the potential to affect all patients requiring OPO services. Findings include:

A review of the facility's QA improvement projects, failed to include the facility's OPO program.

During an interview on 5/29/19 at 2:43 p.m., staff member C stated the facility did not include OPO into their QA program.