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Based on record review and interview, the CAH (Critical Access Hospital) failed to ensure identified medication errors were documented in the patient's medical record for 3 (Patient #7, 8, 9) of 3 hospital identified medication errors reviewed.
Findings:

Review of the hospital's policy titled Medication Errors (reviewed 9/15) revealed in part that when a medication error occurs the following should occur: Notify the physician, record the medication as given in the medical record and record notification of physician in the medical record with any resultant orders.

1. Review of the hospital's occurrence report for patient #7 dated 12/16/15 revealed that the physician wrote an order on 12/16/15 at 8:00 a.m. for the patient to receive Nitroglycerin paste 1/2 inch to chest wall every four hours. Further review of the report revealed that the patient was transferred to another hospital on 12/16/15 at 9:00 p.m. without ever receiving the medication.

Review of patient #7's medical record revealed she was admitted to the hospital on 12/15/15 with diagnoses including unstable angina. There was no documented evidence in the record regarding the medication error.

2. Review of the hospital's occurrence report for patient #8 dated 12/08/15 revealed that the physician ordered for the patient to receive Dilantin (anti-seizure medication) 300 mg (milligrams) every day. Further review of the report revealed that the patient received 100 mg daily which made the patient's Dilantin level was too low and the patient spend extra time in the hospital.

Review of patient #8's medical record revealed he was admitted to the hospital on 12/04/15 with diagnoses including epilepsy, with a physician order for Dilantin 300 mg daily. Further review of the medical record revealed that the patient received Dilantin 100 mg daily from 12/04/15 until 12/08/15. There was no documented evidence in the record regarding the medication error.

3. Review of the hospital's occurrence report for patient #9 dated 11/28/15 revealed that the physician ordered for the patient to receive Lovenox 80 mg subcutaneous every 12 hours. The report revealed the patient received the medication at 1:00 p.m. and then again at 6:00 p.m. (5 hours later). Review of the patient's medical record revealed no documented evidence regarding the medication error or physician notification of the medication error.

An interview was conducted with S2DON (Director of Nursing) on 01/13/16 at 9:45 a.m. She confirmed there was no documentation in the above patients' medical records regarding the medication errors.

Based on observation and interview, the CAH (Critical Access Hospital) failed to ensure the provision of a safe environment consistent with nationally recognized infection control precautions as evidenced by: 1) failing to ensure staff clean and disinfect non-disposable equipment and supplies taken into the patient's room, 2) failing to disinfect the computer on wheels when the computer system was taken into the patient's room. Findings:
1. Failing to ensure staff clean and disinfect non-disposable equipment and supplies taken into the patient's room:
Observation on 01/12/16 at 9:30 a.m. revealed S4LPN (Licensed Practical Nurse) entering a patient's room and placed the IV (Intravenous) tote tray in the bed with the patient. Completing the patient's IV S4LPN with the same gloved hands picked up the IV tote tray and walked into the hallway and placed the IV tote tray on a housekeeping cart. S4LPN then removed her gloves and used alcohol gel to clean her hands. S4LPN then took the IV tote tray and walked to the nurse's station and opened the medication room door and placed the IV tote tray on the counter without cleaning or disinfecting the tray.
Interview on 01/12/16 at 11:00 a.m. with S7RN (Registered Nurse) confirmed the S4LPN should have wiped the IV tote tray before placing back in the medication room.
Interview on 01/13/16 at 9:40 a.m. with S2DON (Director of Nurses) confirmed the nurse should have placed the IV tote tray on the bedside table not in the bed with the patient. S2DON further stated that all staff should be adhering to infection control policies for cleaning and maintaining equipment when used in patient contact.
Review of the hospital policy titled " Infection Control Policies " , reviewed 2/15, revealed in part: Cleaning of Equipment and Work Areas 1. Nurses are responsible to enforce and inspect routine disinfection of equipment, work areas, hand washing, cleanliness of items used in between patients ...
2. On 01/12/16 at 8:40 a.m., observation revealed S4LPN was passing medications using her computer/medication cart on wheels. Further observations at that time revealed that S4LPN was going in and out of patient rooms with the cart and was not observed to clean the cart at any time.

On 01/13/16 at 8:45 a.m., observation revealed S4LPN and S11LPN were passing medications using their computer/medication carts on wheels. Further observations at that time revealed that the nurses were going in and out of patient rooms with the carts and were not observed to clean the carts at any time.

On 01/13/16 at 9:00 a.m., interview with S2DON revealed that the hospital did not have policy and procedure related to the cleaning of the computer/medication cart on wheels. S2DON confirmed that staff is supposed to clean the tops of their workstations on the rolling carts after coming out of each patient's room.


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Based on record review and staff interview, the CAH (Critical Access Hospital) failed to ensure all medications were administered in accordance with physician's orders and accepted standards of practice for 3 (#7, #8, #15) of 3 patients reviewed for medication administration out of a total sample of 20 patients.
Findings:

Review of the hospital policy titled Medication Errors, review date of 09/15, revealed in part that all actual or potential errors identified will be documented through the hospital's risk management system. Types of medication errors include incorrect medication, dose, route or time; omissions (not administered before next scheduled dose due); unordered dose. When a medication error occurs the following should occur in this order: Notify the physician and evaluate the patient. Perform any necessary clinical interventions.... Record the medication as given in the medical record. Record the observed and assessed outcome of the patient in the medical record. Record notification of physician in the medical record with any resultant orders....The practitioner who identifies an error will document all relevant particulars on the incident report form....

Review of the hospital policy tilted Medication Safety, revision date 09/15, revealed that first dose medications should be administered within one hour. Time critical scheduled medications should be administered within 30 minutes before or after their scheduled dosing dose.

Review of the medical record for patient #7 revealed the patient was admitted to the hospital on 12/15/15 with diagnoses including unstable angina and possible pulmonary embolism. Review of the physician orders revealed an order dated 12/15/15 for Lovenox 60 mg
(milligrams) subcutaneously every 12 hours. Review of the record revealed the patient received her first dose of Lovenox 60 mg at 12:09 a.m. on 12/16/15 and her next dose was administered approximately 9 hours later, on 12/16/15 at 9:30 a.m. Further review of the medical record revealed no documentation by the hospital staff as to why this dose was not administered as ordered and no documentation that the physician was notified.

In an interview on 01/12/16 at 11:00 a.m., S3ADON (Assistant Director of Nursing) reviewed the electronic health record and confirmed the Lovenox doses were not administered 12 hours apart on 12/15/15 as ordered by the physician. S3ADON stated that all medication errors are sent to her and she had not received an incident report on this error. S3ADON confirmed there was no documented evidence that the patient's physician had been notified of the medication error.

Review of the medical record for patient #8 revealed the patient was admitted to the hospital on 12/04/15 with diagnoses including urinary tract infection and dehydration. Review of the admit physician orders dated 12/04/15 at 5:05 p.m. revealed an order for Levaquin (antibiotic) 500 mg intravenous now and every 24 hours.
Review of the medication administration record revealed that the first dose of Levaquin was not administered until approximately 5 hours later, at 9:55 p.m. Review of the medical record revealed no documentation by the hospital staff as to why this "now" dose was not administered within the one hour time frame, as per hospital policy. Further review of the medical record revealed no information that the physician was contacted regarding the late administration of the Levaquin. On 01/12/16 at 12:00 p.m., interview with S2DON and S6Pharmacist confirmed that "now" doses should be administered within one hour of the order.
Further review of patient #8's record revealed no documented evidence that the patient was administered the ordered Levaquin dose on 12/07/15 or 12/08/15. Review of the medical record revealed no physician orders to omit these doses, and revealed no documentation by the hospital staff as to why these doses were not administered as ordered. Further review of the medical record revealed no documentation that the physician was contacted regarding the missed doses of Levaquin.

In an interview on 01/12/16 at 11:15 a.m., S3ADON reviewed patient #8's electronic health record and confirmed the Levaquin doses were not administered on 12/07/15 and 12/08/15 as ordered by the physician. Further interview at this time with S3ADON revealed that all medication errors are sent to her and she had not received any incident reports on the medication errors involving the patient's Levaquin. S3ADON further confirmed there was no documented evidence that the patient's physician had been notified of the medication errors.

Review of the medical record for Patient #15 revealed she had been admitted to the hospital on 01/15/16 with the diagnoses of Uncontrolled Diabetes, Ulcer right medial 2nd toe, Superficial phlebitis right medial calf. Review of the physician admission orders reveal an order for "Dextrostix q 4hr. Sliding scale: 10u Reg Insulin s.c. per for sugar > 250 5 u if 200-250."
Review of the Glucose/Insulin Log Sheet revealed the following:
01/05/16 8:35 p.m. Glucose 413,10 units Reg insulin SQ.
01/05/16 9:50 p.m. Glucose 362, No insulin.
01/05/16 11:52 p.m. Glucose 299, No insulin.
01/06/16 3:30 a.m. Glucose 299, No insulin.
01/06/16 6:15 a.m. Glucose 299, No insulin.
01/06/16 10:00 a.m. Glucose 342, 10 units Reg. insulin SQ.
01/06/16 11:30 a.m. Glucose 314, 10 units Reg. insulin SQ

Review of the Nurses' Notes revealed that on 01/05/16 at 10:15 p.m., 11:52 p.m. revealed S8LPN informed S9RN of the glucose readings. Continued review of the Nurses' notes revealed no documented evidence that the patient's physician had been notified of the glucose level reading, omission of insulin and/or administration of a total of 20 units of insulin within 1.5 hours.

In an interview on 01/12/16 at 11:00 a.m.,S2DON confirmed that after review of the Physician orders and Glucose/Insulin log sheet, a medication error had occurred and was not identified by the CAH. S2DON indicated that S8LPN failed to administered insulin at 11:52 p.m. and at 3:30 p.m. for glucose levels of 299. S2DON indicated that on 01/06/16 a total of 20 units of Regular insulin was administered within 1.5 hours. S2DON indicated that the CAH failed to identify the omission and administration of additional insulin as a medication errors. S2ADON further confirmed there was no documented evidence that the patient's physician had been notified of the additional insulin administered at 11:30 a.m.


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Based on record review and staff interview, the CAH (Critical Access Hospital) failed to ensure the quality assurance (QA) program was effective as evidenced by the QA program failed to develop corrective action plans for identified medications errors and failed to identify medication errors for 3 (#7, #8, #15) of 3 patients reviewed for medication administration.
Findings:

Review of the hospital's Performance Improvement Plan revealed the central component of the performance improvement function was to design and implement a system of ongoing quality measurement and analysis. The plan listed general criteria that would be used to select hospital activities and results to monitor. This list included medication use.
The plan did not address any provisions for corrective actions.

Review of the hospital's incident log book revealed the following for the past 6 months:
December 2015 - 6 medication errors
November 2015 - 1 medication error
October 2015 - 2 medication errors
July 2015 - 1 medication error
Further review of the incident log book and occurrence reports revealed there was no documented evidence of any corrective actions identified to address the hospital's medication errors.

The survey team also identified the following medication errors that had not been identified by the hospital:

Patient #7
Review of the medical record for patient #7 revealed the patient was admitted to the hospital on 12/15/15 with diagnoses including unstable angina and possible pulmonary embolism. Review of the physician orders revealed an order dated 12/15/15 for Lovenox 60mg subcutaneously every 12 hours. Review of the record revealed the patient received her first dose of Lovenox 60mg at 12:09 a.m. on 12/16/15 and her next dose was administered approximately 9 hours later, on 12/16/15 at 9:30 a.m.

Patient #8
Review of the medical record for patient #8 revealed the patient was admitted to the hospital on 12/04/15 with diagnoses including urinary tract infection and dehydration. Review of the admit physician orders dated 12/04/15 at 5:05 p.m. revealed an order for Levaquin (antibiotic) 500mg intravenous now and every 24 hours. Review of the medication administration record revealed that the first dose of Levaquin was not administered until approximately 5 hours later, at 9:55 p.m.

Further review of patient #8's record revealed no documented evidence that the patient was administered the Levaquin dose on 12/07/15 or 12/08/15. Review of the medical record revealed no physician orders to omit these doses, and revealed no documentation by the hospital staff as to why these doses were not administered as ordered.

Patient #15
Review of the medical record for Patient #15 revealed she had been admitted to the hospital on 01/15/16 with the diagnoses of Uncontrolled Diabetes, Ulcer right medial 2nd toe, Superficial phlebitis right medial calf. Review of the physician admission orders reveal an order for "Dextrostix q (every) 4hr. (hours) Sliding scale: 10u (units) Reg. (Regular) Insulin s.c. (subcutaneous) for sugar > 250. 5 u if 200-250."
Review of the Glucose/Insulin Log Sheet revealed the following:
01/05/16 8:35 p.m. Glucose 413,10 units Reg insulin SQ.
01/05/16 9:50 p.m. Glucose 362, No insulin.
01/05/16 11:52 p.m. Glucose 299, No insulin.
01/06/16 3:30 a.m. Glucose 299, No insulin.
01/06/16 6:15 a.m. Glucose 299, No insulin.
01/06/16 10:00 a.m. Glucose 342, 10 units Reg. insulin SQ.
01/06/16 11:30 a.m. Glucose 314, 10 units Reg. insulin SQ

Review of the Nurses' Notes revealed that on 01/05/16 at 10:15 p.m., 11:52 p.m. revealed S8LPN (License Practical Nurse) informed S9RN (Registered Nurse) of the glucose readings. Continued review of the Nurses' notes revealed no documented evidence that the patient's physician had been notified of the glucose level reading, omission of insulin and/or administration of a total of 20 units of insulin within 1.5 hours.

In an interview on 01/12/16 at 11:15 a.m., S3ADON (Assistant Director of Nursing) reviewed the above patients' electronic health records and confirmed the medication errors. Further interview at this time with S3ADON revealed that all medication errors are sent to her and she had not received any incident reports on the above medication errors.

Further interview on 01/12/16 at 1:45 p.m. with S3ADON indicated that she was the hospital's Quality Improvement (Assurance) officer . S3ADON indicated that hospital's QA failed to identify a problem with medication errors. She further stated that there had been no documented investigations of the above medication errors and there was no evidence of corrective actions for the identified errors. S3ADON confirmed the QA program had not been effective in identifying medication errors and correcting identified errors.



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