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Based on observation, interview, and record review, the facility failed to ensure patient records were safeguarded for one (Patient 25) of one patient.

This failure had the potential to allow unauthorized use of the patient's records.

Findings:

A review of Patient 25's physician report, dated 4/15/2022, indicated Patient 25 was admitted on 4/15/22 with the diagnosis of High Blood Pressure and was treated for high blood pressure and right arm paresthesia (an abnormal sensation, typically tingling or pricking, caused chiefly by pressure on or damage to nerves.

A concurrent observation and interview on 4/15/2022, at 10:56 a.m., with Director of the Emergency Room (DER) 1, at the nurses' station, Patient 25's medical record print out was left face up and unattended on the printer. DER 1 stated Patient 25's medical record should not be left unattended.

A review of the facility's policy and procedure titled, Patient Confidentiality and Privacy, dated 2/2020, indicated it is the responsibility of every employee and manager to uphold and enforce patient confidentiality and privacy. The access to confidential patient information is held to a minimum of required by the position.

Based on observation, interviews, and record reviews, the hospital failed to ensure that the Condition of Participation for Nursing Services was met as evidenced by:

1. The hospital failed to ensure the registered nurses develop a nursing care plan for two (Patient 28 and 29) of two patients.(Refer to A-0396)

2. The hospital failed to ensure Registered Nurse (RN) 5 was competent in the hemodialysis (a process of purifying the blood of a person whose kidneys are not working normally) emergency termination procedure for Patient 11. (Refer to A-0397)

3. The hospital failed to ensure the portable suction equipment stored on top of the crash carts (wheeled containers carrying medicine and equipment for use in emergency resuscitations) had inspection stickers that had not been past due, for 2 of 2 crash carts located on the 6th floor nursing unit. (Refer to A-0398)

4. The hospital failed to ensure Registered Nurse (RN) 6 labeled the date and time of Patient 10's feeding tube supplies. (Refer to A-0398)

5. The hospital failed to ensure the patient's daily weight was documented as ordered by the physician for three (Patient 31,32, and 33) of three patients. (Refer to A-0398 )

6. The hospital failed to ensure all licensed nurses adhered to the policies and procedures (P/P) of the hospital when RN 1 failed to implement the high fall risk interventions (actions to prevent the patient from falling) one (1) of 30 sampled patients (Patient 1). (Refer to A-0398)

7. The hospital failed to ensure a follow-up point-of-care (POC, a rapid test that is done at/near a patient and does not have to go to the laboratory to process) blood glucose (BG, sugar that is normally found in blood) test per policy & procedure was conducted for one of 30 sampled patients (Patient 2). (Refer to A-0398)

8. The hospital failed to ensure Registered Nurse (RN) 6 document Patient's 10 pain assessment before the administration of pain medication. (Refer to A-0405)

The cumulative effect of these systemic practices resulted in the failure of the hospital to deliver care in compliance with the Condition of Participation: Nursing Services.

Based on interview and record review, the failed to ensure the registered nurses develop a care nursing care plan for two (Patient 28 and 29) of two patients.

This failure had the potential to negatively impact the patient's quality of care.

Findings:

A review of Patient 28's history and physical, dated 4/8/2022, indicated Patient 28 was admitted to the facility on 4/8/2022, for cardiac arrest (sudden heart stop beating).

A review of Patient 28's swallow evaluation, dated 4/12/2022, indicated Patient 28 was recommended to be placed on strict aspiration precautions and one on one feeding assistance due to increased respiratory rate during meals.

A review of Patent 28's physician orders, indicated Patient 28 had aspiration precautions (measures to prevent food and fluid from entering the lungs).

A review of Patient 29's history and physical, dated 4/8/2022, indicated Patient 29 was admitted to the facility on 4/8/2022, for cardiac arrest (sudden heart stop beating).

A review of Patient 28's swallow evaluation, dated 4/13/2022, indicated Patient 29 was recommended dysphagia meals (food altered to reduce choking).

A review of Patent's 29's physician orders, indicated Patient 29 had aspiration precautions (measures to prevent food and fluid from entering the lungs) on 4/13/2022

A concurrent interview and record review on 4/15/2022, at 10:00 a.m., with Charge Registered Nurse (CRN) 1, Patent 28 and 29 electronic medical chart was reviewed. Patient 28 and 29's electronic medical chart did not indicate a nursing care plan for aspiration precautions. CRN 1 stated nursing care plans are important in the treatment of a patient and ensure consistency for nursing care.

A review of the facility's policy and procedure titled, Plan of Care, dated 4/2019, indicated the plan of care is individualized and updated. The patient's status within each care plan of care is reviewed ad documented each shift.

Based on interview and record review, the facility failed to ensure Registered Nurse 5 (RN 5) was competent in the hemodialysis (a process of purifying the blood of a person whose kidneys are not working normally) emergency termination procedure for Patient 11.

This failure had the potential to result in harm to patients receiving hemodialysis treatment.

Findings:

A review of Patient 11's history and physical, dated 4/12/2022, indicated that the Patient 11 was admitted to the facility on 4/12/2022 due to a hemorrhagic stroke (bleeding in the brain). Patient 11's had a history of end state renal disease (loss of kidney function) and hemodialysis treatment three times a week.

An interview on 4/13/2022, at 3:15 p.m., RN 5 stated she is the assigned nurse taking care of Patient 11. She was not able to verbalize the hemodialysis emergency termination procedure. She revealed she had not been trained on what to do if the hemodialysis nurse becomes incapacitated.

An interview on 4/14/2022, at 12:05 p.m., Registered Nurse 6 (RN 6) stated the importance of the hemodialysis emergency termination procedure is to prevent blood clotting (sticking together and blocking the flow) and blood loss in the patient.

A review of the facility's policy and procedure titled, Hemodialysis: Patient Care Coordination, dated 11/2021, indicated in the event of an incapacitated (unable to perform) hemodialysis nurse, the RN shall turn off the hemodialysis machine and clamp the patient's hemodialysis lines.

1. Based on observation, interview and record review, the hospital failed to ensure the portable suction equipment stored on top of the crash carts (wheeled containers carrying medicine and equipment for use in emergency resuscitations) had inspection stickers that had not been past due, for 2 of 2 crash carts located on the 6th floor nursing unit.

This deficient practice had the potential for emergency life saving equipment to not be available.

Findings:

During an observation on 4/13/2022 at 11:10 AM on the 6th floor of the hospital, there was a cove near a service elevator. In the cove, there were 2 crash carts, labeled for 6 East and 6 West nursing stations. On the 6 West crash cart, there was a portable suction machine stored on a side rack of the cart. The portable suction machine had a "biomedical Engineering" inspection sticker. The sticker had "2/22" handwritten on a line above the printed word "due" and a date of "2/21".

During a concurrent interview, the assistant unit manager (AUM 3) stated the suction machine was last serviced in 2/2021 and an annual maintenance check was due in February 2022. Then, AUM 3 took a look at the portable suction machine stored on the 6 East crash cart and stated that there was no biomedical engineering label on the machine, and he was unable to find out if the maintenance for the machine was past due. The 6th floor nursing educator stated the nurses checked the crash carts daily, including functionality of the equipment.

A review of the hospital policy and procedure, "Planned maintenance: crash cart" and effective 12/1/2019, indicated "The Crash Cart(s) will receive an operational check, cleaning and preventive maintenance inspection annually ... The operation, safety ... will be evaluated at this time. ... Complete and affix an inspection sticker ..."



43419

2. Based on observation, interview, and record review the facility failed to ensure Registered Nurse 6 (RN 6) labeled the date and time of Patient 10's feeding tube supplies.

This failure had the potential to result in harm to patients receiving medication through a feeding tube.

Findings:

A review of Patient 10's history and physical, dated 4/10/2022, it indicated Patient 10 was admitted to the facility on 4/10/2022 due to a fall. Patient 10 had a history of spinal stenosis (narrowing of the spinal canal, resulting in painful pressure and compression on the spinal cord and nerves).

A concurrent observation and interview on 4/13/2020, at 2:35 p.m. , with RN 6, in Patient 10's room, Patient 10 was observed with a nasogastric tube (a tube inserted through the nose to the stomach, to provide medication and nutrition) and on the beside counter the feeding tube supplies were not labeled with a date and time. RN 6 stated the feeding tube supplies need a date and time to prevent infection.

A review of the facility's policy and procedure titled, Administration of Medications via Feeding Tubes, dated 12/2019, indicated the feeding tube supplies used for administration of medications, will be labeled with the date and time opened and discarded after 24 hours.

3. Based on interview and record review the facility failed to ensure the patient's daily weight was documented as ordered by the physician for three (Patient 31,32, and 33) of three patients

This failure had the potential to negatively impact the patient's hemodialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) treatment.

Findings:

A review of the history and physical, dated 4/5/2022, indicated Patient 31 was admitted to the facility on 4/5/2022 for shortness of breath. Patient 31 had a history of end state renal disease (loss of kidney function) and hemodialysis treatment.

A review of the Patient 31's physician orders, indicated an order to obtain Patient 31's weight, once a day, starting on 4/5/2022.

A review of Patient 31's daily weight record, indicated from 4/5/2022 to 4/14/2022, Patient 31's weight was not documented six out ten times.

A review of the history and physical, dated 4/6/2022, indicated Patient 32 was admitted to the facility on 4/6/2022 for bleeding in the
brain. Patient 32 had a history of end state renal disease and hemodialysis treatment.

A review of Patient 32's physicians orders, indicated an order to obtain Patient 32's weight, once a day, starting on 4/6/2022.

A review of Patient 32's daily weight record, indicated from 4/6/2022 to 4/14/2022, Patient 32's weight was not documented five out nine times.

A review of the history and physical, dated 4/6/2022, indicated Patient 33 was admitted to the facility on 4/6/2022 for muscle weakness. Patient 33 had a history of end state renal disease and hemodialysis treatment.

A review of the Patient 33's physicians orders, indicated an order to obtain Patient 33's weight, once a day, starting on 4/6/2022.

A review of Patient 33's daily weight record, indicated from 4/6/2022 to 4/14/2022, Patient 33's weight was not documented seven out nine times.

An interview on 4/14/2022, at 12:05 p.m., Registered Nurse (RN) 6 stated the importance of the patient's weight will determine the amount of fluid will be removed from the patient's body during hemodialysis treatment.

A review of the facility's policy and procedure titled, Hemodialysis: Patient Care Coordination, dated 11/2021, indicated the primary registered nurse was responsible in obtaining and documenting the patient's weight before hemodialysis.



43236

4. Based on interview and record review, the facility failed to ensure all licensed nurses adhered to the policies and procedures (P/P) of the hospital when RN 1 failed to implement the high fall risk interventions (actions to prevent the patient from falling) one (1) of 30 sampled patients (Patient 1).

This deficient practice resulted in Patient 1 falling and sustaining an acute complete fracture (bone breaks completely) of the left femoral neck (hip bone fracture). This deficient practice also had the potential for serious injury or death for all patients classified as high risk for falls.

On 4/12/2022, at 4:22 p.m., an Immediate Jeopardy (IJ - a situation in which a facility's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death) situation was identified due to the facility's failure to ensure all licensed nurses adhered to the P/P when RN 1 failed to implement the high-risk interventions for Patient 1 as indicated. The IJ situation was called in the presence of the Chief Executive Officer (CEO), Chief Medical Officer (CMO), Chief Nursing Officer (CNO), Manager of Quality & Patient Safety (QM 1), and Vice President of Ancillary & Support (VPAS).

On 4/14/2022, at 2:06 p.m., the IJ situation was removed in the presence of the CEO, COO, CNO, CMO, VPAS, MQPS, and Corporate VIP of Quality & Risk (CVPQR) after the team validated the hospital's directive action plan through observations, interviews, and record reviews.

Findings:

A review of Patient 1's History & Physical (H&P), dated 3/10/2022, indicated the facility admitted Patient 1 on 3/10/2022 for a fall at Patient 1 ' s assisted living facility on the same day. The H&P also indicated that Patient 1 had dementia (a condition that affects brain function, including remembering things and reasoning).

A review of Patient 1's Fall Risk Assessment Tool, dated 3/10/2022, indicated Patient 1's Fall Risk score was 20 on admission. The Tool also indicated that a score of 11 or greater classifies a patient as high fall risk.

A review of Patient 1's Progress Notes, dated 3/12/2022, indicated that Patient 1 fell while attempting to walk without assistance, and that Patient 1 tripped on SCD (sequential compression device, a machine used to help prevent blood clots while admitted to the hospital) hose.

A review of Patient 1's Physical Therapy Evaluation, dated 3/14/2022, indicated that Patient 1 complained of new onset pain in the left thigh and groin.

A review of Patient 1's X-Ray Report, dated 3/14/2022, indicated that Patient 1 sustained an acute complete fracture of the left femoral neck with displacement (the bone snaps into two or more parts and moves so that the ends are not lined up straight).

A review of Patient 1's Orthopedic Surgery Consultation Progress Notes, dated 3/15/2022, indicated that Patient 1 fell at home (3/10/2022) prior to admission and sustained a head injury, and then had a fall while in the hospital (3/12/2022). The Progress Notes further indicated, "Clearly, the pelvis was intact at the time of admission and the fracture must have happened in the interim. I recommended bipolar arthroplasty [a surgery to repair the hip bone and restore hip function], once the patient is optimized. I explained . . . that the patient is a high surgical risk [for] a number of complications, including death can potentially take place. However, doing nothing is not necessarily a better option."

A review of Patient 1's Orthopedic Surgery Consultation Progress Notes, dated 3/19/2022, at 10:27 a.m., indicated, "Recent developments noted. The patient on comfort care [end of life care]. Will cancel the surgery and sign off the case."

A review of Patient 1's Discharge Summary, dated 3/24/2022, at 5:02 p.m., indicated, "Despite the best efforts of the medical teams [Patient 1] was getting worse instead of better and that we felt continuing aggressive intervention was not going to provide a significant benefit to his quality of life or provide a meaningful recovery. Patient's DPOA [durable power of attorney - a person who has legal authority to make medical decisions for you when you are unable to do so] changed the code status to DNR [do not resuscitate] and patient was placed on comfort care. Patient passed away on 3/19/2022 at 1712 [5:12 p.m.]."

During an interview on 3/25/2022, at 9:24 a.m., RN 1 stated that she was the primary nurse assigned to Patient 1 on 3/12/22. RN 1 stated that she did not turn the bed alarm on and she did not know why she did not turn it on.

During an interview on 4/12/2022, at 12:53 p.m., RN 2 stated Patient 1 had an unwitnessed fall on 3/12/2022. RN 2 found Patient 1 in his room and on the floor. RN 2 stated the bed alarm was not alarming when he found Patient 1.

A review of the facility's policy & procedure (P&P) titled "Fall Risk Assessment, Prevention and Post Fall Care," dated 2/1/2021, indicated, "The registered nurse completes a Fall Risk Assessment . . . Use the established fall risk screening tool. Initiate FALL RISK PREVENTION INTERVENTIONS . . . If high risk: Implement HIGH RISK prevention interventions as listed in Attachment B."

A review of "Attachment B," undated, for the P&P titled "Fall Risk Assessment, Prevention and Post Fall Care" indicated that high fall risk interventions included always ensuring the bed or chair alarm is turned on, except when removed for direct patient care.

5. Based on interview and record review, the facility failed to ensure a follow-up point-of-care (POC, a rapid test that is done at/near a patient and does not have to go to the laboratory to process) blood glucose (BG, sugar that is normally found in blood) test per policy & procedure was conducted for one of 30 sampled patients (Patient 2). This deficient practice had the potential to delay Patient 2's interventions for hypoglycemia (low blood glucose).

Findings:

A review of Patient 2's H&P, dated 2/3/2022, indicated that Patient 2 was admitted to the facility on 2/3/2022 for chest pain and had a history of diabetes (a group of diseases that affect how the body uses glucose, usually leading to too much glucose in the blood).

A review of Patient 2's Physician Orders, dated 2/14/22, indicated that Patient 2's BG should be checked every 6 hours. If the BG is below 54 milligrams per deciliter (mg/dL), then repeat the POC BG test every 15-30 minutes until the BG is equal to or greater than 80, and then conduct a follow-up POC BG test within one hour. A normal BG is between 70-140 mg/dL.

During a concurrent interview and record review with the director of Clinical Transformation (DCT), on 4/18/2022, at 1:06 p.m., Patient 2's BG results and intervention flowsheets (a form in an electronic medical record that collects all the necessary data and displays it for easier review) were reviewed. The flowsheets showed the following:

a. At 6:07 p.m., the BG was 173 mg/dL.
b. At 11:39 p.m., the BG was 29 mg/dL.
c. At 11:45 p.m., Patient 2 received dextrose (a medication used to treat very low blood sugar) to raise the BG.
d. At 11:55 p.m., the BG was 146 mg/dL.
e. Patient 2 did not have another POC BG test until 6:42 a.m., where the BG was 32.

DCT stated that RN 7 did not follow policy and procedure by following up on the POC BG one hour after Patient 2's initial BG of 26 and repeat BG of 146.

A review of the facility's P&P titled "Treatment of Hypoglycemia in the Adult Population," dated 11/3/2020, indicated, "Post-Procedure/Intervention: Repeat POC blood glucose every 15-30 minutes or until BG greater than or equal to 80 mg/dL then follow with a repeat BG within 1 hour."

Based on interview and record review the facility failed to ensure Registered Nurse (RN) 6 document Patient's 10 pain assessment before the administration of pain medication.

This deficient practice had the potential to result ineffective pain management for Patient 10.

Findings:

A review of Patient 10's history and physical, dated 4/10/2022, it indicated Patient 10 was admitted to the facility on 4/10/2022 due to a fall. Patient 10 had a history of spinal stenosis (narrowing of the spinal canal, resulting in painful pressure and compression on the spinal cord and nerves).

A concurrent interview and record review, on 4/13/2022, at 2:45 p.m., with Registered Nurse 6 (RN 6), Patient's 10 electronic medical chart was reviewed. Patient 10's medication administration record indicated Patient 10 was given one tablet of Norco (pain medication) on 4/13/2022, at 2:24 p.m. The pain assessment flowsheet did not indicate Patient 10's pain assessment was documented prior to receiving the pain medication. RN 6 confirmed she did not document Patient 10's pain assessment before giving Patient 10 pain medication.

A review of the facility's policy and procedure titled, Pain: Assessment and Management, dated 4/2021, indicated RNs are responsible for the assessment of pain and documentation in the patient's medical record. The effective management of pain is contingent upon appropriate initial and ongoing pain assessment.

Based on observation, interviews, and record reviews, the hospital failed to ensure that the Condition of Participation for Pharmaceutical Services was met as evidenced by:

1. The hospital failed to ensure a safe and effective medication reconciliation process (a formal process of generating an accurate list of medication a patient is currently taking prior to hospital admission and determine if those medications should be continued during the hospital stay), for one (1) of 33 sampled patients (Patient 2). The patient census was 282. (Refer to A-0500)
2. The hospital failed to ensure unsecured syringes with needles would not be found in patient room. (Refer to A-0502)
3. The hospital failed to ensure medication carts storing medications would be secured from unintended or unauthorized access. (Refer to A-0502)
4. The hospital failed to ensure expired test strips would not be available at patient care area. (Refer to A-0505)
5. The hospital failed to ensure a patient's medication would not be left unattended at a nursing station. (Refer to A-0502)

The cumulative effect of these systemic practices resulted in the failure of the hospital to deliver care in compliance with the Condition of Participation: Pharmaceutical Services.

Based on interviews and record review, the hospital failed to ensure a safe and effective medication ordering process and medication reconciliation process (the process of verifying medications a patient has been taking at home or prior to the hospital admission and determining if those medications should be continued during the hospital stay), for one (1) of 33 sampled patients (Patient 2), as evidenced by:
a. The physician (Physician 1) failed to review and compare the patient's Prior-to-Admission medication list (PTA, patient's home, or past, medications) to his medication orders for one (1) of 33 sampled patients (Patient 2).
b. The pharmacist (Pharmacist 1) failed to verify the indication of use was appropriate for one of Patient 2's medication orders.
c. The physician (Physician 1), the pharmacist (Pharmacist 2), and the pharmacy technician (RxTech 1) failed to collaborate during the medication reconciliation process and communicate the outcome of the process for Patient 2.
d. RxTech 1 and Pharmacist 2 failed to compare Patient 2's PTA list to the current orders.

As a result, Patient 2 received two doses of an unnecessary medication, anastrozole (generic for Arimidex, a chemotherapy [chemical drug therapy] drug used to treat breast cancer [a disease in which abnormal cells divide uncontrollably and destroy breast tissue) in error.

This systemic failure led to a medication error that could potentially cause harm or serious adverse drug reactions to the hospital's patients.

On 4/19/2022, at 3:38 PM, the survey team declared an immediate jeopardy (IJ, a situation in which a facility's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death) in the presence of the hospital Chief Executive Officer (CEO), Chief Medical Officer (CMO), Chief Nursing Officer (CNO), Vice President of Quality & Safety (VPQS), Manager of Quality & Patient Safety (QM), and Vice President of Ancillary & Support (VPAS). The survey team notified the hospital leadership the IJ situation regarding the failure in the patient medication reconciliation process, in which, there was a failure in multidisciplinary collaboration. As a result, Patient 2 received two doses of anastrozole in error, and this failure had the potential to cause harm or serious adverse drug reactions to all currently admitted patients. (Patient census: 282).

On 4/20/2022, at 5:48 p.m., the IJ situation was removed in the presence of the CMO, CNO, VPQR, VPAS, and QM 1 after the team validated the hospital's directive action plan through observations, interviews, and record reviews.

Findings:

a. During a review of Patient 2's History & Physical (H&P), dated 2/4/22 and signed by Physician 1, the H&P indicated the hospital admitted Patient 2 on 2/3/2022 with diagnoses including severe aortic stenosis (narrowing of the valve in the large blood vessel branching off the heart). Patient 2 medical history included other heart diseases such as NSTEMI (non ST-elevation myocardial infarction, a type of heart attack), and history of breast cancer. Anastrozole was not on the PTA medications list.

During an interview, on 4/13/2022 at 2:16 PM, the Corporate Vice President of Quality & Risk (CVPQR) stated there was a medication error report about Patient 2's anastrozole on 2/6/2022. During a review of the aforementioned error report, the report indicated on 2/6/2022, Patient 2's family member contacted the hospital pharmacy to inquire the reason Patient 2 was receiving anastrozole at the hospital. During a concurrent interview, the director of pharmacy (DOP) stated Patient 2's family member informed the pharmacy that Patient 2 last took anastrozole in 2019.

During an interview, on 4/13/2022 at 2:20 PM, the medication safety officer (MSO) stated the medication reconciliation was typically done by nursing staff, physician, and/or Pharmacy. MSO stated the process would be documented in the electronic medical record software program.

During an interview with Physician 1 in the presence of the Chief Medical Officer (CMO), on 4/15/22 at 1:45 PM, Physician 1 stated that he knew (treated) Patient 2 at another hospital (general acute care hospital, GACH 2). Physician 1 stated Patient 2 was not on anastrozole at GACH 2. Physician 1 denied ordering anastrozole for Patient 2. Physician 1 stated he assumed the PTA list of medication were the same medications from GACH 2 and he did not do due diligence to review Patient 2's PTA medications. Physician stated he relied on safety checks by nurses and pharmacy staff. Physician 1 further stated "looking back, I should have reviewed the list one by one."

During a concurrent interview on 4/15/22 at 1:45 PM, CMO stated the physician mistakenly assumed the PTA list was correct.

During a review of the electronic physician order for Patient 2, dated 2/3/2022 at 2:28 PM, the order indicated Physician 1 ordered anastrozole 1 milligram (mg, an unit of measurement) by mouth daily. However, this order was discontinued on 2/6/2022 at 11:41 AM with a "Reason for discontinue: Incorrect/Changed."

A review of the hospital policy and procedure, "Medication & Order Reconciliation policy and procedure" effective 10/1/2019, indicated the physician's responsibilities in the medication reconciliation process include comparing the PTA medication list to currently ordered admission medications and adjust as clinically indicated.

b. During an interview on 4/18/2022 at 2:45 PM, pharmacy operation manager (POM 1) reviewed the anastrozole order for Patient 2 and stated Pharmacist 1 verified (a process to check for therapeutic appropriateness) this order on 2/3/2022 at 2:51 PM. POM 1 stated Pharmacist 1 verified and approved the Patient 2's new anastrozole order because the patient had a history of breast cancer; however, there was no evidence that Pharm 1 had verified Patient 2 required ongoing treatment for breast cancer.

A review of the hospital policy and procedure, "Hazardous and Non-Hazardous Drugs: For Oncologic Indications" effective 2/4/2020, indicated " ... Review hazardous drug orders for oncologic indications."'

A review of the hospital policy and procedure, "Medication Orders: Prescribing, Accepting and Authorization for Administering" effective 3/2/2021, indicated the procedure for drug orders for chemotherapy include "Clarify orders via verbal/telephone order."

c. During an interview on 4/15/22 at 1:45 PM, the CMO stated that Pharmacy Technician 1 (RxTech 1) contacted Family Member 1 to complete the medication reconciliation process for Patient 2. CMO stated the pharmacy department did not communicate to Physician 1 about removing (discontinuing) anastrozole for Patient 2.

During an interview on 4/18/2022 at 9:30 AM, the Quality Manager (QM) and the Director of Clinical Transformation (DCT) reviewed Patient 2's "Reconciliation Comment", dated 2/3/2022 at 3:23 PM, DCT stated RxTech 1 documented "Medication information from [Patient 2' family member]."

During an interview on 4/18/2022 at 9:32 AM, DCT reviewed Patient 2's electronic "Med List Status History" and stated the "med list" referred to Patient 2's PTA medication list. DCT further stated Physician 1 viewed the med list on 2/3/22 at 2:26 PM; then, at 3:13 PM (same date), RxTech 1 started the med list review process (medication reconciliation), and at 4:48 PM, Pharmacist 2 completed the process.

During an interview on 4/18/2022 at 9:35 AM, DCT stated during the aforementioned process, Rx Tech 1 discontinued anastrozole from Patient 2's PTA list and the subsequent med list finalized by Pharmacist 2, on 2/3/2022 at 4:50 PM, did not include anastrozole.

During an interview on 4/18/2022 at 9:40 AM, both DCT and QM confirmed Physician 1 ordered anastrozole for Patient 2, before RxTech 1 and Pharmacist 2 completed the medication reconciliation process and discontinued anastrozole from the PTA med list. DCT stated the electronic medical record system should generate an alert to the reviewer and/or physician, that a medication discontinued (or removed) from the PTA list was also currently on the patient's active medication order list. However, DCT was unable to find evidence of the alert, nor evidence that physician acknowledged such alert.

A review of the hospital policy and procedure, "Medication History Pharmacist and Technician Program" effective 6/15/2021, indicated "... If admission orders have already been entered ... the provider will be notified via the EMR alert banner of the changes ..."

During an interview on 4/20/2022 at 10:51 AM, DCT reviewed Patient 2's progress notes dated between 2/3/2022 and 2/4/2022. DCT confirmed she was unable to find notes about Patient 2's anastrozole. DCT was unable to find evidence that the physician, pharmacists, pharmacy tech, and/or nurses, collaborated in the medication reconciliation process; there was no documented communication about the discontinuing Patient 2's anastrozole.

A review of the hospital policy and procedure, "Medication & Order Reconciliation policy and procedure" effective 10/1/2019, indicated "Medication reconciliation is a collaborative activity that includes patients, families, prescribers, nurses, and pharmacist ... Pharmacist responsibilities in the medication reconciliation process during inpatient admission include: ... Review PTA medication list and compare the list to currently ordered admission medications. Collaborate with the RN and MD in reconciling the PTA medication list to the patient's current orders ..."

d. During an interview on 4/18/2022 at 3:15 PM POM 1 stated Pharmacist 2 should compare PTA med list to the patient's current medication orders; however, in the case of Patient 2, Pharmacist 2 did not compare the two lists. During a concurrent interview, DOP stated Pharmacist 2 validated the discontinuation of anastrozole from the previous med list, however, Pharmacist 2 missed there was a current order of anastrozole for Patient 2.

During a review of Patient 2's Medication Administration Record (MAR), the MAR for Patient 2's anastrozole indicated Patient 2 received a total of two doses of anastrozole 1 mg: one dose on 2/4/2022 at 1:05 PM and one dose on 2/5/2022 at 11:16 AM.

During a review of the Physician Progress Notes for Patient 2, dated 2/6/22 at 5:24 PM, the Physician Progress Notes indicated Physician 1 documented "Somehow patient received 2 doses of Anastrozole by mistake which was discontinued."

During an interview on 4/20/2022 at 11:28 AM, DOP stated medications have side effects (undesirable effects). Those side effects range from mild to severe and could manifest in a patient as discomfort, pain, or in some cases, death. DOP also stated unnecessary medications could potentially cause physical and psychosocial harm to patients who received them.

During an interview on 4/20/2022 at 11:43 AM, DOP stated anastrozole was considered a chemotherapy drug because it was used to treat breast cancer. During a concurrent record review, the DOP referred to the anastrozole drug reference printout, dated receipt on 4/6/2022. DOP stated the anastrozole drug reference printout indicated side effects of anastrozole included stomach and muscular skeletal pain. DOP also stated anastrozole could increase the risk for bone fractures and ischemic cardiovascular events (heart attack). DOP further stated she would not be able to determine if the side effects from anastrozole had affected Patient 2 because of the patient's comorbidities and other medications that the patient was on.

A review of the hospital policy and procedure, "Medication Errors and Adverse Drugs Reactions, Reporting" effective 10/1/2021, indicated a medication error is "[any] preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health care professional, patient or consumer. Such events may be related to profession practice . . . including prescribing, order communication . . . dispensing."

Based on observation, interview, and record review the facility failed to ensure medication was securely stored.

This failure had the potential to result in tampering and diversion (redirected from its intended destination for personal use, sale, or distribution to others) of the medication for the patients.

Findings:

A concurrent observation and interview, on 4/13/2022, at 2:59 p.m., with the Assistant Unit Manager 4(AUM 4), at the intensive care unit's nurses' station, a medication cart was not secured and unattended. The medication cart contained medication pills, vials, and liquid bags specific to the patients in the unit. AUM 4 stated the medication carts are to be locked when not in use.

A concurrent observation and interview, on 4/13/2022, at 3:13 p.m., with Director of Clinical Operations (DCO), in Patient Room 721, 10 unopened syringes (used to administer medication to patients) were found in an unsecured drawer. DCO stated that syringes are stored in a secured area and she will remove the 10 syringes from the patient room.

A concurrent observation and interview, on 4/14/2022, at 10:22 a.m., with Charge Registered Nurse 1 (CRN 1), in the telemetry unit supply room, a medication cart was not secured and unattended. The medication cart contained medication pills, vials, and liquid bags specific to the patients in the unit. CRN 1 stated the medication carts are to be locked when not in use.

A concurrent observation and interview, on 4/14/2022, at 10:32 a.m., with Medical Surgical Director 2 (MSD 2), in the 4th floor nurses station, a bottle of magnesium oxide (medication to treat upset stomach) was left unattended by the pneumatic tube station (a system that transports items through the facility). MSD 2 stated the medication should be stored in the medication cart.

A review of the facility's policy and procedure titled, Storage and Security: Inpatient Medication, dated 5/2019, indicated medications are to be properly and safely stored with appropriate security. Medication cards are to be locked when not in immediate use.

Based on observation, interview, and record review, the facility failed to ensure expired urinalysis test strips (a test to detect irregularities in the patient's urine) were not available for patient use.

This failure had the potential to result in inaccurate test results of a patient's urine.

Findings:

A concurrent observation and interview on 4/13/2022, at 3:18 p.m., with Assistant Unit Manager 4 (AUM 4), in the intensive care unit medication room, a container of urinalysis test strips were found and the container had the expiration date of 12/3/2021. AUM 4 stated the container should have been thrown away because it could give inaccurate test results from the patient's urine.

A review of the facility's policy and procedure titled, Point of Care Testing: Urinalysis, dated 3/2022, indicated the testing strips are stable in the original capped vial until the listed expiration date.

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff stored food with a date that the food was opened.

This deficient practice had the potential to cause food borne illness in the patients.

Findings:

A concurrent observation and interview on 4/15/2022, at 2:10 p.m., with Director of Dietary (DD) 1, in the kitchen, one opened container of dairy cream was found in the refrigerator without an opened date. DD 1 stated the importance of adding an opened date on the container, is to prevent food borne illness in the patients.

A review of the facility's policy and procedure titled, Storage of Food and Supplies, dated 2/2020, indicated to ensure the proper storage of food, all prepared foods are dated with the first date opened.