HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to ensure that the medication list entered upon admission matched the identity of the patient. This potentially placed all patients who were admitted to the Hospital at risk for serious harm. As a result, the Condition of Participation, 42 CFR 482.23 Nursing Services, was not in compliance.

Findings include:

1. The Hospital failed to ensure that the correct medication list was verified to match the identity of the patient. (A-0405).

An immediate jeopardy (IJ) began on 7/7/18, when a patient (Pt. #1) came to the Emergency Department with altered mental status. The patient arrived from a group home [Nursing Facility] with the wrong medication list and subsequently received incorrect medications for 2 days during the hospitalization. The Hospital failed to address improper identification and verification of a medication list.

An IJ was identified and announced on 9/11/18 at 2:25 PM, during a meeting with the Chief Nursing Executive, Director of Patient Care Services, Accreditation & Clinical Compliance Manager, Director of Pharmacy, Manager of Accreditation, Manager of Emergency Department, Manager of Medical/Surgical Unit Y1, and the Human Resources Director. The Hospital failed to implement and evaluate corrective measures. The immediate jeopardy was not removed by the survey exit date of 9/12/18.

Based on document review and interview, it was determined that for 1 of 3 patients (Pt. #1) admitted from another facility, the Hospital failed to ensure that the correct medication list was verified to match the identity of the patient. This failure has the potential to affect all current and future patients admitted to the Hospital.

Findings include:

1. The Hospital's policy titled, "Medication Reconciliation" (revised 04/2017) was reviewed on 9/10/18 and required, "The patient's home medication history will be obtained at point of entry to the hospital ... Medication information brought by the patient [or representative] to the hospital will be compared with medications ordered in order to identify and resolve discrepancies ... For every patient presenting to the hospital, the home medication history will be obtained at the point of entry. If the patient presents to the Emergency Department (ED), this is the point of entry where medication reconciliation is started. Medication Reconciliation includes entering all medications by name, dose, route, frequency and last time/date taken. Staff will complete the following steps as a 'good faith effort' to reconcile medications: ... Ask for a list of current medications and review any existing list available in the electronic record with the patient/ patient's caregiver. These may be communicated verbally, written on a list, or from a nursing home/sending facility medication list ... In extenuating circumstances where patient condition is compromised and time does not allow for medications to be entered into the EMR but a copy of the patient's medication list exists, the list is to be updated and verified with the patient/ patient's family/caregiver[,] dated, timed and signed by reconciling RN and will be scanned into the chart ..."

2. The clinical record of Pt. #1 was reviewed on 9/10/18 and 9/11/18. Pt. #1 was a 61 year old female, who was transferred from a nursing facility to the Hospital's ED (emergency department) on 7/7/18 at 6:26 PM, with altered mental status. Pt. #1 was admitted to the Medical/Surgical Unit on 7/7/18 at 10:12 PM, with diagonoses of toxic encephalopathy (infection in the brain) secondary to UTI (urinary tract infection). Pt #1's medical records indicated Pt. #1 had a history of Down Syndrome, IDD (intellectual or developmental disability), vision impairment, hearing deficit and seizure disorder. Pt. #1 was discharged from the Hospital on 7/10/18 at 4:45 PM.

- A copy of Pt. X's [another patient at nursing facility] medication list was scanned into Pt. #1's electronic health record (EHR) on 7/7/18. Pt. #1's correct list of medications was scanned into the EHR on 7/9/18. There were no similarities between Pt. #1's and Pt. X's name or date of birth. Pt. #1's record indicated that Pt. X's medications were entered into Pt. #1's EHR by the ED Triage Nurse (E#1).

- Pt. #1's medication administration record (MAR) indicated that Pt. #1 received 7 medications incorrectly and did not receive one intended medication for 1 - 2 days (7/8/18 and 7/9/18) on the Medical-Surgical Unit, as follows:

- Midodrine [medication to treat low blood pressure]: 10 mg [milligrams] on 7/8/18 at 2:22 PM and 5:27 PM; 7/9/18 at 9:33 AM, 3:10 PM, and 6:39 PM. Pt. #1 received a total of 5 doses of midodrine, a medication with a potential side effect of bradycardia (slowed heart rate, less than 60 beats per minute), between 7/8/18 and 7/9/18.

- Clonazepam (Klonopin) [a sedative]: 0.5 mg on 7/8/18 at 2:02 AM and at 8:41 PM (2 doses).

- Primidone (Mysoline) [anti-seizure]: 250 mg on 7/8/18 at 2:02 AM and 8:41 PM (2 doses); and 100 mg on 7/9/18 at 9:33 AM (1 dose). Total of 3 doses.

- Florastor [a probiotic - health digestion & immune support]: 250 mg on 7/8/18 at 8:41 PM; 7/9/18 at 9:35 AM; and on 7/10/18 at 1:13 AM and 10:38 AM (total 4 doses).

- Megestrol (Megace) [appetite stimulant]: 400 mg on 7/9/18 at 9:33 AM (1 dose).

- Miralax [medication for constipation]: 17 g[grams] on 7/9/18 at 9:36 AM (1 dose).

- Lacosamide (Vimpat) [anti-seizure] 150 mg on 7/8/18 at 8:41 PM and 7/9/18 at 10:01 AM (total 300 mg per day). Pt. #1's MAR from [Nursing Facility] had a Vimpat order for 50 mg twice daily and 100 mg at bedtime (total 200 mg per day). Pt. #1 received an extra 100 mg.

- Pt. #1 did not receive her first of dose of Keppra [anti-seizure] at the Hospital until 7/10/18 at 2:13 PM. Pt. #1 should have received 500 mg of Keppra twice daily (total of at least 4 missed doses between 7/7/18 and 7/9/18).

- Propranolol [cardiac medication to treat high blood pressure] (60 mg daily) was ordered incorrectly for Pt. #1; however, Pt. #1's MAR indicated that the scheduled doses (on 7/8/18 at 9:02 AM and 7/9/18 at 11:25 AM) were not given due to Pt. #1 having a low heart rate.

- The attending physician's (MD#4) progress notes dated 7/8/18 at 3:56 PM included, " ... will check EEG [electroencephalogram] for subclinical seizure giving unusual eye movement. Consider neurology consult."

- The neurologist's (MD#2) consult notes dated 7/9/18 at 3:49 PM included, " ...Possible breakthrough seizure: It is unclear if patient had a seizure or not but it would be likely provoked in the setting of urinary tract infection or possibly missing her medications ... Seizure disorder: Patient is followed by [Neurologist / MD#6] as outpatient ... Patient is currently on Vimpat [anticonvulsant] 150 mg twice daily and primidone [anticonvulsant] 100/250 mg; unclear when this was changed as review of patient's recent visit with [MD#6] shows that patient is on Vimpat and Keppra [anticonvulsant]. Will try to clarify with group home [Nursing Facility] and see when this was changed or if this is a mistake."

- The attending physician's (MD#4) progress notes dated 7/9/18 at 4:16 PM included, " ... Bradycardia [slow heart rate less than 60]. Asymptomatic. Hold propranolol [cardiac medication to treat high blood pressure, chest pain or uneven heartbeat] ..."

- The neurologist's (MD#2) progress notes dated 7/10/18 at 9:42 AM included, " ... Yesterday it was identified that patient was on wrong medications and her medications were changed to her home medications ... PLAN: ... Medications were clarified and were wrong, will continue home medications: Vim[p]at 50/150 mg and Keppra 500 mg BID [twice daily] ..."

- Nursing notes included:
- On 7/8/18 at 2:45 PM: "SB [sinus bradycardia] 40's-50's, propranolol is ordered, not given."
- On 7/9/18 at 11:21 AM: "Per Tele[metry]=- Pt [patient] running SB 38-40's AM dose of propranolol was held ..."
- On 7/9/18 6:32 PM: "Per Telemetry- pt had HR [heart rate] in the 30s for a minute or two, then rebounded to 47. Informed them to monitor for sustained 30's."

- Nursing flowsheets included the following vital signs:
- Pulse/heart rate [HR]:
- 7/9/18: HR 44 at 2:22 AM; HR 59 at 3:33 AM; HR 48 at 8:00 AM; HR 40 at 9:30 AM; HR 50 at 4:34 PM; HR 56 at 7:12 PM; and HR 46 at 11:48 PM.
- 7/10/18: HR 50 at 3:45 AM and 9:07 AM; and HR 56 at 2:41 PM.
- Blood pressure [BP]:
- 7/7/18 at 6:43 PM: 116/78
- 7/8/18 at 11:37 PM: 90/60
- 7/9/18 at 3:33 AM: 96/60
- 7/10/18 at 2:41 PM: 112/61

- The discharge summary dated 7/10/18 at 2:28 PM included, "Patient [Pt. #1] had a mix[-]up with medications as [the] medications list [of another patient / Pt. X was] given from group home [Nursing Facility] was incorrect. This has been clarified and her home medications were resumed, including Vimpat and Keppra [both anti-seizure]. Patient had received propranolol [cardiac medication to treat high blood pressure], with noted bradycardia [slowed heart rate] which was discontinued. Patient was evaluated by cardiology, bradycardia has significantly improved, and patient is stable for discharge at this time..."

3. An interview was conducted with the ED Triage/Registered Nurse (E#1) and the ED Manager (E#5) on 9/10/18, at approximately 1:40 PM. Both E#1 and E#5 stated that they did not know about Pt. #1 receiving the wrong medications until today (9/10/18). E#1 and E#5 stated that they did not receive any education or huddle regarding this incident. E#1 stated that Pt. #1's medication list was scanned into the Hospital's EHR in the ED triage area on 7/7/18. E#1 stated that she did not know that the medication list scanned was the wrong one for Pt. #1. E#1 stated that she should have checked the name on the medication list prior to entering the medications into the Pt. #1's clinical record and completing the medication reconciliation process.

4. A telephone interview was conducted on 9/11/18, between 9:03 AM and 9:22 AM, with the admitting physician/provider (MD#3) who approved and ordered the incorrect medications. MD#3 stated that a patient who receives the following medications he/she was not intended to receive could have the following potential side effects:
- Propranolol: bradycardia, low blood pressure, arrhythmias.
- Midodrine: decreased cardiac output, decreased heart rate.
- Clonazepam (Klonopin): decreased anxiety, decreased respiratory rate.
- Primidone: decreased anxiety
- Lacosimide (Vimpat): "If a patient receives a higher dose than intended, the patient can have increased irritability."
- Keppra: "If patient misses prescribed doses for less than 72 hours, there may be no effect because the medication level should remain adequate in the blood. After 72 hours, the patient may experience withdrawal symptoms (including tremors, anxiety, and seizures)."

5. An interview was conducted with the Director of Pharmacy (E#7) on 9/11/18, at approximately 10:00 AM. E#7 stated that the pharmacy will perform the medication reconcilation for an ED admitted patient if the admission occurs within certain time frames (Monday through Friday 10:30 AM to 8:30 PM and Weekends 12:00 PM to 5:00PM). E#7 stated, "If the admission occurs outside of these hours, it is the nursing staff who will perform the medication reconcilation." E#7 stated that the potential effect of a patient receiving Midodrine for 2 days could be a change in heart rate. E#7 stated, "Every person is different. Some patients may get tachycardia [increased heart rate] and some patients may get bradycardia [decreased heart rate]." E#7 stated that the potential effect of not getting Keppra for 2 days would be a lower seizure threshold [increased susceptibility to seizures].