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Based on record review and interview, the registered nurse failed to ensure the effective supervision and evaluation of care provided to 1 of 6 sampled patients (#5) as evidenced by failing to ensure stat orders for laboratory testing were obtained and resulted in accordance with the hospital's policy/procedure and by failing to ensure the ordering practitioner was notified of the hospital's failure to obtain and result the stat laboratory order in a timely manner. Findings:

Patient #5: Medical record review revealed Patient #5 was admitted to the hospital on 9/24/11 with diagnoses that included Renal Failure and A/V shunt failure. Review of the medical record revealed an order written by S20 dated 9/24/11 at 12:15 p.m. that read "STAT Renal Panel, CBC, PT/PTT/INR". Review of the laboratory reports in the medical record revealed the blood sample was collected on 9/24/11 at 12:42 p.m. with no indication of the time the STAT Renal Panel, CBC, PT/PTT/INR were resulted and available for review.

The hospital's policy/procedure titled "Medical Order Priorities" "#MD-0500-0040" was reviewed. The policy/procedure documents the purpose as "To establish and define priorities for ordering and carrying out medical orders at North Oaks Health System". The policy/procedure documents stat orders as "These orders are to be keyed in as STAT. Initiate a response within 5 minutes. Results in 45 minutes to one hour (where applicable)".

S19 (Laboratory Director) was interviewed on 9/26/11 at 11:10 a.m. S19 reviewed data from the hospital's laboratory network and indicated there was a delay in the processing of the stat lab work (STAT Renal Panel, CBC, PT/PTT/INR) for Patient #5. S19 indicated that the PT was not resulted until 1:27 p.m. on 9/24/11, the PTT was not resulted until 2:00 p.m. on 9/24/11, and the Renal Panel was not resulted until 3:15 p.m. on 9/24/11. S19 reported the STAT Renal Panel, CBC, PT/PTT/INR should have been resulted and available for review within one hour of being ordered by the physician.

Further review of Patient #5's medical record revealed no evidence to indicate the ordering practitioner (S20) was notified of the hospital's delay in obtaining and resulting the laboratory tests (STAT Renal Panel, CBC, PT/PTT/INR) as ordered.

S20 (attending physician) was interviewed on 9/26/11 at 11:20 a.m. When asked if he was notified of the delay in obtaining and resulting the STAT Renal Panel, CBC, PT/PTT/INR for Patient #5, S20 reported that he was not notified of the delay. When asked if he has any concerns relating to the hospital's ability to obtain and result laboratory tests in a timely manner, S20 replied yes and indicated that he has had other issues relating to the hospital's processing of laboratory tests in a timely manner.

Based on record review and interviews the registered nurse failed to administer an extended release antihypertensive medication according to acceptable standards of practice by crushing an extended release antihypertensive medication and administering the medication to a patient for 1 out of 6 sample patients reviewed (Patient #3).
Findings:

Patient #3 was an 80 year old male admitted to the hospital on 07/20/11 with confusion and encephalitis. His other diagnoses included: pneumonia, peripheral vascular disease, hypertension, respiratory failure with pleural effusion, and chronic Atrial fibrillation.

Review of the medical record revealed Patient #3 was NPO (nothing by mouth) and had a nasal gastric or an oral gastric tube on 07/21/11 through 07/26/11.

Review of Patient #3's Medication Reorder Form dated 07/20/11 revealed an order for Metoprolol 50 mg (milligrams) tablet CR (extended release tablet) 24 HR (hours) once daily. DO NOT CRUSH.

Review of the MAR for 07/22/11 to 07/25/11 revealed an order for Metoprolol Succ(Succinate) 50 mg CR 24h (Toprol XL) Dose: 50 mg/1 tablet CR 24 H (oral) with instructions written on the MAR stating DO NOT CRUSH.

An interview was conducted with S5RN on 09/21/11 at 2:45 p.m. She stated while she took care of the patient she crushed the Toprol medication and administered the medication to the patient. She stated she took care of the patient 7 a.m. to 7 p.m. on 07/25/11, 07/26/11 and 07/27/11.

An interview was conducted with S4Supervisor of ICU on 09/21/11 at 3 p.m. He reported that Metoprolol CR (Toprol) should not have been crushed and put down the nasal gastric or oral gastric tube because the medication was timed release. The nurse should have called the physician and got the order changed to a liquid form of the medication or another medication that could be crushed. With review of the medical chart, he stated the Toprol was crushed once the patient was intubated until he was extubated from the ventilator. He was intubated from on 07/21/11 and extubated on 07/26/11.

An interview was conducted with S13MD on 09/22/11 at 11 a.m. She reported she was the hospitalist that took care of the patient until 08/02/11 when the family requested another physician to take care of Patient #3. When questioned if she was aware the nurses were crushing the patient's extended release antihypertensive medication, Toprol, she stated she was not aware the medication was being crushed.

An interview was conducted with S16Pharmacy Director on 09/21/11 at 11 a.m. She reported the adverse side effects of crushing an extended release antihypertensive medication could be hypotension (low blood pressure) soon after administration and hypertension in the evening (if medication was administered in the morning).

Review of the hospital's policy for Medication Administration, policy # NRMC 0080-0100 revealed in part, "...D. Administration of Medication Via NG (nasal gastric)/gastrostomy tubes: No medication will be crushed and given via tubes unless ordered by M.D. When medications are ordered "per tube", the pharmacy will dispense liquid forms whenever available."

Based on record review and interview, the hospital failed to notify a physician of chromium being in Total Parenteral Nutrition (TPN) of a patient with an allergy listed to Potassium Dichromate in his medical record for 1 out of 6 sample patients reviewed (Patient #3). Findings:

Patient #3 was an 80 year old male admitted to the hospital on 07/20/11 with confusion and encephalitis. His other diagnoses included: pneumonia, peripheral vascular disease, hypertension, respiratory failure with pleural effusion, and chronic Atrial fibrillation.

Review of the Medication Reorder Form dated 07/20/11 and timed 9:08 p.m. revealed under the section labeled allergies: "Potassium dichromate/Penicillin analogues/tape."

Review of the top portion of Patient #3's MARs (Medication Administration Record) during the patient's hospital stay, his allergies were listed as "Latex/Potassium/Penicillin/tape."

An interview was conducted with S16Pharmacy Director on 09/23/11 at 2 p.m. She reported when the admission nurse does the Medication Reorder Form, the pharmacist goes through all the medications prior to the first administration of a medication. In the pharmacy's computer software, there is a drop down box to select an allergy. If it is an unusual allergy, the pharmacist may have to free text (type in) an allergy in the program if it is not included in product file or drop down box. She went on to say that Potassium dichromate was a rare allergy and had to be free texted into the computer, meaning the pharmacist had to go through all the medication his or herself to determine if a medication had potassium dichromate in the medication. S16Pharmacy reported she had no documentation that a pharmacist went through all the medications and the software would not have flagged an allergy for potassium dichromate since it had to be free texted into the system. If an allergy would have flagged in the system for the potassium dichromate, the pharmacist would have had to then call the nurse to verify the allergy and/or get more information on the patient's allergy. The next step would have been to call the doctor to see if the benefits of the medications outweighed the potential adverse effects of the medication on the patient.

Review of the Parenteral Nutrition Solution order form revealed TPN (Total Patenteral Nutrition) was ordered on 08/05/11 with MVI (multivitamins) and trace elements to the first liter daily at 80 cc/hr (cubic centimeters per hour). Review of the Verbal Telephone Order Sheet dated 08/07/11 at 1530 (3:30 p.m.) revealed an order to d/c (discontinue) TPN and lipids.

An interview was conducted with S16Director of Pharmacy and S15Pharmaist on 09/26/11 at 9 a.m. They reported with review of Patient #3's medications and intravenous fluids, the trace elements in the TPN contained Chromium. The patient received the trace elements in his TPN on the following days, 08/05/11, 08/06/11, and 08/07/11. They went on to say this was a rare allergy and the pharmacy had no specific policy for the manually checking of allergies not in the software system. They reported they found no documentation that the pharmacist notified the physician or nurse that the TPN contained chromium.

Review of the insert for the trace elements added to the TPN revealed in part, " ...each ml (milliliter) contains ...Chromic Chloride Hexahydrate 51.3 mcg (microgram) (equivalent to 10 mcg Chromium) ...Chromium (trivalent) is part of glucose tolerance factor, and activator of insulin-mediated reactions. Chromium helps to maintain normal glucose metabolism and peripheral nerve function."

Review of the hospital's policy on Allergy Management, policy # RXMC-0040-0010 revealed in part, "...1. When pharmacy receives a medication or food allergy on a patient, the pharmacist will enter the allergy into the patient's profile in the allergy field. 2. Allergies transfer from visit to visit and need to be verified if there is a discrepancy. If an allergy on the patient's chart conflicts with an allergy that has already been entered, the pharmacist will clarify that allergy with the nurse and/or patient. If the patient states that they are not allergic to the entered allergy, the allergies will be removed and pharmacy will update the allergy profile with a reason. 3. If the pharmacist contacts the physician about an allergy and the physician can confirm that the patient is not allergic to the perceived medication then an order must be written by the physician to remove an allergy from a patient's profile. The pharmacist will document the out come of the intervention in pharmacy intervention system. 4. If an order is written for a specific medication and the patient is allergic to the medication or class of medication, the physician will be notified and an intervention will be documented. In the event that the physician allows the patient to use the medication, an order must be written to state that the medication is able to be used. Also, a note on the MAR must indicate that the medication can be used..."

Review of the Physician Orders for 08/08/11 at 5 p.m. revealed blood chromium level, urine chromium level.

Review of the Lab results collected 08/09/11 and reported 08/19/11 revealed Chromium, serum 2.5 mcg/l (micrograms per liter). The reference range was 1.4 or less. Review of the results of the Chromium, random urine collected 08/09/11 and reported 08/12/11 revealed the result as 3.2 ng/ml (nanagrams/milliliter) with a reference range of less than 2.