HospitalInspections.org

Based on interview and record review, the facility failed to protect patient's rights by failure to review daily medication orders to assure correct medication administration and medication end dates for 1 of 1 patients (Patient #1), failed to administer tube feedings according to written orders for 1 of 1 patients (Patient #1), failed to administer medications via correct route for 1 of 1 patients (Patient #1), and failed to report a safety event within 24 hours of an abuse allegation per policy for 1 of 1 patients (Patient #11) in a sample of 11 records reviewed.

Findings:

The facility failed to review daily medication orders to assure correct medication administration and medication end dates. See tag A-0144

The facility failed to administer tube feedings according to written orders. See tag A-0144

The facility failed to administer medications via correct route. See tag A-0144

The facility failed to report a safety event within 24 hours of an abuse allegation - per facility policy. See tag A-0145

Based on interview and record review, the facility failed to provide a safe setting by failure to review daily medication orders to assure correct medication administration and medication end dates for 1 of 1 patients (Patient #1), failed to administer tube feedings according to written orders for 1 of 1 patients (Patient #1), and failed to administer medications via correct route for 1 of 1 patients (Patient #1) in a sample of 11 records reviewed.

Findings Include:

A review of facility policy, titled "Medication Reconciliation Policy", last reviewed 08/24/2022, revealed: "...Purpose: To provide safety measures that will minimize patient risk from inadvertent omission or continuation of medication across the continuum of care. The reconciliation process is used to increase the accuracy in medications that patients receive by identifying duplications, omissions, dosing errors or drug interactions...Policy:...every patient who will receive a medication will have their medication list reconciled initially, at each change in level of care, and at discharge, which is consistent with the Joint Commission National Patient Safety Goals...B. Transfer medication Reconciliation: 1. Medication reconciliation must occur whenever a patient is transferred (e.g., transfer to another level of care). 2. The prescribing provider will review both the medication history and the current inpatient medication list and will indicate if each of the medication is to continue or to be held. a. The pharmacist will handle the transfer medication list as medication orders per policy..."

Patient #1 was admitted on 11/13/2023 for Shortness of Breath. Per medical review, Patient #1 was prescribed Dexamethasone 4mg QID (4 times daily) on an outpatient basis. Medication Reconciliation was completed on admission per policy, and the orders revealed Dexamethasone 4mg QID was continued and administered as ordered from 11/13/2023 at 10:11 PM until the last dose administered on 11/22/2023 at 5:07 PM.
Further review of the medical record revealed discharge for Patient #1 was ordered on 11/22/2023. Discharge medication reconciliation was completed per policy, which revealed continuation of the Dexamethasone 4mg QID was indicated on an outpatient basis. Review indicated further doses of the Dexamethasone were not present on the MAR once the discharge order was placed. Patient #1's discharge was cancelled on 11/22/2023 due to a decline in condition. A consequent Medication Reconciliation was not completed per policy when Patient #1's discharge was cancelled.
As a result, Patient #1 did not receive Dexamethasone from 11/22/2023 at 5:07 PM until 11/24/2023 at 5:09 PM (7 missed doses).

During an interview with Executive Director of Patient Safety/Patient Relations F on 04/16/2024 at 1:00 PM, when asked about Patient (Pt.) #1's missed Dexamethasone medication during her 11/13/2023 admission and the complaint investigation results, Executive Director F stated "Not sure who the error of omission fell on." The admitting physician "resumed" the steroid order from an outside provider with an original stop date of 11/22/2023, the home steroid prescription was for tapering. Pt. #1 was a discharge on 11/22/2023 but then was re-admitted the night of 11/22/2023 due to "weakness/hypoxia." Discharge order was canceled on 11/22/2023 after the discharge med reconciliation had been done, "the discharge med reconciliation had steroids being resumed at discharge, but the steroid fell off the list and not put back on the med list; deviation was the med reconciliation."

During an interview with Pharmacy Director G on 04/16/2024 at 2:20 PM, Director G stated that Pt. #1's discharge status changed and remained admitted, the steroid medication fell off the medication list. "Med reconciliation was done on admission with 36 doses with a stop date of 11/22/2023. There was a 'gap' with the nurse who stopped the med for a day or 2, there was team miscommunication; there was an order that was discontinued due to an expiration date."

During an interview with Medication Safety Officer H on 04/16/2024 at 2:24 PM, Officer H stated the pharmacists round every morning on the units and meds are reviewed during daily rounding, the steroid medication error "wasn't caught that next morning, that should have been traditionally been caught the next morning; it was caught on 11/24/2023 by Pharmacist [I]. Previous dose ended on 11/22/2023 at 12:59 PM, EPIC (electronic health record) dropped the steroid off the MAR (medication administration record)."

During an interview with Pharmacy Director G on 04/16/2024 at 2:26 PM, Director G stated the steroid was ordered on admission as an "outpatient retail prescription, the order was accepted as is" and the team accepted the transfer prescription from home med list with a discontinue date. A medication reconciliation was done, but Dexamethasone (steroid) was ordered with an end date, Neurosurgery Outpatient was prescribing the Dexamethasone every 2 weeks and patient was to follow-up in 2 weeks for steroid refills. Director G stated, "We should be looking closer at end dates that don't appear to be relevant."

During an interview with Pharmacist I on 04/18/2024 at 12:00 PM, when asked if she recalled rounding on the 7CFAC unit on the morning of 11/23/2023, Pharmacist I stated "We do not round on holidays or weekends unless the Attending Physician requests." Pharmacist I could not recall if she was the pharmacist who rounded the next day (11/24/2023) on the 7CFAC unit. The missed steroid medication wasn't caught on rounding on the 24th, "it was caught due to a family member asking about the steroid." The steroid fell off the MAR, "I've caught this a couple of times, the end date is not flagging us on end dates on admission reconciliation."

During an interview with Quality & Regulatory Coordinator B on 04/17/2024 at 1:00 PM, Coordinator B stated that Medication Safety Officer H confirmed "there are no care coordinator rounds on holidays, there is an 'ad-hoc' (on-demand) for CCR's (care coordinator rounds) as needed."

During an interview with Oncologist K on 04/17/2024 at 10:55 AM, when asked about the effect on Pt. #1 regarding the missed steroid doses, Oncologist K stated that there was "weakness noted" on Pt. #1's exams but this was a "temporary effect, there may have been a sharper downward trajectory until the steroid took affect again." Oncologist K confirmed that Pt. #1 should have resumed taking Dexamethasone after discharge was canceled on 11/22/2023.


- Tube Feeding Findings:

A review of facility policy, titled "...Food and Nutrition Services Enteral Feeding (Tube Feeding) Policy", last reviewed 04/10/2024, revealed: "..Purpose: To define the enteral feeding process for patient in the inpatient environment...1. All enteral feeding orders are ordered by completing the IP (inpatient) Enteral Nutrition order set in the electronic health record (EHR)...6. Nursing will: a. Verify and document feeding tube position with each assessment as needed..."

A review of Pt. #1's medical record, revealed:
- 04/12/2023 at 10:59 PM: placement of GJT (gastrojejunostomy tube with a G portion inserted into the stomach and J portion inserted into the small intestine).
- 04/24/2023 at 10:30 AM: Standing order placed by NP II for Continuous PEG (Percutaneous Endoscopic Gastrostomy - a tube to the stomach) feeds, initial delivery rate 195mL/hour with goal delivery rate of 390mL/hour (cycled feedings 0000, 0600, 1200, 1800).
- 04/24/2023 at 11:38 AM: Medical Nutrition Therapy Progress Note by Dietician JJ, "Enteral Nutrition Regimen: Pt (patient) tolerating continuous EN (Enteral) at goal of Osmolite 1.2 @ 65 mL/h via PEG + 1 Prosource daily...Plan to transition to intermittent feedings...goal 390 mL 4 times per day at 0600 (6:00 AM), 1200 (12:00 PM), 1800 (6:00 PM), 0000 (12:00 AM)...RN to assess for tolerance run first feeding over two hours at 195 ml/hr."
- 04/24/2023 at 12:49 PM: Patient received first intermittent (bolus) feeding of Osmolite 1.2 (full strength) at 195 mL/hr via J-port (tube to the small intestine).
- 04/24/2023 at 5:19 PM: Patient received intermittent (bolus) feeding of Osmolite 1.2 at 390 mL/hr via J-port.
- 04/25/2023 at 12:26 PM: Patient received intermittent (bolus) feeding of Osmolite 1.2 at 195 mL/hr via J-port.
- 04/25/2023 at 2:12 PM: Medical Nutrition Therapy Progress Note by Dietician FF, "Per discussion with provider, patient currently receiving bolus feeds via J-port while enteral nutrition order specifies G-tube (PEG). Loose stools and discomfort with feeds likely (due to) using wrong port of tube."

During an interview with Oncologist K on 04/17/2024 at 10:55 AM, when asked about intermittent/bolus feedings via J tube instead of via G tube portion, Oncologist K stated, "J tube was probably an error."


- Medication Administration Route Findings:

A review of Pt. #1's medical record, revealed:
- 02/05/2024 at 9:18 PM: Patient admitted to the Emergency Department (ED) via ambulance for "Shortness of Breath" and husband reports "increased oxygen requirement, and inability to tolerate GJ (G-tube/J-tube) medications/feeds over the past few days
- 02/06/2024 at 9:59 AM: Progress Note by Physician MM, "GJ tube evaluated in fluoro with concern for aspirating tube feeds. Positioned properly and functioning well...all medications through J portion of tube except PPI [Pantoprazole] (to be given through G tube portion).
- 02/11/2024 at 9:00 AM: Medication order written for Pantoprazole (PPI) oral suspension 40mg daily via JT (J tube) route.
- 02/12/2024 at 10:00 AM: Pantoprazole oral suspension 40mg given via G tube.

During an interview with Executive Director of Patient Safety/Patient Relations F on 04/16/2024 at 1:00 PM, Executive Director F stated that "EPIC (electronic health record) function does not flag when multiple routes are being used for a patient."

Based on record review and interview, the facility staff failed to ensure that patients are free from abuse by failure to report a safety event within 24 hours of an abuse allegation per facility policy for 1 of 1 patients (Patient #11) in a sample of 11 records reviewed.

Findings Include:

A review of policy, titled "...Caregiver Misconduct Policy" last reviewed 08/09/2022, revealed: "...I. Any known or suspected report of caregiver misconduct will be investigated and a safety event report generated..."

A review of policy, titled "...Patient Safety Serious Safety Event Management Policy" last reviewed 04/11/2024, revealed: "...Submit a Safety Event report in our Safety Reporting system. Staff must enter the occurrence using the event reporting software within 24 hours of the occurrence or upon becoming aware of an event..."

During an interview with Pt. #11 (at bedside) on 04/18/2024 at 1:58 PM, Pt. #11 stated that there was a male in her room a few days ago that "man-handled" her and grabbed her "with force" when she was trying to get out of bed to use the bathroom. When asked if she had reported the incident to anyone, Pt. #11 stated, "There was someone that came in to talk to me after the incident" but could not recall who it was.

Review of Patient (Pt.) #11's medical record, revealed: Pt #11 was 81-year-old female admitted to the hospital on 03/24/2024 with chief complaint of shortness of breath; Pt #11 was a current inpatient on the Oncology 8CFAC unit at the time of survey. Per Pt #11's medical record, Pt #11 had a history of lung adenocarcinoma, COPD and chronic respiratory failure. Patient was fall risk with a bed alarm at time of survey.

A review of Pt. #11's Nursing skin assessments documented from 04/16/2024 - 04/18/2024 revealed no new wounds and/or bruising.

On 04/16/2024 at 5:33 AM, Registered Nurse (RN) III's note, revealed: "Pt set off bed alarm attempting to get out of bed without assistance and writer responded to alarm and attempted to assist pt back to bed to prevent fall. Pt became aggressive and yelling/swearing at writer and significant other in room and not following instructions to stay safe. CNA (JJJ) came to room to try to assist and pt remained belligerent with staff. Contacted charge nurse (LLL) to assist and pt was speaking to family in [sic] personal phone and was able to place pt on bed pan to void/bm (bowel movement) and then return to bed."

A review of the text message from the Nurse KKK to Manager GGG (sent on 04/16/2024 at 9:31 AM), revealed: "...I told Charge Nurse [LLL] about a minor situation that happened last night but wanted to fill you in as well in case you wanted to round w the patient/family. Room 18 felt RN [III] and CNA [JJJ] were "man handling" her to stay in bed when she set off the bed alarm (she is a heavy 2 assist/hoyer). I was able to diffuse the situation, but she did call her son and said a security guard was manhandling her and forcing her to do things (stay in bed). I explained he was a nurse but she was still upset so I just wanted to make sure you were in the loop about it. I also put a flag for no males on her bc (because) I think she has been that way in the past and am wondering if that could have made the situation worse."

As of survey exit on 04/18/2024, there was no evidence found that a safety event report regarding Patient #11's allegation of abuse was entered, per facility policy.

During an interview with 8CFAC Nurse Manager GGG on 04/18/2024 at 2:28 PM, Manager GGG stated that the incident happened on the evening shift on 04/15/2024 - she was made aware via a text message from Nurse [KKK] on 04/16/2024 at 9:31 AM. Manager GGG went in to talk to Pt. #11 after the incident (with pt's husband at bedside) for her recollection of the event, Pt. #11 set off her bed alarm and was a hoyer lift, she said that RN III came in said "you have to swing your legs in" and she said "no, I have to go to the bathroom. RN [III] held her shoulders on both sides to prevent her from getting up, the husband was asleep and then awoke mid-incident. Husband said another CNA [JJJ] got her back to bed and they were 'tossing her back and forth in bed'. Patient shut her husband down and said he was in the bathroom at the time." Manager GGG stated s/he talked with RN III on the morning of 04/17/2024 about the event. RN III stated that Pt. #11 was "belligerent and cussing", her alarm was going off, she was not safe to walk and needed to use bedpan. CNA JJJ was called to help, got her back to bed and also called Charge Nurse LLL to help. When Manager GGG asked RN III if he put his hands on Pt. #11's shoulders he said, "I think so." When asked if Manager GGG had submitted a Safety Event through their internal reporting system, Manager GGG stated that she was still waiting to get a hold of CNA JJJ who was a witness to the event and then she was going to put an event into the facility's "Reli" reporting system. When asked if RN III has worked with Pt. #11 or other patients on the floor since the reported event, Manager GGG stated that RN III hasn't worked with Pt. #11 since the event and has worked another night shift on the floor since that event.

During an interview with 8CFAC Director HHH on 04/18/2024 at 3:18 PM, when asked if she was aware of the incident and/or the investigation regarding Pt. #11, Director HHH stated that she was not aware and that her staff prepare the investigation first and then they come to her.

During an interview with Human Resources (HR) MMM on 04/18/2024 at 4:20 PM, when asked if an allegation of man-handling would be reported as physical abuse, HR MMM stated "Yes."