HospitalInspections.org

The Hospital was out of compliance for the Condition of Participation for Nursing Services.

Findings included:

Based on record review and interviews, the Hospital failed to ensure physician orders (medication administration) were followed for one Patient (#1) out of a total sample of ten patients.

Cross Reference:

482.23(c) - Standard: Preparation and Administration of Drugs (405)

Based on records reviewed and interviews, the Hospital failed to ensure intravenous (IV) Levophed (a vasoconstrictive medication used to manage low blood pressure) was administered as ordered for 1 Patient (#1) out of a total sample of 10 patients.  

Findings included: 

Review of the Hospital policy titled "Medication Use (Ordering, Transcription, and Administration of Medications), revised 1/2024, indicated: 

-Verify the five rights of medication (right patient, medication, dose, route, and frequency) administration against the electronic medication administration record (e-MAR). 

-Scan medications and administer, assisting the patient as necessary. 

-If the medication was omitted, held for parameters or refused, document the reason it was not given on the e-MAR prior to saving. Notify the provider if the patient is refusing the medication. 

Patient #1 was admitted to the Hospital on 3/11/25 for weakness, difficulty ambulating and abnormal labs. 

Review of Patient #1 ' s medical record indicated that on 3/31/25, Patient #1 had a Magnetic resonance cholangiopancreatography (MRCP- an imaging test used to diagnose problems with the liver, pancreas, gallbladder, pancreatic ducts and bile ducts) which identified large volume ascites (a condition in which fluid collects in abdominal spaces), and a mass at the pancreatic tail concerning for primary malignancy with additional hepatic lesions suspected to be metastatic disease burden. On 4/7/25, Patient #1 was observed to have bradycardia (low heart rate) and a rapid response was called. During the rapid response, Patient #1 became pulseless, was not responsive and compressions were started. Patient #1 was intubated and after four rounds of cardiopulmonary resuscitation (CPR), return of spontaneous circulation (ROSC) was achieved. Patient #1 was transferred to the Intensive Care Unit (ICU) and on 4/8/25, Patient #1 ' s code status was changed to Do Not Attempt Resuscitation (DNAR) with no further escalation of care. 

On 4/8/25, Patient #1 was ordered to receive continuous intravenous (IV) Norepinephrine (Levophed- a vasoconstrictive medication used to treat life threatening low blood pressure) 8 milligrams (mg)/ 250 milliliters (ml) at a rate of 50.1 ml/hour. Review of Patient #1 ' s Medication Administration Report (MAR) indicated that on 4/12/25 at 7:37 P.M., Registered Nurse (RN)#1 hung a new 250ml bag of Levophed at a rate of 50.1ml/hour. Further review of Patient #1 ' s medical record indicated no additional bags of Levophed were administered after the bag at 7:37 P.M. was hung. On 4/13/25 at 1:00 A.M., Patient #1 ' s blood pressure was 42/16 and his/her pulse was 42. On 4/13/25, at 1:26 A.M., Patient #1 was pronounced dead. 

During an interview on 5/2/25 at 11:30 A.M., Registered Nurse (RN) #1 said that she cared for Patient #1 during the overnight shift on 4/12/25-4/13/25. RN#1 said that Patient #1 began to decompensate around midnight on 4/13/25 and would have runs of ventricular tachycardia (an abnormal heart rhythm) and then revert to normal sinus rhythm. She said she notified the Nurse Practitioner of this and said another nurse came into Patient #1 ' s room to assist her during this time. RN #1 said she was in the room with Patient #1 continuously after he/she started to decompensate until Patient #1 expired. She said that she couldn ' t remember hanging the bag of Levophed or how often the bag was changed during her shift. RN#1 said a 250ml bag would last for about 5 hours at a rate of 50.1 ml/hour. RN#1 said the medical record documentation shows Patient #1 ' s Levophed bag ran dry, but said she didn ' t recall the bag running dry while she was in the room. RN#1 said that when an IV bag is hung, the nurse will scan the patient ' s identification band and then the bag and it will automatically populate in the patient ' s record with the date and time the medication was hung. RN #1 said medications should be administered as ordered and if a medication isn ' t administered, it should be documented in the medical record with the reason why it wasn ' t administered.  

During an interview on 5/2/25 at 1:28 P.M., the Chief Nursing Officer said that the Hospital investigation into this event was ongoing but indicated that Patient #1 ' s Levophed would have run dry at 12:36 A.M. on 4/13/25 and that Registered Nurse (RN) #1 did not hang another bag in accordance with physician orders. 

The Hospital failed to ensure IV Levophed was administered to Patient #1 as ordered.