HospitalInspections.org

The Condition of Participation for Medical Staff has not been met.
Based on clinical record review and staff interview for 1 of 12 sampled patients reviewed for medication management, Patient #33, the facility failed to ensure the patient received appropriate medical management of a critical anti-seizure medication and failed to ensure that blood levels for the critical medication were monitored.


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Based on a review of clinical records and staff interview, for one of twelve (12) patients reviewed for antiseizure medication (Patient #33) the hospital failed to ensure that numerous medical staff that assumed the care of the patient, effectively managed the patient's critical medication during hospitalization. The finding includes:


Patient #33 was admitted to the Emergency Department (ED) on 3/18/17 for increased lethargy. The admission history and physical dated 3/18/17 identified the patient had a history of seizure disorder and was receiving Depakote Sprinkles 50 0mg twice a day prior to admission. A physician History and Physical note dated 3/18/17 identified Patient #33 had an altered mental status/possible Urinary Tract Infection (UTI) and was started on Intravenous (IV) antibiotics and IV hydration. Review of admission laboratory blood work dated 3/18/17 identified Patient #33's Valproic acid (Depakote) level was 65 (norm 50-100ug/mL). Patient #33 was admitted for in-patient care from 3/19/17 until discharge on 3/28/17.


Review of Patient #33's medication administration record dated from 3/18/17 to 3/28/17 identified that the patient did not receive any Depakote or similar anti-seizure medication during the 10 day hospitalization.

Review of Patient #33's clinical record dated from 3/19/17 to 3/28/17 identified that no additional Valproic acid blood levels were requested or drawn.

Review of the clinical record identified that Patient #33 was under the care of 3 or more physicians and/or Advanced Practice Registered Nurses (APRN) from 3/19/17 to 3/28/17.

Review of Patient # 33's discharge paperwork dated 3/28/17 identified Patient #33's discharge medications included Depakote Sprinkles 500mg twice a day.

Interview with MD #7 on 1/10/19 at 8:50AM stated when Patient #33 was admitted to the ED, he/she had an altered mental status and he felt it was not safe for the patient to take anything by mouth. MD #7 held Patient #33's medications, including the Depakote Sprinkles on the night of 3/18/17. MD #7 further stated that he did not document in the clinical record that he held Patient #33's Depakote Sprinkles and was not involved in Patient #33's care after being admitted for in-patient care.


Interview with MD #8 on 1/15/19 at 11:30AM stated she assessed Patient #33 on 3/19/17 and 3/20/17. MD #8 stated she reviewed the patient's history including medications the patient was taking prior to the hospital admission. MD #8 stated that when she assessed the patient, the patient was somnolent so she held the seizure medication (Depakote). MD #8 identified that she did not document in the clinical record that the Depakote continued to be held or why no Depakote level was ordered. MD #8 was not involved in Patient #33's care after 3/20/17.


Interview with MD #10 on 1/28/19 at 11:30 AM identified that he cared for Patient #33 on 3/21/17. MD #10 reviewed Patient #33's medications, knew the patient's anti-seizure medication was on hold, and continued to hold the medication due to continued altered mental status. MD #10 did not document in the clinical record that the Depakote continued to be held. MD #10 was not involved in the patient's care after 3/21/17.


Interview with MD #9 on 1/28/19 at 10:45AM stated that he took care of Patient #33 on 3/22/17 and 3/23/17. MD #9 reviewed Patient #33's history prior to admission including the patient's medications. MD #9 stated that she was focused on Patient #33's active issues of pneumonia and hypertension and did not have any recollection of the patient being on Depakote. MD #9 further stated that she did not know why the patient was not started back on Depakote Sprinkles when the patient's health continued to improve. MD #9 was not involved in the patient's care after 3/23/17.


Review of Patient #33's clinical record between 3/24/17 and 3/2/17 identified Patient #33 was seen by multiple practitioners who were unavailable for interview.


Interview with MD #11 on 1/7/19 at 2:00 PM stated that he took care of Patient #33 on 3/28/17, the day of discharge. MD #11 reviewed Patient #33's home medication and included the Depakote on the discharge paperwork. MD #11 was not aware that Patient #33 did not receive Depakote during admission.


Patient #33 was readmitted to the hospital ED on 3/28/17 at 8:35PM. Review of the ED admission documentation identified Patient #33 arrived with prolonged seizure activity (status epilepticus) and arrived actively seizing as the paramedic was medicating the patient with a second dose of Versed. Patient #33 was then assessed as postictal (altered state of consciousness after an epileptic seizure). The clinical record identified that Patient #33 was discharged today (3/28/17) from the hospital and now was re-admitted for prolonged seizure activity lasting approximately 10 minutes. Patient #33 arrived unresponsive to painful or verbal stimuli. Documentation identified that Patient #33 was supposed to be on Depakote Sprinkles but the Valproic acid level was less then therapeutic at this time. Review of the Valproic acid level dated 3/28/17 at 9:37PM identified the level was 3 (norm 50-100 ug/mL).


While in the ED, Patient #33 was treated with multiple medications including Versed on admission. An ED observation note dated 3/29/17 identified that at 1:20AM Patient #33 was noted to have recurrent seizure activity. Blood gases were drawn that showed significant acute respiratory acidosis. Patient #33 was intubated related to the blood gas levels and the need for sedation to treat the seizures. Despite treatment efforts, Patient #33 was placed on comfort care and expired on 4/11/17.


Interview with the Accreditation Regulatory Specialist on 12/17/18 at 1:45PM and review of Pt # 33's clinical record identified that although Pt #33's admission paperwork dated 3/18/17 identified the patient was on Depakote Sprinkles 500mg twice a day, the clinical record lacked any documentation of why the patient did not receive the seizure medication during the 10 day admission. The Accreditation Regulatory Specialist stated she spoke to a pharmacist who confirmed that no anti-seizure medications was ordered for Patient #33 and that Patient #33 did not receive anti-seizure medication while hospitalized from 3/17/17 through 3/28/17.


Interview with the Chief Medical Officer on 1/31/19 at 12:30 PM identified that prior to this investigation of Patient #33's medical care, the hospital did not have a policy or formalized process to ensure that home medications placed on hold were communicated between practitioners. Subsequent to investigator inquiry, the medical staff enhanced their practitioner to practitioner hand-off of a patient's care to include critical medication status if a medication is placed on hold. In addition, the hospital will be enhancing the computerized medical record to identify critical medications that are on hold or other critical medication information necessary for practitioner to practitioner hand-off of a patient's care.