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Based on a review of medical records, staff interviews, and facility policies and procedures, it was determined that the facility failed to take measures necessary to ensure the safety of one (#1) of ten (10) sampled patients.
Findings were:

Review of Patient #1's medical record revealed that Patient #1 presented to the facility's Emergency Department (ED) with a potassium level of 10.5 (normal range of potassium is 3.5 - 5), was seen and admitted as an in-patient on 01/18/17 with a diagnosis of hyperkalemia (elevated potassium in the blood).

Review of the facility policy, "Critical Results Notification using the Critical Result Notification PowerForm in EeMR", last reviewed 07/02/15, revealed that staff members of diagnostic areas are responsible for identifying results within the critical ranges for individual patients and reporting these results to a licensed caregiver responsible for the patient's care within a reasonable time frame. Each area establishes an appropriate procedure for documenting the date, time, name of reporting staff, name of licensed caregiver receiving the report, and the results reported from its area. Further review revealed that persons receiving results will read back and verify patient identifiers and critical value(s).

Review of the facility's policy entitled "Critical Value Reporting", approved 02/07/14, revealed that critical results are reported directly to a responsible, licensed caregiver immediately upon identification of the value. Telephonic reporting of critical test results is verified by having the person receiving the test result "read back" the test result. Notification of the appropriate clinical caregiver for all critical values is documented in the laboratory computer system (Cerner). Documentation includes the date, time, responsible laboratory individual, the person notified, and test results. Further review of the policy revealed that the technologist will ask the caregiver to read back and verify the full name of the patient, medical record number, the test and name and result. The technologist will document the receiver's information as well as the time the result was reported in Cerner as a chartable comment using the "CRIT" template.

Review of the facility's policy entitled "Critical Diagnostic Test Value and Procedure Result Reporting", last reviewed 08/12/14, revealed that critical results/values are to be expeditiously communicated to the responsible care provider in order to ensure timely and appropriate follow-up care and treatment.

Review of the facility's policy entitled "Medication Administration", last reviewed 07/29/14, revealed that the Bar Code Medication Administration is utilized at EHC Hospitals to maximize patient safety and to ensure the five rights: right patient, right medication, right dose, right route and the right time.

Review of Patient #1's laboratory results dated 01/26/17 revealed the following potassium results on 01/26/17:

at 4:00 a.m. - 4.8,
at 5:30 a.m. - 5.7,
at 7:30 a.m. - 5.9.

Review of the Omnicell Transaction dated 01/26/17 at 4:38 a.m. revealed that RN#6 withdrew forty (40) mEq of Potassium Chloride tablets for Patient #1.

Review of the electronic record via PowerChart revealed that on 01/26/17 at 4:44 a.m. RN #7 administered to Patient #1, forty (40) mEq of potassium chloride PO (by mouth), as ordered by the physician.

Review of the electronic record via PowerChart revealed that on 01/26/17 at 4:58 a.m. RN #7 administered Patient #1, ten (10) mEq of potassium chloride IV (into the vein).

During a phone interview with the Staff #5 (Medical Technologist) on 02/07/17 at 1:05 p.m. in the Administration Swing Office, Staff #5 confirmed that he/she was aware of the incident and stated that the only critical potassium that he/she had called in on 01/26/17, to RN #6 was not for Patient#1 but for another patient.

During a telephone interview with RN #6 on 02/07/17 at 7:50 p.m., RN #6 stated that on 01/26/17 he/she was working as a charge nurse, and assisted other nurses with any problems they may encounter during the shift. RN #6 asserted that he/she was at the desk talking with RN #3 when a call came in from the lab regarding a critical potassium level of 2.4 for Patient #1. RN #6 stated that after receiving lab result of 2.4 potassium for Patient #1, Physician #3 ordered forty (40) mEq of potassium by mouth and two (2) doses of ten (10) mEq of potassium to be given via IV. RN #6 explained that he/she went to the Omni Cell (medication dispensing system) and pulled out the forty (40) mEq of potassium and gave it to Patient #1 via the orogastric (OG - a thin flexible tube inserted down the mouth and into the stomach) tube. Patient #1 further stated that he/she then handed the empty packaging to Patient #1's primary care nurse (RN #7) so that the medication could be scanned. RN #6 stated that shortly thereafter, the respiratory therapist came by with the patient's arterial blood gas (ABG - a test of blood from the artery that measures the amount of certain gases dissolved in the blood) results. RN #6 stated that the results showed that Patient #1 had a potassium level of 4.2. RN #6 stated that he/she then notified the MD #3 of the conflicting lab results. RN #6 stated that MD #3 wanted to continue with the potassium depletion therapy until the new lab results were available. RN #6 further explained that RN #7 went into another patient's room and discovered that the critical potassium level of 2.4 received belonged to that other patient, not Patient #1.

During a telephone interview with RN #7 on 02/08/17 at 12:15 p.m. in the Conference Room, RN #7 acknowledged that he/she was working the 7:00 p.m. - 7:00 a.m. shift on 01/26/17. RN #7 recalled that Patient #1 was in the CCU. RN #7 stated that he/she remembered that either the charge nurse (RN#6), or MD #3 reported that Patient #1 had a critical potassium of 2.4 and that MD #3 ordered potassium for Patient #1 based on the lab result. RN #7 stated that he/she remembered RN #6 giving Patient #1 forty (40) mEq of potassium in the OG tube. RN #6 subsequently handed RN #7 the empty packaging to scan. RN #7 then scanned Patient #1's wristband and medication wrappers. RN #7 stated that he/she then scanned ten (10) mEq of potassium to give via IV per the MD orders. RN #7 further stated that he/she was proceeded to do some charting on his/her two patients and pulled up both patients' labs. It was then that RN #7 discovered that Patient #1 had a potassium level 4.2, and not 2.4 as reported. RN #7 stated that he/she noted his/her other patient's potassium level was 2.4. RN #7 stated that he/she stopped the infusion of potassium, and notified the MD of the error.

Based on review of medical records, facility policies and procedures and staff interviews, it was determined that the facility failed to prepare and administer patient medications according to hospital policies for one (#1) of ten (10) sampled patients.


Findings were:

Review of Patient #1's medical record revealed that Patient #1 presented to the facility's Emergency Department (ED) with a potassium level of 10.5 (normal range of potassium is 3.5 - 5), was seen and admitted as an in-patient on 01/18/17 with a diagnosis of hyperkalemia (elevated potassium in the blood).

Review of the facility policy, "Critical Results Notification using the Critical Result Notification PowerForm in EeMR", last reviewed 07/02/15, revealed that staff members of diagnostic areas are responsible for identifying results within the critical ranges for individual patients and reporting these results to a licensed caregiver responsible for the patient's care within a reasonable time frame. Each area establishes an appropriate procedure for documenting the date, time, name of reporting staff, name of licensed caregiver receiving the report, and the results reported from its area. Further review revealed that persons receiving results will read back and verify patient identifiers and critical value(s).


Review of the facility's policy entitled "Medication Administration", last reviewed 07/29/14, revealed that the Bar Code Medication Administration is utilized at EHC Hospitals to maximize patient safety and to ensure the five rights: right patient, right medication, right dose, right route and the right time.

Review of Patient #1's laboratory results dated 01/26/17 revealed the following potassium results on 01/26/17:

at 4:00 a.m. - 4.8,
at 5:30 a.m. - 5.7,
at 7:30 a.m. - 5.9.

Review of the Omnicell Transaction dated 01/26/17 at 4:38 a.m. revealed that RN#6 withdrew forty (40) mEq of Potassium Chloride tablets for Patient #1.

Review of the electronic record via PowerChart revealed that on 01/26/17 at 4:44 a.m. RN #7 administered to Patient #1, forty (40) mEq of potassium chloride PO (by mouth), as ordered by the physician.

Review of the electronic record via PowerChart revealed that on 01/26/17 at 4:58 a.m. RN #7 administered Patient #1, ten (10) mEq of potassium chloride IV (into the vein).

During a phone interview with the Staff #5 (Medical Technologist) on 02/07/17 at 1:05 p.m. in the Administration Swing Office, Staff #5 confirmed that he/she was aware of the incident and stated that the only critical potassium that he/she had called in on 01/26/17, to RN #6 was not for Patient#1 but for another patient.

During a telephone interview with RN #6 on 02/07/17 at 7:50 p.m., RN #6 stated that on 01/26/17 he/she was working as a charge nurse, and assisted other nurses with any problems they may encounter during the shift. RN #6 asserted that he/she was at the desk talking with RN #3 when a call came in from the lab regarding a critical potassium level of 2.4 for Patient #1. RN #6 stated that after receiving lab result of 2.4 potassium for Patient #1, Physician #3 ordered forty (40) mEq of potassium by mouth and two (2) doses of ten (10) mEq of potassium to be given via IV. RN #6 explained that he/she went to the Omni Cell (medication dispensing system) and pulled out the forty (40) mEq of potassium and gave it to Patient #1 via the orogastric (OG - a thin flexible tube inserted down the mouth and into the stomach) tube. Patient #1 further stated that he/she then handed the empty packaging to Patient #1's primary care nurse (RN #7) so that the medication could be scanned. RN #6 stated that shortly thereafter, the respiratory therapist came by with the patient's arterial blood gas (ABG - a test of blood from the artery that measures the amount of certain gases dissolved in the blood) results. RN #6 stated that the results showed that Patient #1 had a potassium level of 4.2. RN #6 stated that he/she then notified the MD #3 of the conflicting lab results. RN #6 stated that MD #3 wanted to continue with the potassium depletion therapy until the new lab results were available. RN #6 further explained that RN #7 went into another patient's room and discovered that the critical potassium level of 2.4 received belonged to that other patient, not Patient #1.

During a telephone interview with RN #7 on 02/08/17 at 12:15 p.m. in the Conference Room, RN #7 acknowledged that he/she was working the 7:00 p.m. - 7:00 a.m. shift on 01/26/17. RN #7 recalled that Patient #1 was in the CCU. RN #7 stated that he/she remembered that either the charge nurse (RN#6), or MD #3 reported that Patient #1 had a critical potassium of 2.4 and that MD #3 ordered potassium for Patient #1 based on the lab result. RN #7 stated that he/she remembered RN #6 giving Patient #1 forty (40) mEq of potassium in the OG tube. RN #6 subsequently handed RN #7 the empty packaging to scan. RN #7 then scanned Patient #1's wristband and medication wrappers. RN #7 stated that he/she then scanned ten (10) mEq of potassium to give via IV per the MD orders. RN #7 further stated that he/she was proceeded to do some charting on his/her two patients and pulled up both patients' labs. It was then that RN #7 discovered that Patient #1 had a potassium level 4.2, and not 2.4 as reported. RN #7 stated that he/she noted his/her other patient's potassium level was 2.4. RN #7 stated that he/she stopped the infusion of potassium, and notified the MD of the error.

Based on review of patient's medical records, policies and procedures and staff interview, it was determined that the facility failed to provide laboratory services in accordance with facility policy to read back and verify critical lab values for one (one) of ten (10) sampled patients.

Findings were:


Review of Patient #1's medical record revealed that Patient #1 presented to the facility's Emergency Department (ED) with a potassium level of 10.5 (normal range of potassium is 3.5 - 5), was seen and admitted as an in-patient on 01/18/17 with a diagnosis of hyperkalemia (elevated potassium in the blood).

Review of the facility policy, "Critical Results Notification using the Critical Result Notification PowerForm in EeMR", last reviewed 07/02/15, and revealed that staff members of diagnostic areas are responsible for identifying results within the critical ranges for individual patients and reporting these results to a licensed caregiver responsible for the patient's care within a reasonable time frame. Each area establishes an appropriate procedure for documenting the date, time, name of reporting staff, name of licensed caregiver receiving the report, and the results reported from its area. Further review revealed that persons receiving results will read back and verify patient identifiers and critical value(s).

Review of the facility's policy entitled "Critical Value Reporting", approved 02/07/14, revealed that critical results are reported directly to a responsible, licensed caregiver immediately upon identification of the value. Telephonic reporting of critical test results is verified by having the person receiving the test result "read back" the test result. Notification of the appropriate clinical caregiver for all critical values is documented in the laboratory computer system (Cerner). Documentation includes the date, time, responsible laboratory individual, the person notified, and test results. Further review of the policy revealed that the technologist will ask the caregiver to read back and verify the full name of the patient, medical record number, the test and name and result. The technologist will document the receiver's information as well as the time the result was reported in Cerner as a chartable comment using the "CRIT" template.

Review of the facility's policy entitled "Critical Diagnostic Test Value and Procedure Result Reporting", last reviewed 08/12/14, revealed that critical results/values are to be expeditiously communicated to the responsible care provider in order to ensure timely and appropriate follow-up care and treatment

Review of Patient #1's laboratory results dated 01/26/17 revealed the following potassium results on 01/26/17:

at 4:00 a.m. - 4.8,
at 5:30 a.m. - 5.7,
at 7:30 a.m. - 5.9.

Review of the Omnicell Transaction dated 01/26/17 at 4:38 a.m. revealed that RN#6 withdrew forty (40) mEq of Potassium Chloride tablets for Patient #1.

Review of the electronic record via PowerChart revealed that on 01/26/17 at 4:44 a.m. RN #7 administered to Patient #1, forty (40) mEq of potassium chloride PO (by mouth), as ordered by the physician.

Review of the electronic record via PowerChart revealed that on 01/26/17 at 4:58 a.m.

Review of the Clinical Results Notification dated 01/26/17 revealed that RN #6 entered the notes for Patient #1 at 8:22 a.m. Further review revealed that the notification was timed at 4:40 a.m. and that the results were read back and verified by RN #6. The results were reported as critical potassium of 2.4 and reported to MD #3.

Review of the lab results for the RN #7's second patient on 01/26/17, revealed that the patient had a critical lab called to RN #6 at 4:27 a.m. The results indicated a potassium level of 2.4. The computer documented time stamped the notification on 01/26/17 at 4:36 a.m. Staff #5 (Lab Tech) made the notation. Staff #5's noted that the results were called in, and read back and verified by RN #6.

During a phone interview with the Staff #5 (Medical Technologist) on 02/07/17 at 1:05 p.m. in the Administration Swing Office, Staff #5 confirmed that he/she was aware of the incident and stated that the only critical potassium that he/she had called in on 01/26/17, to RN #6 was not for Patient#1 but for another patient.


During a telephone interview with RN #6 on 02/07/17 at 7:50 p.m., RN #6 stated that on 01/26/17 he/she was at the desk talking with RN #3 when a call came in from the lab regarding a critical potassium level of 2.4 for Patient #1.
When asked if RN #6 had repeated back the patient's name, medical record number, room number, and critical value to the lab tech when it was called in, RN #6 stated she had not repeated it all back. RN #6 stated that he/she said the patient's name and the value back as the tech reported the result, but that he/she has never repeated back all of the information in the three (3) years that he/she has been employed by the facility. RN #6 added that he/she was unaware of any policy that stated that he/she needed to repeat back the patient's name, medical record number, room number, and lab value. RN #6 stated that no staff had ever asked him/her to repeat back all of those patient identifiers.