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Based on record review and interview, the Hospital failed to ensure nursing staff followed the Hospital's policies and procedures for 2 Patients (#2 and #1) out of a total sample of 10 patients. 1. For Patient #2 the Hospital Nursing Staff failed to monitor magnesium levels and administer magnesium repletion as ordered by a physician; Patient #2's magnesium levels remained low, and the Patient experienced a cardiac arrest and transfer to a critical care unit. 2. For Patient #1 the Hospital nursing staff failed to follow the Hospital policy for assessment of a patient with Suicidal Ideation (SI).

Refer to Tag 0398.

Based on record review and interview, the Hospital failed to ensure nursing staff followed the Hospital's policies and procedures for 2 Patients (#2 and #1) out of a total sample of 10 patients. 1. For Patient #2 the Hospital Nursing Staff failed to monitor magnesium levels and administer magnesium repletion as ordered by a physician; Patient #2's magnesium levels remained low, and the Patient experienced a cardiac arrest and transfer to a critical care unit. 2. For Patient #1 the Hospital nursing staff failed to follow the Hospital policy for assessment of a patient with Suicidal Ideation (SI).

Findings include:

1. Review of the Hospital Policy titled "Electrolyte Protocol for Standard Med-Surg Patients", revised on 9/21/18 indicated the following:
-Provider placed order for Med/Surg STANDARD Electrolyte Replacement Protocol.
-Registered Nurse (RN) reviews patients' electrolyte lab values.
-If lab values indicate the need for electrolyte replacement per protocol criteria, RN opens the Med/Surg standard electrolyte replacement protocol order set and orders appropriate replacement based on the lab value.
-RN follows any additional instructions as indicated in the protocol.

Patient #2 presented to the Hospital Emergency Department on 5/7/23 with a diagnosis of alcohol intoxication.

Review of Patient #2's medical record indicated the Patient was evaluated by a Physician on 5/7/23 and diagnosed with hypomagnesemia (low magnesium level); the Patient's magnesium level was 1.1 milligrams per deciliter (mg/dL), a low level. Patient #2 was administered 2g (grams) of magnesium sulfate intravenously (IV) at 4:54 P.M. on 5/7/23 prior to transfer to an inpatient unit. On 5/7/23 at 5:20 P.M., a physician ordered a magnesium sulfate sliding scale with the following parameters:
-Magnesium less than 1.2 mg/dL - administer magnesium sulfate 2g IV x1 over 2 hours, page provider, repeat magnesium level six hours after completing replacement.
-Magnesium 1.2-1.5 mg/dL, - magnesium sulfate 1g IV x 1 over 2 hours, repeat magnesium level six hours after completing replacement.
-Magnesium 1.6-2.0 mg/dL - magnesium oxide tablet 800mg (milligrams) by mouth x 1, repeat magnesium level in the morning.
-Magnesium above 2.0 mg/dL - no replacement.

Further review of Patient #2's medical record indicated a magnesium level of 1.3mg/dL was drawn on 5/8/23 at 6:44 A.M and resulted at 7:27 A.M. Patient #2's medical record failed to indicate any orders were placed for magnesium replacement nor did the Patient receive any magnesium on 5/8/23; a magnesium level was not repeated within 6 hours of the low finding per the physician's order. A magnesium level of 1.2 mg/dL was drawn on Patient #2 on 5/9/23 at 5:15 A.M. (over 22 hours from the previous magnesium level), however, the magnesium level was not resulted until 11:15 A.M. Patient #2's medical record failed to indicate any orders were placed for magnesium replacement following the results of his/her low magnesium level. Patient #2's medical record failed to indicate the magnesium level result obtained on 5/8/23 was acknowledged or addressed by Hospital staff. On 5/9/23 at 7:50 A.M., Patient #2 experienced cardiac arrest, required cardiopulmonary resuscitation and intubation, and transfer to a critical care unit.

Review of Patient #2's Medication/Fluid Event Report dated 5/9/23 indicated the Patient was ordered for standing magnesium replacement but the order was not fulfilled; the 5/9/23 magnesium level drawn on Patient #2 was not checked. Patient #2 arrested at 7:50 A.M., and torsade's (high ventricular heartbeat which can cause ventricular fibrillation (life threatening); magnesium sulphate suppresses torsade's). The report further indicated the event type was policy/protocol not followed with a severity level of harm - permanent, intervention required to sustain life.

During an interview with the Risk Manager on 5/31/23 at 1:05 P.M., she said the Hospital was investigating Patient #2's magnesium medication errors from 5/8/23 - 5/9/23. She said Patient #2's Electronic Medical Record (EMR) was reviewed, and no issues were identified with the order sets for the magnesium sliding scale ordered on 5/7/23. She said the incident with Patient #2 was a result of human error and the magnesium labs from 5/8/23 and sliding scale order were missed by Nursing staff. She said patient lab results are available to the nursing staff to review in patient's EMRs. She said the magnesium sliding scale/electrolyte repletion was nurse driven; once an electrolyte level (such as magnesium) was available in the EMR, the nurse should place an order in the EMR based on the sliding scale ordered by the physician. She said the Hospital was still conducting audits to identify any additional learning needs for the nursing staff, then formal training on this process would be rolled out for the nursing staff.

During an interview with the Nurse Manager on 5/31/23 at 1:25 P.M., she said Patient #2's physician's orders for the magnesium electrolyte repletion protocol/sliding scale were in place on arrival to the inpatient unit. She said the nursing staff involved in Patient #2's care did not see the order for the magnesium sliding scale. She said some of the nursing staff was unaware of a time marking feature in the EMR to check off new lab results as read, and it was possible the nursing staff missed Patient #2's magnesium levels because it was overlooked in the EMR. She said she sent an update to the nursing staff on Patient #2's unit regarding electrolyte replacement sliding scale orders after the event but the Hospital was still auditing other records.

The Hospital failed to ensure Patient #2's magnesium levels were monitored and a physician's order for magnesium repletion was followed per Hospital policy.

2. Review of the Hospital policy, "Suicide/self-harm Screening and Precautions", dated 4/11/23, indicated the following:
-Registered Nurse (RN) screens for "harm to self in past 3 months" during triage process of all patients.
-Patients that report yes to harm self-question and all patients with a primary behavioral health condition or concern as their presenting problem will be screened for suicide using the Columbia Suicide Severity Rating Scale (C-SSRS) by the ED RN while in Triage.

Patient #1 presented to the Hospital Emergency Department (ED) on 1/22/23 with a complaint of abdominal pain for three days.

Review of Patient #1's medical record indicated the Patient reported having thoughts of SI to the RN during the rapid triage assessment on 1/22/23. The Nurse documented Patient #1 admitted to having SI without any formulated plan to self-harm. Further review of Patient #1's medical record failed to indicate any C-SSRS assessment was completed for Patient #1 prior to his/her discharge on 5/7/23.

During an interview with the ED Associate Clinical Nursing Officer on 5/31/23 at 12:45 P.M., she said if a Patient in the ED was assessed and identified to have suicidal ideation or thoughts of self-harm, a C-SSRS assessment should then be completed by a RN to determine the level of risk (low, medium, or high) for self-harm for the patient.