HospitalInspections.org

Based on record review and interview the facility failed to ensure that patient's on high alert medications (medications that may have an increased risk of causing significant patient harm) were monitored according to established procedures for 1 (P[patient]1) of 10 (P1-P10) patients reviewed for seeking acute care at the hospital. This deficient practice could likely lead to patients suffering adverse outcomes that can include but are not limited to: tissue damage, irregular heartbeat, allergic reactions, chest pain.

The findings are:

A. Record review of the facility's policy titled, "High Alert Medication Policy" dated 11/16/2021 revealed the purpose of the policy was, "To designate 'high alert' medications at [facility name] and provide standardized drug safety procedures for these 'high alert' medications to enhance their safe use." The policy defines high alert medications as. "medications that may have an increased risk of causing significant patient harm when they are used incorrectly." Under "Policy" it is stated, "d. The medication process shall also include verification of appropriate indication, appropriate lab values, calculations, and pump settings as well as the review of potential contraindications, medication administration record verification, calculations of preparation, and visualization of the medication in the form it is delivered." Under "Procedure:. . .b. Independent Verification" it is stated, "i. Certain high alert medications require additional verification safeguard checks during either or both the medication or medication administration processes. . ." This policy included an attachment - high alert medication list and this list included norepinephrine (medication used to increase blood pressure in critically ill patients).

B. Record review of the facility's "Standard drip preparation guidelines" for norepinephrine (medication given for severely low blood pressure) under "Patient Monitoring" it stated, "Cardiac Monitoring of HR [heart rate], and BP [blood pressure]. . ."

C. Record of P1's medical record for ICU admission date 03/14/2024 revealed the following:

1. Under "Provider Order Summary" on 03/14/2024 at 5:29 AM a norepinephrine drip was ordered with the following instructions: "Goal: (SBP [systolic blood pressure - pressure of heart beating] or MAP [mean arterial pressure - measurement of the bodies ability to supply organs with blood flow] (or both). . . Maintain SBP between 90-100 mmHg [millimeters of Mercury, method of measurement] Maintain MAP between 65-75 mmHg"

2. Review of nurse's notes for date 03/14/2024 revealed that the norepinephrine drip was last adjusted on 03/14/2024 at 4:10 PM with a blood pressure recording of 77/66 (low blood pressure indicating patient had continued need for norepinephrine and would warrant follow-up based on adjustment to medication).

3. Review of blood pressures recorded in patient's chart for 03/14/2024 revealed staff did not monitor blood pressure from 4:10 PM until 7:15 PM.

D. During an interview on 05/29/2024 at 4:45 PM with S(Staff)9, RN (Registered Nurse), S9 explained that vital signs (clinical measurements like pulse and blood pressure) are monitored every 15 minutes while a patient is on norepinephrine.

E. During an interview on 05/29/2024 at 4:50 PM with S3, RN, S3 confirmed that vital signs are monitored every 15 minutes while a patient is on norepinephrine. S3 also explained that this has been passed down verbally, it is not written anywhere for reference.