HospitalInspections.org

Based on closed record review and interview, the hospital failed to ensure medication errors were entered into the medical record of the patient when there was a medication error. (patients # 19 and 20). Findings:

Interview on 4/19/11 at 11:00 AM with S3 Rph revealed medication errors were often discovered by her when drugs were reconciled. S3 was asked if an entry was made in the patient's medical record and she stated they were not because it was not always the nurse that found the error. S3 provided the surveyor with a log of medication errors that occurred within the last 3 months. S3 explained that patient #19 had an order for Ativan 2.5 mg ordered PRN (as needed) for anxiety but during drug count reconciliation, it was discovered that Ambien 20 mg was administered on one occasion. S3 also explained that patient #20 had an order for Trazodone 50 mg ordered (indications: depression or insomnia) but Tramadol 50 mg was administered one time (centrally active analgesic). S3 confirmed there was no entry in the patient's charts to indicate the patient received a drug different from what was ordered because as part of her investigation, she reviewed nurse notes and did not recall there ever being an entry by the nurse of a medication error.

Review of the medical records for patient #19 and #20 confirmed the drug errors were not entered at the time of discovery as reported by S3 Rph.

Based on review of medical records, "Plan of Care Documentation" policy and interview with the S1, DON (Director of Nursing Services) the nurse failed to ensure care plans were kept current by not having documented evidence that individual care plans approaches were developed for 3 of 3 patients (#1, #8, #21) in a total sampled of 21. Findings:

1. Review of the medical record revealed patient #1 was a 93 year old who was admitted on 4/14/2011 with diagnoses of pneumonia, chronic renal insuffiencey, possible heart failure, probable constipation, hypertension and organic brain syndrome. Review of the problem list and pre-printed care plan revealed the nurse failed to address impaired circulation, infection control, potential respiratory insufficiency and altered urinary elimination.

2. Review of the medical record revealed patient #21 was a 68 year old who was admitted on 4/15/2011 with diagnoses of COPD (chronic obstructive pulmonary disease, exacerbation, anemia and lung cancer. Further review revealed the problem list and pre-printed care plan failed to address anemia, exacerbation and the blood transfusions (2 units of packed red blood cells) that were administered on 4/16/2011.

3. Review of the closed medical record for patient #8 revealed she was admitted on 10/29/10 with diagnoses that included pneumonia, ascites, diabetes mellitus, dehydration and hypertension. Review of the Discharge Summary dated 11/2/11 revealed that during the course of treatment, iron deficiency anemia was identified which required the transfusion of 2 units of packed red blood cells. Review of the comprehensive care plan failed to reveal approaches to address the anemia or the transfusion of the packed red blood cells.

Review of the policy for careplans revealed "all patients admitted to the hospital will have a plan of care. Goals and interventions for each problem are addressed on the PATIENT PROBLEMS Form within 24 hours of admission to the hospital". In an interview on 4/18/2011 at 10:45 AM, S2 LPN (licensed practical nurse) confirmed that the patient's careplan failed to address their diagnoses and failed to address the blood transfusions that were administered to patient #21 and to #8.

Review of the medical record, blood transfusion consent form, blood transfusion policy and interview with S1, DON the hospital failed to ensure consent was properly executed for 1 of 1 patients (#21) in a total sample of 21, by not ensuring the physician signed the blood transfusion consent indicating that he explained the risk and benefits of receiving blood. Findings:

Review of the medical record revealed patient #21 was a 68 year old who was admitted on 4/15/2011 with diagnosis of anemia. Review of the 4/15/2011 admit orders revealed an order to type and crossmatch 2 units of packed red blood cells. Further review revealed 2 unit of packed red blood cells were administered on 4/16/2011. Review of the blood transfusion consent form revealed an empty blank where the physician's signature was requested indicating that he/she (physician) had explained the risks and benefits of receiving blood.

Review of the policy for administering blood revealed "when an order is written for blood or blood products, informed consent must be obtained prior to administration". Further review revealed the "ordering physician is responsible for providing an explanation to the patient (or responsible party) of possible risk, benefits and alternatives to transfusion/administration, as well as providing an opportunity for the patient to ask questions. The nurse is responsible for verifying that a consent for blood or blood components has been signed".

An interview on 4/18/2011 at 11:00 AM with S1 RN confirmed the physician did not sign the blood transfusion consent acknowledging that he explained the risks and benefits of receiving blood.