HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure Patient care was delivered in accordance with the facility's policies (P&P) and procedures, for three of 20 sample patients (Patient 1, 7, and 11) when:

1. For Patient 7, the patients' behavior and the interventions provided were not assessed every two hours;

2. For Patient 1, the violent restraint assessment was not completed every two hours was incomplete; and

3. For Patient 11, the patient received an unintended bolus of heparin when Resident 1 placed the medication order which was not in accordance with the attending physician's instructions.

These failures had the potential to compromise patient safety and may cause delay in treatment for the patients.

Findings:

1. A tour of the Medical-Surgical- Telemetry Unit (MST) was conducted on May 12, 2025, at 9:22 a.m., with Nurse Coordinator (NC 2), NC 3, and Charge Nurse (CN) 1.

On May 12, 2025, at 10 a.m., in Room A , Patient 7 was observed sitting at the edge of the bed with Patient Safety Assistant (PSA) 1 observed sitting by the room door observing Patient 7.

On May 12, 2025, at 10:02 a.m., in Room A, an interview was conducted with PSA 1. PSA 1 stated he was assigned to sit and watch Patient 7 because patient was on a 5150 hold (an involuntary hold for patients deemed a danger to self [DTS] or others)) for DTS..

An interview was conducted on May 13, 2025, at 4:55 p.m., with the Chief Clinical Integration Officer (CCIO). The CCIO stated the facility P&P titled, "Suicide Prevention," is the policy being followed for the assessment of patients with sitters (staff assigned to observe a patient) conducted by registered nurses (RN) every two hours.

A review of Patient 7's record was conducted on May 14, 2025, at 8:30 a.m., with NC 1.

A facility document titled, "Application for Assessment, Evaluation, and Crisis Intervention or Placement for evaluation and Treatment (5150 hold)," dated May 10, 2025, at 2:48 a.m., was reviewed. The document indicated,"...subject [Patient 7] wanted to jump off the bridge and self-harmed [sic] himself by punching the fence multiple times...Based upon the above information, there is probable cause to believe that said person is, as a result of mental disorder...a danger to self..."

A facility document titled, "History and Physical," dated May 11, 2025, was reviewed. The document indicated, "...ASSESSMENT/PLAN...Anger problem and depression...5150...Assessment/Plan ...Sitter..."

A facility document titled, "Sitter at Bedside," dated May 10, 2025, was reviewed. The document indicated,"...Order Date/Time...05/10/2025 [May 10, 2025]...03:39 P.M. [3:39 p.m.]...Frequency...Until discontinued..."

A facility document titled, "View Doc Flowsheet: Safe Environment," dated May 11, 2025, was reviewed. There was no documented evidence assessment of Patient 7's behavior and the intervention provided were conducted by the RN every two hours on the following dates and times:

- May 10, 2025, from 12 midnight to 2 a.m.;

- May 10, 2025, from 2 a.m. to 4 a.m.;

- May 10, 2025, from 4.a.m. to 6 a.m. ;

- May 11, 2025, from 8 a.m. to 10 a.m.;

- May 11, 2025, from 10 a.m. to 12 noon;

- May 11, 2025, from 12 noon to 2 p.m.;

- May 11, 2025, from 2 p.m. to 4 p.m.; and

- May 11, 2025, from 4 p.m. to 6 p.m..

An interview was conducted on May 14, 2025, at 9:11 a.m., with NC 1. NC 1 stated the facility policy was not followed when the RN did not document the patients' behavior and intervention every two hours.

A review of the facility P&P titled, "Suicide Prevention," dated December 6, 2024, was conducted the P&P indicated, "...documentation...patient behavior and intervention will be documented every 2 [two] hours by the assigned licensed nurse in the medical record on designated forms or flowsheet..."

2. On May 12, 2025, at 10:06 a.m., in Room B, Patient 1 was observed lying in bed, with a two point restraint on both wrists, watching a movie on a mobile phone, with Nurse Assistant (NA) 1 observed sitting by the bedside observing Patient 1.

On May 12, 2025, at 10:02 a.m., in Room B, an interview was conducted with NA 1. NA 1 stated she was assigned to sit and watch Patient 1 for safety and to prevent self-harm.

On May 12, 2025, at 10:09 a.m. in Room B, an interview was conducted with RN 2. RN 2 stated Patient 1 is on restraints due to self-harm and episodes of harming staff.

A review of Patient 1's record was conducted on May 12, 2025, at 1:04 p.m., with NC 1.

A facility document titled, " ED [Emergency Department] Provider Notes," dated February 17, 2025, was reviewed. The document indicated, "...patient medical history includes significant for autism [a developmental disability], development delay, macular degeneration [an eye disease that can blur vision], and eye injury secondary [due to] to hitting self. Brought in by ambulance for new onset of seizures [convulsions] from [Name of Hospital] ED. Patient was restrained upon arrival...Impression...Seizure..."

A facility document titled, "... Restraint Violent or Self -Destructive adult (Age18 and older)," dated, March 25, 2025, was reviewed. The document indicated,"...Restraint type: Polyurethane [a plastic material]/lock and key...restraint location...wrist, bilateral [affecting both sides]...restraint location...leg, bilateral...reason for restraint: imminent threat to harm self/others...reason for restraint...violent/self-destructive behavior..."

A facility document titled, "... Restraint Violent or Self -Destructive adult (Age18 and older)," dated, April 20, 2025, was reviewed. The document indicated, "...Restraint type...soft...restraint location...wrist, bilateral...reason for restraint: imminent threat to harm self/others...reason for restraint...violent/self-destructive behavior..."

A facility document titled, "...Restraint Violent or Self -Destructive adult (Age18 and older)," dated, April 27, 2025, was reviewed. The document indicated, "...Restraint type...Polyurethane/lock and key...restraint location...wrist, bilateral...restraint location...leg, bilateral...reason for restraint: imminent threat to harm self/others...reason for restraint...violent/self-destructive behavior..."

A facility document titled, "Restraint Monitoring/Assessment," dated March 25, 2025, through April 27, 2025, was reviewed. The document indicated, "...Patient was assessed every 2 hours per Patient Care Practices..." There was no documented evidence assessment was completed every two hours on the following dates and times:

- March 25, 2025, from 7 a.m. to 9 a.m.;

- March 25, 2025, from 9 a.m. to 11 a.m.;

- March 25, 2025, from12 p.m. to 1 p.m.;

- April 20, 2025, from 7:30 a.m. to 9:30 a.m.;

- April 20, 2025, from10:43 a.m. to 12:43 p.m.;

- April 26, 2025, from 5:09 a.m. to 7:09 a.m.; and

- April 27, 2025, from 7:09 a.m. to 9:09 a.m.

On May 13, 2025, at 10:30 a.m. an interview was conducted with NC 1. NC 1 stated the RN did not document the every two-hour assessment in accordance with the facility's P&P.

A facility P&P titled, "Restraints and Seclusion," dated December 6, 2021, was reviewed. The P&P indicated, "...Assessment of patients requiring Violent or Self Destructive Restraints...Assessments by a registered nurse, physician assistant or physician shall occur as often as indicated by the patient's condition, behavior, and environmental conditions or at least every 2 hours...documentation...episodes of restraints shall be documented as indicated on currently approved assessments, monitoring, and ordering forms and computerized flowsheets..."

3. On May 13, 2025, at 9:54 a.m., a review of Patient 11's record was conducted with the Regulatory Compliance (RC). A facility document titled, "Surgical ICU [Intensive Care Unit] History & [and] Physical," dated March 30, 2025, was reviewed and indicated Patient 11 was admitted to the facility on March 30, 2025, and presented after a twelve (12)-foot fall from a scaffolding. The document indicated, "...CT [computerized tomography, an imaging procedure] scans showing multiple cervical [neck] spine fractures for which the patient is being admitted for...holding ASA [aspirin, a blood thinner], heparin [a blood thinner] due to paraspinal [muscles, nerves, and tissues located along the sides of the spine] and sternal hematomas [collection of clotted blood outside the blood vessels]..."

A facility document titled, "Adult Trauma History & Physical/Consult," dated March 30, 2025, was reviewed. The document indicated, "...CT scan revealed the following injuries: Grade 2 right internal carotid BCVI [Blunt Cerebral Vascular Injury, trauma to the blood vessels in the brain that involves moderate to severe injury], C1 [cervical spine bone 1] and C2 ... fx [fracture, a break in the bone], T3 [thoracic spine bone 3] and T4 ...fracture with large paraspinal hematoma, T3 TP [transverse process, a break in one of the bony projections on the sides and back of a vertebrae] fracture, T2 and T3 ...fracture, right 4th [fourth] rib fracture, and sternal [referring to the sternum, a bone in front of the mid chest] fracture with small retrosternal [behind the sternum] hematoma..."

A facility document titled, "Orthopedic Spine Surgery History & [and] Physical," dated March 30, 2025, was reviewed. The document indicated, "...tentative plan for OR [operating room] on 3/30/25 [May 30, 2025] for odontoid screw fixation [a surgical procedure used to stabilize and heal fractures of the odontoid process, a toothlike projection from the spine bone] and possible fusion [a surgical procedure to connect two or more spine bones]...DVT [deep vein thrombosis, a condition where a blood clot forms in a deep vein] prophylaxis [treatment which aims to reduce blood clots] per primary team..."

A facility document titled, "REPORT OF OPERATION," dated March 30, 2025, was reviewed. The document indicated, "...DATE OF SURGERY: 03/31/2025 [March 31, 2025]...PREOPERATIVE DIAGNOSIS: Odontoid process fracture type II, closed stable Jefferson fracture [a bone fracture of the anterior and posterior arches of the C1 vertebrae], T3 burst pathologic fracture [a type of fracture], T4 burst pathological fracture...POSTOPERATIVE DIAGNOSIS: Odontoid process fracture type II [a type of fracture], closed stable Jefferson fracture, T3 burst pathologic fracture, T4 burst pathological fracture...TITLE OF OPERATION: Anterior Odontoid Screw Placement [a surgical procedure used to stabilize and heal fractures]...Use of Fluoroscopy [an imaging technique that uses x-rays to produce real time, moving images of internal structures]..."

A facility document titled, "Trauma Tertiary Survey," dated March 31, 2025, was reviewed and indicated, "...Biffl gr 2 R ICA [BCVI grade 2 right internal carotid artery, a big blood vessel supplying the brain] injury: recommend discussion with Ortho [orthopedics, a branch of medicine which specializes in the treatment and diagnosis of bone disorders and fractures] regarding ASA or Hep [Heparin] fixed rate..."


An untitled and undated facility document was reviewed and indicated, "...Medication...by [name of Resident 1]...Heparin D5W [dextrose 5 water, a type of fluid administered through the vein (intravenous, IV)] 25,000 unit/250 mL [units per milliliter, units of measurement] (100 unit/mL) continuous infusion PREMIX...Ordered dose: 400 units/hr [units per hour]...Intravenous...Admin Dose: 400 Units/hr...Scheduled Start Date/Time: 3/31/25 1755 [5:55pm]...Admin [administration] Instructions: Fixed rate 400ml/hr...Ordering User [name of Resident 1]...Ordering Date/Time: Mon [Monday] Mar [March] 31, 2025 1754 [5:54 pm]...Authorizing Provider:[name of Physician 1]...Indication for use: Biffl grade 2...Date/Time Reviewed: Mon Mar 31, 2025 1801 [6:01 pm]...Reviewed By: [name of Pharmacist 2]...Verified by Pharmacy..."

An untitled and undated facility document was reviewed and indicated, "...Medication...by [name of Resident 1]...Heparin D5W REBOLUS [a relatively large amount administered in a short time] From bag 3,260 Units...Ordered dose: 60 units/kg [unit per kilogram, unit of measurement] x [times] 54.4 kg...Route: Intravenous...Frequency: As needed for Rebolus 60 units/kg when PTT [Partial Thromboplastin Time, a laboratory test to determine how long it takes for a blood sample to clot] < [less than] 46 seconds...Admin Dose: 3,260 Units...Scheduled Start Date/Time: 3/31/25 [March 31, 2025] 1648 [4:48pm]...Ordering User: [name of Resident 1]...Ordering Date/Time: Mon [Monday] Mar 31, 2025 1754 [5:54 pm]...Authorizing Provider: [name of Physician 1]...Date/Time Reviewed: Mon Mar 31, 2025 1802 [6:02 pm]...Reviewed By: [name of Pharmacist 2]...Verified by Pharmacy..."

An untitled facility document was reviewed and indicated, "...March 31, 2025 ...Heparin in D5W 25,000 unit/250mL (100 unit/mL) continuous infusion Premix...Dose: 400 units/hr : 4mL/hr...1826 [6:26 pm] New Bag 400 Units/hr...," was administered by the Registered Nurse (RN).

An untitled facility document with unknown date, was reviewed and indicated, "...Heparin BOLUS [a single, large dose of medicine] From Bag...Ordered Dose: 60 Units/kg x 54.4 kg...Admin Dose: 3,260 units...Intravenous...Order Start Time 1836 [6:36pm] Bolus/Bag 3,260 Units..." was administered by the RN.

An untitled facility document, dated April 1, 2025, at 8:13 a.m., was reviewed. The document indicated, "...0732 [7:32 a.m.]: Called to patient bedside by NOC [night shift] and AM primary RN: during handoff noted patient no longer responsive...0734 [7:34 a.m.]: Called SICU resident...endorsed findings, recommended CT for abrupt change in LOC [Level of consciousness]...0737 [7:37 a.m]: called a code stoke...0739 [7:39 a.m]: Code team arrives to unit...Determine pt [patient] needs to be intubated [a tube inserted into the windpipe (trachea) to assist breathing]...0752 [7:52 a.m.] Intubation successful...0813 [8:13 a.m.]: Pt to CT with Code Team..."

A facility document titled, "Neurosurgery H&P Note," dated April 1, 2025, was reviewed and indicated "...R [right] ICA [internal carotid artery] Biffi grade 2 s/p [status post, after] heparin bolus had a decline in neuro [neurologic, related to cognition and functions of the brain] exam with CT shows extensive posterior fossa [part of the brain] hematoma with compression on the brainstem [part of the brain] and associated with hydrocephalus [fluid on the brain]...due to epidural, subdural and subarachnoid [parts of the spinal cord] hemorrhage [bleeding] causing significant brainstem compression [buildup of pressure], emergent suboccipital craniectomy [a surgical procedure where a portion of the skull is removed to relieve pressure on the brain] is recommended..."

A facility document titled, "OPERATIVE NOTE," dated April 1, 2025, at 10:05 a.m., was reviewed. The document indicated, "...DATE OF SURGERY: 04/01/2025 [April 1, 2025]...PREOPERATIVE DIAGNOSIS: Epidural hematoma, subdural hematoma, subarachnoid hemorrhage causing brainstem compression and hydrocephalus...POSTOPERATIVE DIAGNOSIS: Same...DESCRIPTION OF FINDINGS: 1. Epidural and subdural hematoma 2. Nonviable [no longer living] cerebellar [part of the brain] tissue bilaterally 3. Decompressed [surgical procedure to relieve pressure] posterior fossa 4. External ventricular drain [thin plastic tube placed in the spinal cord] placed with clear CSF [cerebral spinal fluid] under moderate pressure..."

An untitled facility document, dated April 1, 2025, at 11:21 a.m., was reviewed. The document indicated, "...[name of Physician 1]...Significant Event...Taken down for Stat [immediate] stroke protocol [procedures implemented when a patient is suspected of having a stroke] head CT which revealed hemorrhage in the posterior fossa around the brainstem...Upon chart review, patient was on appropriate fixed rate heparin at 400 units/hr, but did receive bolus dose which is typically not given for this..."

An untitled facility document, dated April 1, 2025, at 11:52 a.m., was reviewed. The document indicated, "...[name of Physician 1]...Significant Event Note-SICU [surgical intensive care unit, unit for patients needing critical care after a surgery] attending documentation: Explained a multidisciplinary discussion between myself and [name of Physician], spine surgeon about risks and benefits of the treatment of Blunt Cerebrovascular Injury and the risks of stroke they carry...I explained our standard practice for blunt cerebrovascular injuries, these type of injuries carry a high risk for thrombotic (clot based) stroke given their nature. I explained current treatment includes heparin at a fixed rate dose for high-risk bleeding individuals. Patient received the appropriate fixed rate heparin at 400 units/hr over the course of the night but did receive a bolus dose of heparin which was not intended..."

During an interview, on May 13, 2025, at 2:23 p.m., conducted with Resident 1, Resident 1 stated, "The SICU team, including myself, made the initial plan to start heparin at 400 units/hr fixed dose without a bolus. When I placed the order in the computer, the heparin automatically had bolus preselected. Typically, I unselect the bolus order but this time, I must have forgotten to unselect bolus." Resident 1 stated Patient 11 received the unintended bolus of heparin.

During an interview, on May 13, 2025, at 3:11 p.m., conducted with Physician 1, Physician 1 stated they supervise the residents, train them to be future leaders, and give autonomy as much and safely as possible. Physician 1 stated the plan was to start heparin at 400 units/hr fixed rate without a bolus based on guidelines for management of blunt cerebrovascular disease. Physician 1 stated, "I do not have to cosign when a resident inputs orders however, I try to be clear with what I want ordered." Physician 1 stated Resident 1 is a vascular [a branch of medicine specializing in the disorders of the blood vessels] physician and puts in plenty of heparin orders. Physician 1 stated, "To my knowledge, he [Resident 1] was well aware that I didn't want a [heparin] bolus ordered." Physician 1 stated Patient 11 had potential increased risk factors for bleeding prior to the administration of heparin.

The facility P&P titled, "Supervision and Accountability," dated August 19, 2024, was reviewed. The P&P indicated, "...The policy of [name of facility] is to provide both training programs and trainees our commitment to and to be responsible for promoting patient safety...In all cases, the final responsibility for the supervision of residents and fellows who have not been granted medical staff privileges lies with the supervising attending physician. This responsibility includes ensuring the quality of care provided to patients, patient safety and provision of high-quality education..."

Based on interview and record review, the facility failed to ensure a medication order is verified and approved in accordance with the facility's policy and procedure, for one of 20 sample patients (Patient 11),, when Pharmacist 2 verified and approved a medication order without being familiar with the medical diagnosis.

This failure resulted in Patient 11 receiving an additional dose of heparin, (a blood thinner) and had the potential for an increased risk of bleeding for Patient 11.

Findings:

On May 13, 2025, at 9:54 a.m., a review of Patient 11's record was conducted with the Regulatory Compliance (RC). A facility document titled, "Surgical ICU [Intensive Care Unit] History & [and] Physical," dated March 30, 2025, was reviewed and indicated Patient 11 was admitted to the facility on March 30, 2025, and presented after a twelve (12)-foot fall from a scaffolding. The document indicated, "...CT [computerized tomography, an imaging procedure] scans showing multiple cervical [neck] spine fractures for which the patient is being admitted for...holding ASA [aspirin, a blood thinner], heparin [a blood thinner] due to paraspinal [muscles, nerves, and tissues located along the sides of the spine] and sternal hematomas [collection of clotted blood outside the blood vessels]..."

A facility document titled, "Adult Trauma History & Physical/Consult," dated March 30, 2025, was reviewed. The document indicated, "...CT scan revealed the following injuries: Grade 2 right internal carotid BCVI [Blunt Cerebral Vascular Injury, trauma to the blood vessels in the brain that involves moderate to severe injury], C1 [cervical spine bone 1] and C2 ... fx [fracture, a break in the bone], T3 [thoracic spine bone 3] and T4 ...fracture with large paraspinal hematoma, T3 TP [transverse process, a break in one of the bony projections on the sides and back of a vertebrae] fracture, T2 and T3 ...fracture, right 4th [fourth] rib fracture, and sternal [referring to the sternum, a bone in front of the mid chest] fracture with small retrosternal [behind the sternum] hematoma..."

A facility document titled, "Orthopedic Spine Surgery History & [and] Physical," dated March 30, 2025, was reviewed. The document indicated, "...tentative plan for OR [operating room] on 3/30/25 [May 30, 2025] for odontoid screw fixation [a surgical procedure used to stabilize and heal fractures of the odontoid process, a toothlike projection from the spine bone] and possible fusion [a surgical procedure to connect two or more spine bones]...DVT [deep vein thrombosis, a condition where a blood clot forms in a deep vein] prophylaxis [treatment which aims to reduce blood clots] per primary team..."

A facility document titled, "REPORT OF OPERATION," dated March 30, 2025, was reviewed. The document indicated, "...DATE OF SURGERY: 03/31/2025 [March 31, 2025]...PREOPERATIVE DIAGNOSIS: Odontoid process fracture type II, closed stable Jefferson fracture [a bone fracture of the anterior and posterior arches of the C1 vertebrae], T3 burst pathologic fracture [a type of fracture], T4 burst pathological fracture...POSTOPERATIVE DIAGNOSIS: Odontoid process fracture type II [a type of fracture], closed stable Jefferson fracture, T3 burst pathologic fracture, T4 burst pathological fracture...TITLE OF OPERATION: Anterior Odontoid Screw Placement [a surgical procedure used to stabilize and heal fractures]...Use of Fluoroscopy [an imaging technique that uses x-rays to produce real time, moving images of internal structures]..."

A facility document titled, "Trauma Tertiary Survey," dated March 31, 2025, was reviewed and indicated, "...Biffl gr 2 R ICA [BCVI grade 2 right internal carotid artery, a big blood vessel supplying the brain] injury: recommend discussion with Ortho [orthopedics, a branch of medicine which specializes in the treatment and diagnosis of bone disorders and fractures] regarding ASA or Hep [Heparin] fixed rate..."


An untitled and undated facility document was reviewed and indicated, "...Medication...by [name of Resident 1]...Heparin D5W [dextrose 5 water, a type of fluid administered through the vein (intravenous, IV)] 25,000 unit/250 mL [units per milliliter, units of measurement] (100 unit/mL) continuous infusion PREMIX...Ordered dose: 400 units/hr [units per hour]...Intravenous...Admin Dose: 400 Units/hr...Scheduled Start Date/Time: 3/31/25 1755 [5:55pm]...Admin [administration] Instructions: Fixed rate 400ml/hr...Ordering User [name of Resident 1]...Ordering Date/Time: Mon [Monday] Mar [March] 31, 2025 1754 [5:54 pm]...Authorizing Provider:[name of Physician 1]...Indication for use: Biffl grade 2...Date/Time Reviewed: Mon Mar 31, 2025 1801 [6:01 pm]...Reviewed By: [name of Pharmacist 2]...Verified by Pharmacy..."

An untitled and undated facility document was reviewed and indicated, "...Medication...by [name of Resident 1]...Heparin D5W REBOLUS [a relatively large amount administered in a short time] From bag 3,260 Units...Ordered dose: 60 units/kg [unit per kilogram, unit of measurement] x [times] 54.4 kg...Route: Intravenous...Frequency: As needed for Rebolus 60 units/kg when PTT [Partial Thromboplastin Time, a laboratory test to determine how long it takes for a blood sample to clot] < [less than] 46 seconds...Admin Dose: 3,260 Units...Scheduled Start Date/Time: 3/31/25 [March 31, 2025] 1648 [4:48pm]...Ordering User: [name of Resident 1]...Ordering Date/Time: Mon [Monday] Mar 31, 2025 1754 [5:54 pm]...Authorizing Provider: [name of Physician 1]...Date/Time Reviewed: Mon Mar 31, 2025 1802 [6:02 pm]...Reviewed By: [name of Pharmacist 2]...Verified by Pharmacy..."

An untitled facility document was reviewed and indicated, "...March 31, 2025 ...Heparin in D5W 25,000 unit/250mL (100 unit/mL) continuous infusion Premix...Dose: 400 units/hr : 4mL/hr...1826 [6:26 pm] New Bag 400 Units/hr...," was administered by the Registered Nurse (RN).

An untitled facility document with unknown date, was reviewed and indicated, "...Heparin BOLUS [a single, large dose of medicine] From Bag...Ordered Dose: 60 Units/kg x 54.4 kg...Admin Dose: 3,260 units...Intravenous...Order Start Time 1836 [6:36pm] Bolus/Bag 3,260 Units..." was administered by the RN.

An untitled facility document, dated April 1, 2025, at 8:13 a.m., was reviewed. The document indicated, "...0732 [7:32 a.m.]: Called to patient bedside by NOC [night shift] and AM primary RN: during handoff noted patient no longer responsive...0734 [7:34 a.m.]: Called SICU resident...endorsed findings, recommended CT for abrupt change in LOC [Level of consciousness]...0737 [7:37 a.m]: called a code stoke...0739 [7:39 a.m]: Code team arrives to unit...Determine pt [patient] needs to be intubated [a tube inserted into the windpipe (trachea) to assist breathing]...0752 [7:52 a.m.] Intubation successful...0813 [8:13 a.m.]: Pt to CT with Code Team..."

A facility document titled, "Neurosurgery H&P Note," dated April 1, 2025, was reviewed and indicated "...R [right] ICA [internal carotid artery] Biffi grade 2 s/p [status post, after] heparin bolus had a decline in neuro [neurologic, related to cognition and functions of the brain] exam with CT shows extensive posterior fossa [part of the brain] hematoma with compression on the brainstem [part of the brain] and associated with hydrocephalus [fluid on the brain]...due to epidural, subdural and subarachnoid [parts of the spinal cord] hemorrhage [bleeding] causing significant brainstem compression [buildup of pressure], emergent suboccipital craniectomy [a surgical procedure where a portion of the skull is removed to relieve pressure on the brain] is recommended..."

A facility document titled, "OPERATIVE NOTE," dated April 1, 2025, at 10:05 a.m., was reviewed. The document indicated, "...DATE OF SURGERY: 04/01/2025 [April 1, 2025]...PREOPERATIVE DIAGNOSIS: Epidural hematoma, subdural hematoma, subarachnoid hemorrhage causing brainstem compression and hydrocephalus...POSTOPERATIVE DIAGNOSIS: Same...DESCRIPTION OF FINDINGS: 1. Epidural and subdural hematoma 2. Nonviable [no longer living] cerebellar [part of the brain] tissue bilaterally 3. Decompressed [surgical procedure to relieve pressure] posterior fossa 4. External ventricular drain [thin plastic tube placed in the spinal cord] placed with clear CSF [cerebral spinal fluid] under moderate pressure..."

An untitled facility document, dated April 1, 2025, at 11:21 a.m., was reviewed. The document indicated, "...[name of Physician 1]...Significant Event...Taken down for Stat [immediate] stroke protocol [procedures implemented when a patient is suspected of having a stroke] head CT which revealed hemorrhage in the posterior fossa around the brainstem...Upon chart review, patient was on appropriate fixed rate heparin at 400 units/hr, but did receive bolus dose which is typically not given for this..."

An untitled facility document, dated April 1, 2025, at 11:52 a.m., was reviewed. The document indicated, "...[name of Physician 1]...Significant Event Note-SICU [surgical intensive care unit, unit for patients needing critical care after a surgery] attending documentation: Explained a multidisciplinary discussion between myself and [name of Physician], spine surgeon about risks and benefits of the treatment of Blunt Cerebrovascular Injury and the risks of stroke they carry...I explained our standard practice for blunt cerebrovascular injuries, these type of injuries carry a high risk for thrombotic (clot based) stroke given their nature. I explained current treatment includes heparin at a fixed rate dose for high-risk bleeding individuals. Patient received the appropriate fixed rate heparin at 400 units/hr over the course of the night but did receive a bolus dose of heparin which was not intended..."

During an interview, on May 13, 2025, at 2:08 p.m., conducted with Pharmacist 2, Pharmacist 2 stated the BCVI diagnosis was new to him and he was unfamiliar with the diagnosis, but since this was a standard order for low dose heparin, it did not seem questionable to him. Pharmacist 2 stated, "I did not call the physician to clarify the diagnosis before verifying the Heparin order."

The facility policy and procedure (P&P) titled, "Adult Inpatient Pharmacy Anti-Coagulation Protocol," dated February 15, 2024, was reviewed. The P&P indicated, "...Initial orders: Pharmacist should obtain the following information: Patient's diagnoses and indication for anticoagulation, patients height, weight, age and gender..."

The facility P&P titled, "Medication Orders," dated June 29, 2023, was reviewed. The P&P indicated, "...Use a HARD STOP when reviewing orders and question any medication order that does not seem appropriate to the patient's condition...Clarification of an Unclear Order: If a medication order is received that is unclear incomplete, unacceptable or illegible, the prescriber will be contacted for clarification prior to filling the order...Pharmacist Review of Medication Orders: Pharmacist will review medication orders and contact the prescriber if questions arise..."