HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the nursing staff adhered to the hospital's P&P for one of two sampled patients (Patient 2) when Patient 2's change of condition was not addressed in the patient's plan of care. This failure posed the risk of adverse health outcomes to the patient.

Findings:

Review of hospital's P&P titled Critical Care Standards of Practice dated March 2024 showed the policy is to establish the standards for nursing practice in the Medical Intensive Care Unit (MICU) and Cardiovascular Intensive Care Unit (CVICU) (beds 7-12) at the hospital. Nursing Plan of Care is assessed, updated, and documented in the electronic medical record every shift.

On 1/16/25 at 0910 hours, Patient 2's medical record review was initiated with the Patient Safety Officer.

Patient 2's medical record showed Patient 2 was brought into the ED on 12/21/24, with the chief complaint of lactic acidosis and acute pancreatitis.

Review of the Nurse Practitioner's order dated 1/5/25 at 0755 hours, showed to transfuse one unit of Red Blood Cells (PRBC); the indication was for the Hgb less than 7 g/dl or Hct less than 21% in stable patient.

Review of the document titled Single Transfusion Record showed the PRBC transfusion was started on 1/5/25 at 1431 hours, and completed on 1/5/25 at 1545 hours.

Review of Patient 2's Plan of Care failed to show documented evidence the patient's plan of care dated 12/21/24 at 1554 hours was updated with Patient 2's change of condition related to active bleeding.

The above finding was verified with the Patient Safety Officer.

Based on observation, interview, and record review, the hospital failed to ensure the nursing staff followed the hospital's P&P on administering the medications enterally for one of two sampled patients (Patient 1). This failure posed the risk of adverse health outcomes to the patient.

Findings:

Review of the hospital's P&P titled Enteral Feeding Administration dated April 2024 showed under the section Medication Delivery:

- Do not mix medications together due to the risks for physical and chemical incompatibilities, tube obstructions, and altered therapeutic drug responses.

- Each medication should be administered separately using a clean 30 ml or larger enteral syringe.

On 1/16/25 at 0911 hours, an observation of the medication administration for Patient 1 by RN 1 was conducted.

RN 1 was observed crushing the following three medications together and administered them via Patient 1's NG tube (not separately as per the hospital's P&P):

- One tablet of amiodarone (an anti-arrhythmic drug) 200 mg,
- One tablet of midodrine (a medication to treat low blood pressure) 5 mg, and
- One capsule of rifampin (an antibiotic) 300 mg.

On 1/16/25, RN 1 verified the findings following the medication administration observation.

On 1/16/25 at 1530 hours, the Patient Safety Officer acknowledged the findings.