The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|ST ANTHONY HOSPITAL||2801 ST ANTHONY WAY PENDLETON, OR 97801||Nov. 9, 2011|
|VIOLATION: NURSING SERVICES||Tag No: C1049|
|Based on interviews and review of medical records, it was determined that the hospital failed to assure all drugs and medications were administered by a registered nurse in accordance with the orders of the practitioner responsible for the patient's care.
1. An interview with the Emergency Department (ED) Nurse Manager and Vice President of Patient Care Services on 11/08/2011 at approximately 0850 hours reflected their findings following a medication error caused by an ED RN (Employee #9) . The incident occurred during the care of a patient who presented emergently with a possible allergic reaction.
2. A medical record review of 1 out of 10 (patient #4) ED patients revealed the following: The patient was admitted emergently to the ED on 7/26/2011 with a possible allergic reaction. The patient was short of breath, had a swollen tongue and an "itchy red rash" over his arms and trunk. At 1800 hours the physician gave a verbal order for Epinephrine 0.5 mg sub Q. Employee #9 wrote the order on the "ER Physician Order Sheet" as "Epinephrine 0.5 mg sub Q" then administered the medication using an IV route. He/she documented giving Epinephrine 0.5 mg IV at 1800. Documentation at 1802 reflected he/she informed the physician that the Epinephrine was given IV. The physician's documented the patient's cardiac rhythm changed to "V-Tach X 2 min." The incident was documented on a Medication Safety Report form per policy.