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.
| SOUTHEASTERN REGIONAL MEDICAL CENTER | 300 W 27 ST PO BOX 1408 LUMBERTON, NC 28359 | Nov. 1, 2017 |
| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and procedures, medical record review, written statement by RN #5, review of reporting document from the named facility to the NCBON and staff interviews, the facility staff failed to provide supervision of care for 1 of 1 patient receiving an IV (Intravenous) antibiotic infusion (Patient #7) and provide adequate supervision to 1 of 1 NA (Nursing Aide) (#2) who provided care outside the scope of practice. The findings include: Review of policy and procedure on 11/01/2017 titled "IV Guidelines" last revised date 12/2015 revealed, "POLICY: The RN and LPN are responsible for ensuring safety of the initiation and administration of intravenous fluids and/or medications for therapeutic and/or diagnostic indicators.... PROCEDURE STEPS: ...F. DOCUMENTATION IN THE PATIENT MEDICAL RECORD...3. Rate, location of IV site, condition of site... G. DISCONTINUATION OF IV THERAPY ...The NAI, NAII ...may discontinue peripheral IV therapy if the appropriate training has been documented. Review of policy and procedure on 11/01/2017 titled "Medication Administration" last revision date 02/04/2015 revealed, "POLICY: The RN/LPN is responsible for the safe administration of medications to all patients...PURPOSE: To provide guidelines for safe administration of medication... B. MEDICATION ORDER REQUIREMENTS: 3. Medication orders are to include the medication name, dose, route, frequency...D. Who May Administer Medications:...1. Nursing personnel who are licensed to administer medications... E. SAFE ADMINISTRATION OF MEDICATIONS:...Begin by observing the "Five Rights"...c. RIGHT DOSE: ...Is the dose correct is it necessary to calculate the amount of drug to give for correct dosage? Closed medical record review on 10/31/2017 revealed patient #7 was a [AGE] year old female who presented to the ED (Emergency Department) on 09/17/2017 at 1322 with the chief complaint of fever. Review of the H&P revealed patient #7 had a temperature of 103.1 degrees Fahrenheit, ulceration to the left lower leg and skin breakdown to bilateral thighs. Review revealed laboratory and urine test, blood cultures and chest x-ray were performed. Further review revealed patient #7 was admitted with the plan of care to start on the following IV antibiotics Levaquin and Vancomycin. Review of the FLOWSHEET" revealed patient #7 arrived from the ED to the unit at 1845. Review of the "Physician Orders..." Pharmacy order number 74 revealed a medication order for 1250 (MG) Milligrams of Vancomycin to be given routinely daily at 1600 for seven days. The order was started on 09/18/2017 and was to be discontinued on 09/25/2017. Review of the MAR (Medication Administration Record) dated 09/19/2017 thru 09/20/2017 revealed RN #5 started the 1250 MG of Vancomycin on 09/19/2017 at 1722. Review of the "FLOWSHEET" by RN #6 (Charge Nurse) dated 09/19/2017 at 1844 revealed an IV located in the right antecubital had infiltrated and was discontinued by NA #2. Review revealed no available documentation of the infusion rate or delivery method. Review of a written statement by RN #5 dated 10/18/2017 revealed on "September 19, 2017 I began infusing the medication vancomycin for the patient regarding this complaint. It was around 1730 when I started the vancomycin at less than the ordered rate. The vancomycin was ordered to infuse within the hour; however I chose not to run it at that exact rate....Within 5-10 minutes of beginning infusion the nursing assistant came to let me know the IV had started to beeping and the arm had appeared to be swollen. At that time I was in the room with a patient in respiratory distress, which I could not leave at that moment. I asked Nursing assistant if she could shut to the pump off...Nursing assistant returned to me and asked if she could remove IV. I thanked her for offering and told her yes, and that I would be there as soon as my more critical patient was stable." Review of a reporting document on 10/31/2017 from the named facility by the CNO dated 10/31/2017 at 1430 revealed the CNO called and left a message with the NCBON concerning an incident involving the IV removal for patient #7. Review revealed a return call from the NCBON was received 10/31/2017 at 1441 and both the CNO and RN #7 were involved in the conversation. Review revealed the CNO and RN #7 made the NCBON aware of the follow up to the letter sent to RN #5 from the NCBON. The investigation confirmed that RN #5 instructed NA #2 to "...stop an IV pump, at which medication was being infused, and to remove an IV before the nurse actually assessed the site...So at this time we believe the nurse in fact direct a NA to practice outside of her scope. Review revealed the NCBON was satisfied and complaint form was submitted and no further action needed to be taken by the NCBON. Further review revealed on 10/31/2017 at 1515 "the NC office of Nursing Assistant regulations was also called to report the incident with the NA..." Interview attempted on 10/31/2017 with RN #5 but RN #5 was not available per interview with RN #7 (Director of Critical Care Units) on 10/31/2017 at 1200. Interview on 11/01/2017 at 1221 with NA #2 revealed RN #5 instructed her to discontinue an IV that had filtrated. Interview revealed RN #5 was notified that the IV pump was beeping and patient #7's arm was swollen. Upon request from RN #5 NA #2 turned the pump off and discontinued the IV. NA #2 stated "We never take out an IV unless a nurse tells us to. Usually when I discontinue an IV there is not any fluids hooked up to the IV." Interview revealed per policy NA #2 was not to disconnect IV's with fluids infusing with medication or via delivery per pump. Interview with the CNO on 10/31/2017 at 1419 revealed a written statement by RN #5 was provided. The written statement was reviewed and has been incorporated into the survey. Interview revealed "The NA (NA #2) was told by the nurse (RN #5) to remove the IV. The IV had Vancomycin infusing in a primary line with fluid. The NA cannot assess IV's which is outside of her scope of practice." NC 697 |
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| VIOLATION: ADMINISTRATION OF DRUGS | Tag No: A0405 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and procedures, closed medical record review, pharmacy order, review of photographs submitted by the complainant, review of letter from NCBON (North Carolina Board of Nursing), written statement by RN #5, review of reporting document from the named facility to the NCBON and staff interviews, the facility staff RN #5 failed to administer medication as ordered for 1 of 1 patient receiving an IV (Intravenous) antibiotic infusion (Patient #7) in accordance with approved staff policies and procedures.. The findings include: Review of policy and procedure on 11/01/2017 titled "IV Guidelines" last revised date 12/2015 revealed, "POLICY: The RN and LPN are responsible for ensuring safety of the initiation and administration of intravenous fluids and/or medications for therapeutic and/or diagnostic indicators....PROCEDURE STEPS:...F. DOCUMENTATION IN THE PATIENT MEDICAL RECORD...3. Rate, location of IV site, condition of site...." Review of policy and procedure on 11/01/2017 titled "Medication Administration" last revision date 02/04/2015 revealed, "POLICY: The RN/LPN is responsible for the safe administration of medications to all patients...PURPOSE: To provide guidelines for safe administration of medication... B. MEDICATION ORDER REQUIREMENTS: 3. Medication orders are to include the medication name, dose, route, frequency...D. Who May Administer Medications:...1. Nursing personnel who are licensed to administer medications....E. SAFE ADMINISTRATION OF MEDICATIONS:...Begin by observing the "Five Rights"...c. RIGHT DOSE:...Is the dose correct is it necessary to calculate the amount of drug to give for correct dosage? Closed medical record review on 10/31/2017 revealed patient #7 was a [AGE] year old female who presented to the ED (Emergency Department) on 09/17/2017 at 1322 with the chief complaint of fever. Review of the H&P revealed patient #7 had a temperature of 103.1 degrees Fahrenheit, ulceration to the left lower leg and skin breakdown to bilateral thighs. Review revealed laboratory and urine tests, blood cultures and chest x-ray were performed. Further review revealed patient #7 was admitted with the plan of care to start on the following IV antibiotics Levaquin and Vancomycin. Review of the FLOWSHEET "revealed patient #7 arrived from the ED to the unit at 1845. Review of the "Physician Orders..." Pharmacy order number 74 revealed a medication order for 1250 (MG) Milligrams of Vancomycin to be given routinely daily at 1600 for seven days. The order was started on 09/18/2017 and was to be discontinued on 09/25/2017. Review of the MAR (Medication Administration Record) dated 09/19/2017 thru 09/20/2017 revealed RN #5 started the 1250 MG of Vancomycin on 09/19/2017 at 1722. Review revealed no available documentation of the infusion rate or delivery method. Review of pharmacy documentation on 11/01/2017 dated 11/01/2017 at 1551 revealed the order for patient #7 was "VANCOMYCIN IN 0.9% SODIUM CL 1,250 MG/ML...Infuse over 2 HOURS" Review of photographs on 11/13/2017 submitted by the complainant revealed patient #7 was to receive Vancomycin 1250 MG in 250 ML (Milliliters) of 0.9% Sodium Chloride fluid on 09/19/2017. Review revealed the antibiotic was to be infused in a two hour timeframe. Review of letter to RN #5 from the NCBON dated 10/ 7 revealed a complaint had been received and alleged that RN #5 "failed to maintain minimum standards of practice related to setting the IV pump at the wrong rate for the Vancomycon (sic) infusion and may have neglected a patient whose IV had infiltrated while the Vancomycin was infusing on or about 09/19/2017." Review of written statement by RN #5 on 10/31/2017 dated 10/18/2017 revealed on" September 19, 2017 I began infusing the medication vancomycin for the patient regarding this complaint. It was around 1730 when I started the vancomycin at less than the ordered rate. The vancomycin was ordered to infuse within the hour; however I chose not to run it at that exact rate....Within 5-10 minutes of beginning infusion the nursing assistant came to let me know the IV had started to beeping and the arm had appeared to be swollen. Review of a reporting document on 10/31/2017 from the named facility by the CNO dated 10/31/2017 at 1430 revealed the CNO called and left a message with the NCBON concerning an incident involving the IV removal for patient #7. Review revealed a return call from the NCBON was received 10/31/2017 at 1441 and both the CNO and RN #7 were involved in the conversation. Review revealed the CNO and RN #7 made the NCBON aware of the follow up to the letter sent to RN #5 from the NCBON. The investigation confirmed that RN #5 instructed NA #2 to "...stop an IV pump, at which medication was being infused, and to remove an IV before the nurse actually assessed the site...So at this time we believe the nurse in fact direct a NA to practice outside of her scope. Review revealed the NCBON was satisfied and complaint form was submitted and no further action needed to be taken by the NCBON. Interview attempted on 10/31/2017 with RN #5 but RN #5 was not available per interview with RN #7 (Director of Critical Care Units)on 10/31/2017 at 1200. Interview on 11/01/2017 with a Pharmacist at 1530 revealed medication mixed by the pharmacy and sent to the floor will have a label attached with instructions to include the medication infusion rate. Interview revealed the system would not allow the reprinting of the label for patients over thirty days. Interview revealed the order and what was on the label could be reprinted. Interview with the CNO on 10/31/2017 at 1419 revealed a written statement by RN #5 was provided. The written statement was reviewed and has been incorporated into the survey. Interview revealed the CNO was not aware of the complaint concerning patient #7, until RN #5 received a letter from the NCBON. Interview revealed RN #5 received the letter and notified the contract agency and the hospital's HR (Human Resources) Department. There are no available dates as to when the agency and HR department was notified. Interview revealed the CNO was under the impression that patient # 7's family was complaining about a NA not being qualified to remove an IV. The CNO stated "That is not correct NA's can remove IV's if they are trained. The issue was closed. But after reviewing the file today I realized it was more than just complaining..." Interview revealed the CNO became aware of the issues on 10/31/2017 and reported the issues to the NCBON. NC 697 |
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| VIOLATION: CONTENT OF RECORD | Tag No: A0458 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical staff rules, medical record review, staff interview, internal email review, personnel record review, and deficiency statistic summary report review MD #1 failed to complete a history and physical within 24 hours for 1 of 5 medical records reviewed where MD #1 was the admitting physician. Review on 11/01/2017 of "MEDICAL STAFF RULES AND REGULATIONS" last revised 04/24/2017 revealed "...a. An Admission History and Physical Examination or Updated History and Physical Examination must be entered in the medical record by the attending physician or his/her designated covering physician within 24 hour of admission ..." Review on 10/31/2017 of Patient #3's medical record revealed an [AGE] year old female admitted on [DATE] at 0320. Review of MD #2's emergency room note revealed "...arrives to the ED (emergency department) with social worker...for admission for neglect...Patient has hx (history) of [DIAGNOSES REDACTED] and has not had a bowel movement in 5 days. Patient normally is supposed to be disimpacted every other day...After the evaluation in the Emergency Department, my clinical impression is medical screening evaluation, [DIAGNOSES REDACTED] wheelchair bound not ambulatory, victim of neglect, constipation. PLAN admitted to pediatrics..." Review of Patient #3's orders revealed a telephone order from MD #1 "...Admit to PEDS (pediatrics)..." Further review of Patient #3's medical record on 10/31/2017 failed to reveal a history and physical by the admitting physician MD #1. A history and physical for Patient #3 was requested from the facility on 10/31/2017. Continued review of Patient #3's medical record revealed Patient #3 was discharged on [DATE] at 1254 to her grandmother's custody. Facility staff provided a history and physical for Patient #3 on 11/01/2017. Review of Patient #3's history and physical on 11/01/2017 revealed MD #1's signature and "...DD/TD (Date Dictated/Time Dictated): 11/01/2017 10:41:53 AM DT/TT (Date Transcribed/Time Transcribed): 11/01/2017 12:15:17 PM..." (23 days after Patient #3 was admitted ) Review of Patient #3's history and physical on 11/01/2017 at 1350 with HIM Manager revealed "DD/TD stood for Date Dictated/Time Dictated and DT/TT stood for Date Transcribed/Time Transcribed." Interview with HIM Manager on 11/01/2017 at 1605 revealed a history and physical should be completed within 24 hours of a patient's admission to the hospital. Interview revealed if a history and physical was not completed within 24 hours physicians would get a deficiency on their EMR (electronic medical record) account. Interview revealed the incomplete history and physical would go into the physician's work list in the EMR for them to complete. Interview revealed the HIM Manager kept a record of physicians who had been deficient in completing documents of patient's medical records. Incomplete documents that would trigger a deficiency in the EMR would be a history and physical, discharge summary, or unsigned orders. Interview revealed if a physician was deficient with completing documents in the medical record after 14 and 21 days the HIM analyst called their office. Interview revealed if the physician was still delinquent at or past 30 days they would get an email from the HIM Manager. Interview revealed the email was copied to the medical executive committee who decided if physicians would be suspended. Interview revealed the medical executive committee sent out suspension letters for physicians. Interview revealed physicians would be suspended for a minimum of 24 hours. Review of internal emails from the HIM Manager to MD #1 revealed an email was sent on 10/19/2017 to MD #1 that showed his deficiencies and requested them to be completed by 10/26/2017. Review of the email revealed MD #1 had a total number of 466 deficiencies for documents of incomplete medical records. Review revealed 228 deficiencies were more than 30 days past due. Review of the "Deficiency Statistics Summary by Physician Report" dated 10/25/2017 revealed MD #1 had a total of 343 deficiencies for documents of incomplete medical records. Review of a report dated 11/01/2017 revealed MD #1 had a total of 248 deficiencies for documents of incomplete medical records. Interview on 11/01/2017 at 1725 with HIM Manager after review of MD #1's deficiencies revealed "this is a pattern." Interview revealed HIM Manager planned to send MD #1's deficiencies to the medical executive committee on 11/01/2017 where suspension would be decided. |
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