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CHRISTUS GOOD SHEPHERD MEDICAL CENTER MARSHALL 811 S WASHINGTON MARSHALL, TX 75670 Nov. 18, 2014
VIOLATION: CARE OF PATIENTS - RESPONSIBILITY FOR CARE Tag No: A0068
Based on document review and interview the facility failed to insure the physician documented awareness of a medication error that occurred with 1 of 20 patients (#1) reviewed.

On 11/18/2014 at 9:20 in the Administrators office a medication error report was reviewed and confirmed that patient (Pt/pt) #1 received the wrong oral medication on 5/23/2014 at 1035 PM. Pt #1 was given oral Lopressor 25 mg. Lopressor is an antihypertensive drug used to lower the blood pressure. Pt #1 did not have high blood pressure. Pt #1 had low blood pressure. The medication error report indicated the wrong patient's medication had been prepared and given to pt #1.

On 11/18/2014 at 9:30 AM the medical record (MR) of pt #1 was reviewed and revealed the following: on 5/23/2014 at 2230 (1030 PM), the Registered Nurse (RN) documented "BP (blood pressure) meds (medications) given to pt. MD (Medical Doctor) notified. New orders noted". Review of the physician's telephone orders found no new order written. The only order written on 5/23/2014 was timed at 1805 (6:05 PM). The next physician's order appeared on 5/24/2014 at 1550 (3:50 PM) This order was electronically signed by physician #6, the on-call physician at 1743 (5:43 PM).

Further review of the MR revealed no documentation from the On-call physician that the RN, staff #8 had notified him that #1 had received oral Lopressor by mistake.

On 11/18/2014 in the administrators office staff #2 confirmed the above findings.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review and interview the facility failed to insure the Registered Nurse assessed 1 of 20 patients after a medication error was discovered.

On 11/18/2014 at 9:20 in the Administrators office a medication error report was reviewed and confirmed that patient (Pt/pt) #1 received the wrong oral medication on 5/23/2014 at 1035 PM. Pt #1 was given oral Lopressor 25 mg. Lopressor is an antihypertensive drug used to lower the blood pressure. Pt #1 did not have high blood pressure. Pt #1 had low blood pressure. The medication error report indicated the wrong patient's medication had been prepared and given to pt #1.

On 11/18/2014 at 9:30 AM the medical record (MR) of pt #1 was reviewed and revealed the following: on 5/23/2014 at 2230 (1030 PM), the Registered Nurse (RN) documented "BP (blood pressure) meds (medications) given to pt. MD (Medical Doctor) notified. New orders noted". Review of the physician's telephone orders found no new order written. The only order written on 5/23/2014 was timed at 1805 (6:05 PM). The next physician's order appeared on 5/24/2014 at 1550 (3:50 PM) This order was electronically signed by physician #6, the on-call physician at 1743 (5:43 PM).

Further review of pt #1's MR revealed that in the absence of physician orders the RN documented the following: Pulse, Respirations and blood pressure in that order;
At 2230 (1030 PM) 80, 20, 107/54.
At 2300 (1100 PM) 75, 18, 116/50.
At 0045 (1245 AM) 70, 20, 105/56.
At 0130 (1:30 AM) 72, 18, 100/53.
At 0231 (2:31 AM) 70, 18, 98/54.
At 0300 (3:00 AM) only the pulse of 68 and blood pressure of 105/62 was recorded.
On 5/24/2014 at 0700 the vitals signs were recorded as follows; 81,18, 102/47.

The RN failed to fully evaluate pt #1. The documentation reflected the only full assessment conducted was documented at 19:17 (7:17 PM) on 5/23/2014. Nursing documentation did not reflect any new order was written. The documentation did not reflect the patient or his family was given any expectation of what was to follow after the wrong medication was given to him. Documentation did not reflect the RN asked the patient how he felt after giving him the wrong medicine. There were no changes to the patient's care plan and no documentation of follow with either the patient or his family prior to leaving the hospital.
VIOLATION: REPORTING ADVERSE EVENTS Tag No: A0508
Based upon document review and interview the facility failed to thoroughly investigate 1 event where medication was administered to the wrong patient, and failed to document the on-call physician and admitting physician were notified of the drug error in 1 of 20 patients reviewed.

On 11/18/2014 at 9:20 in the Administrator's office a medication error report was reviewed and confirmed that patient (Pt/pt) #1 received the wrong oral medication on 5/23/2014 at 1035 PM. Pt #1 was given oral Lopressor 25 mg. Lopressor is an antihypertensive drug used to lower the blood pressure. Pt #1 did not have high blood pressure. Pt #1 had low blood pressure. The medication error report indicated the wrong patient's medication had been prepared and given to pt #1.

Further review of the medication error report revealed the pharmacist requested further information regarding the error. The following statement was identified: "I need more information about the med that was given in error. Was it (the) wrong patient, wrong med, or what?" The pharmacist was only given a description of the medication error.

The following documentation was identified in pt #1's MR but was not included in the medication error report received by the pharmacist. "BP (blood pressure) meds (medications) given to pt. MD (Medical Doctor) notified. New orders noted". Review of the physician's telephone orders indicated no orders were written. Review of the physician's telephone orders revealed the only order written on 5/23/2014 was timed at 1805 (6:05 PM).The medication error occurred 3.5 hours later. The next physician's order appeared the next day on 5/24/2014 at 1550 (3:50 PM) This order was electronically signed by physician #6, the on-call physician on 5/24/2014 at 1743 (5:43 PM). This order was written 21 hours after the medication error.

Without documentation of a new order there was no indication which physician had been notified of the medication error, or if any physician had actually been notified of the medication error. Review of the physician schedules indicated an on-call physician was scheduled, not the admitting physician.

On 11/18/2014 at 11:00 AM in the administrator's office an interview with staff #7 revealed notification of physician's of medication errors involving their patients was not reflected in the pharmacy reviews. Staff #7 further indicated she reviewed all medication error reports that came to the pharmacy. She found consistently the physician failed to document notification of medication errors. This was confirmed by staff #2.

On 11/18/2014 at 11:30 AM Policy number II-C-19 Reporting of Medication Errors was reviewed and revealed the following: "Each medication error will be reported by the healthcare team member who discovers the error. The person who discovers the error will complete a Medication Error Report Form, and submit it to the Director of Pharmacy. Medication Errors may also be reported by calling the Safety Hotline as 6600. After reviewing the Medication Errors Report, The Director of Pharmacy refers the error to the Director of the unit on which the error occurred for further investigation. Findings are resubmitted to the Director of Pharmacy. The Director of Pharmacy tracks trends the errors and reports findings quarterly to the Medication use team".

The policy for Reporting of Medication Errors failed to 1.) contain notification of the on-call physician nor the admitting physician after recognizing an error has occurred. 2.) indicate whose responsibility it would be to notify the admitting physician.

There was no documentation the pharmacy department had notified either the on-call physician or the admitting physician upon completion of their investigation. Documentation from the pharmacy department indicated minimal involvement in the investigation and resolution process.