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UNIVERSITY MEDICAL CENTER OF EL PASO 4815 ALAMEDA AVE EL PASO, TX 79905 March 27, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview and record review the facility failed to provide care in a safe environment when (4) patients identified with medication allergies did not have the facility required red allergy bands on, to alert the staff of a possible adverse allergic reaction.

Findings:

Review of the facility provided training handout on Color-Coded Wristbands 2018 reflected, "Color-coded wristbands were created to identify patient-specific risk factors ...Red- Allergy ... Green- Latex Allergy .... Color-Coded Wristband Process
1. Initiate banding upon admission or changes in condition.
2. Colored wristbands must be placed on the same extremity as the admission identification band with the exception of the limb alert ....
5. Staff to verify the patient's color-coded 'alert' wristbands upon assessment, during hand-off of care, before invasive procedures and for facility transfer communication.
6. The patient and family will be educated on the importance of colored wristbands and the rationale on why wristbands are not to be removed ...."

Observations on the morning of 3/27/18, in the Emergency Department, revealed:
Patient#4, in room #3, did not have a red or green allergy band on to reflect allergies to Latex and Aspirin and Nitroglycerin and Patient #10, in room #37, did not have a red allergy band on to reflect an allergy to Fentanyl.

During an interview on the morning of 3/27/18, in the facility's Emergency Department (ED) Staff #4, ED Director confirmed the findings and stated, " ...We place an allergy band on anyone with an allergy, if a patient doesn't have a red band on they don't have an allergy .... the bands don't list every single thing they are allergic to .... The first person getting the allergy information pts the allergy band on the patient ...the band only says they have an allergy, you are expected to go to the chart to see what they are allergic to .... if someone has an allergy, the nurse will put it in the system ...."

Observations on the morning of 3/27/18, on the medical surgical unit, revealed:
Patient #5, in room #732, did not have a red allergy band on to reflect an allergy to Penicillin. Patient#2, in room #710, did not have a red allergy band on to reflect an allergy to Tylenol. Additionally, Patient #2 had a current order, overridden by the physician, for Tylenol #3 with Codeine PRN (as needed) for pain.


During a tour on the morning of 3/27/18, on the facility's Medical Surgical Unit Staff #7, Medical Surgical Director confirmed the findings.