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.

Based on interview and document review the facility failed to conduct a thorough and complete investigation of this case with follow through by the Quality Committee. Findings are:

-The facility's patient representative stated on interview on 6/7/2018 at 9:30 AM that he had received a complaint regarding the hospital's inability to obtain medication (desmopressin) to properly care for this patient. The Patient Representative stated that he requested an investigation by the ED Medical Director and the ED Assistant Nursing Supervisor.

-Review of a 2/27/2018 e-mail from the ED Assistant Nursing Manager to the Patient Representative indicated that she confirmed with the Pharmacy Manager that desmopressin tablets were not on the hospital formulary. She apologized to the patient's family for not requesting that the family bring the desmopressin in from home sooner in the evening.

-No documentation existed that other facility staff who cared for the patient were interviewed to investigate this case and identify areas of improvement.

-Review of an undated written response from the ED Medical Director indicated that he informed the Attending Physician in Observation that the case could have been handled better.

The Patient Concern Report dated 12/19/17 used by the facility contains a summary of the complaint. The Investigation Summary section and Recommendation & Conclusion section are blank.

-Areas of failure with communication and documentation by nurses and midlevel providers were not identified.

-No documentation was provided to demonstrate that actions of all staff involved with the patient's care were reviewed by Quality.

-No written plan was presented that would describe a plan of action to address the identified problems.

-No hospital policies or procedures were modified as a result of the investigation.

-There was no documentation to indicate that the results of the investigation were presented to a Quality Committee for corrective measures.

-There was no documentation of remedial actions, thus no monitoring to determine effectiveness.
Based on medical record review, ED Nursing staff failed to include a thorough patient assessment in that an accurate reconciliation of the patient's home medications was not recorded in the medical record.

Review of the index patient's medical record on June 7, 2018 showed that documentation of home medications and medication reconciliation, recorded approximately 4:30 PM on 12/17/2017 did not list when the patient took his most recent dose for any of the 16 medications listed (including desmopressin, a medication to treat diabetes insipidus).
Based on interview and record review nursing staff failed to notify the responsible practitioner in a timely fashion, issues that impact care being provided to a patient.


The Index Patient's medical record, reviewed by survey staff on 6/7/2018, indicated that Staff #B, the Observation Unit PA who assumed care of the patient beginning at 7:00 AM on 12/18/2017, wrote an order at 9:43 AM for desmopressin 0.2 milligrams three times per day with a start time of 9:45 AM. The order was acknowledged by the RN at 9:57 AM. The order was edited by the PA and resubmitted at 1:27 PM as a medication being supplied by the patient, with a start time of 2:00PM. This order was acknowledged by the RN at 1:29PM. The Medication Administration Summary entry by the RN at 2:51 pm indicates that the medication was not given with a reason as desmopressin in tablet form taken by the patient was not on the hospital formulary. Nursing staff failed to notify the ordering provider that desmopressin had not been received from the patient's home supply and that neither dose of desmopressin had been administered to the patient. Staff # B, interviewed by survey staff on 6/13/2018, stated that had she been made aware that the patient had received no desmopressin she would have changed the order to another route of administration.
Based on interview and record review, medical record documentation by physicians, physicians assistants, and nurses concerning a serious medical condition, diabetes insipidus, and a medication used to treat it, desmopressin, is inconsistent, incorrect or absent.

Findings: The following deficiencies were identified regarding care of this patient in the Emergency Department and in the Observation Unit.

-Based on record review Emergency Department provider (Staff F) examined the Index patient on 12/17/2017. Provider notes omitted a significant past medical diagnosis (diabetes insipidus) which is not listed as a current or past problem in the ED medical record.

-The plan of care for this patient established by Staff #A, the Observation Unit PA responsible for the patient from 7:00PM on 12/17/2017 to 7:00 AM to 12/18/2017, includes continuation of prehospital medications. But review of the patient's medical records by DOH survey staff on 6/7/2018 shows that desmopressin was not recorded as a prehospital medication in this provider's History and Physical. Medication orders were entered electronically and desmopressin was not ordered by Staff #A.

-Staff #A stated on interview with the DOH on 6/12/18 at 1:00PM, that he had multiple in person and telephone conversations with the patient's at home caregiver concerning desmopressin being brought from home. Additionally, Staff #A stated that because the dosage of desmopressin was not known by the caregiver, he (Staff #A) was unable to convert to a different route of administration. DOH survey staff reviewed the patient's medical record on 6/7/2018 and found no documentation by Staff #A of conversations about medication being brought from home. There is no documentation by Staff #A concerning desmopressin dosage or the consideration of another route of administration.