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KINGS COUNTY HOSPITAL CENTER 451 CLARKSON AVENUE BROOKLYN, NY 11203 Aug. 26, 2015
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on record review, review of relevant policies and interviews, it was determined that the hospital failed to ensure compliance with medication administration policies that require medications to be administered to patients in a safe manner to avoid errors.


Findings include:

Review of MR #2 on August 26, 2015 at 11:00 AM, identified that on 11/14/14 at 2233 hrs (10:33 PM), Lorazepam 2mg. IVP STAT was administered by the Emergency Department (ED) nurse to the patient, who was not intended to receive the drug.


At interview with the ED Nursing Director on 8/26/2015 at 11:00 AM, it was stated that this medication error was made by the ordering ED resident and that this event represented "human error." The ED RN who administered the medication was no longer employed at the facility and no interview was possible.

At interview with the Pharmacy Director on 8/26/15 at 1:00 PM , it was stated that this event was not preventable and that the system in use for checking bar codes on orders does not include patient identification.


Further review of the medical record (MR#2) identified that the indication for the administered medication was "ulcer of heel and mid-foot." This patient had no such condition during the ED visit. Lorazepam is not indicated for treatment of a foot ulcer.

Review of the policy titled "Medication Administration - Nursing Responsibilities," issued 2009 and revised 1/2015, specifically requires PRN (which includes STAT (immediate) orders where there is a specific reason for the drug) must specify the indication for the medication administration. There is no evidence the staff correlated the order with the indication for use as required by this policy.

The facility was unable to provide the medical record of the patient who was intended to receive the Lozazepam.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interviews and observation, it was determined that the emergency department did not formulate and implement policies and procedures to ensure that patients who present to the Emergency Department (ED) are provided with a timely triage assessment. Specifically, there is no guidance developed for actions to be taken for patients who are assigned to wait for complete triage after the performance of an initial visual pre-triage assessment. This finding was identified in three (3) of thirteen (13) emergency room medical records reviewed.

Findings include:

Review of MR#1 on 8/25/15 identified the following information: This patient arrived to the triage area of the walk- in ED on 7/21/15 at 1911 hours (7:11 PM) with the complaint of headache in the back of the head with nausea for 2 days. The patient was seen by the pre-triage nurse (RN) and the mini-registration clerk and the above complaint was recorded. Further review of the ED record revealed that the patient was called for full triage at 2129 hours (9:29 PM), 2 hours and 10 minutes after she was pre-triaged, and was marked "no answer." The second and third calls for the patient were made by emergency staff at 2311 hrs (11:11 PM) and 2327 hrs. (11:27 PM).

Review of MR#3 identified that this patient who was 3 months pregnant, (MDS) dated [DATE] at 1308 hrs (1:08 PM), with complaint of abdominal pain and cramping for 3 days. Patient was called for full triage at 5:01 PM with "no answer- walk out" noted. This was 3 hours and 53 minutes after receiving "visual pre-triage." Subsequent calls for triage at 1722 (5:22 PM) and 1730 (5:30 PM) revealed "no answer-walk out" notation in the record.

Review of MR#4 identified that this [AGE] year old male was "visually assessed" by the mini triage RN on 7/20/15 at 0957 ( 9:57 AM ) for complaint of abdominal pain, status post colonoscopy 2 weeks ago. At 1239 hours (12:39 PM) the patient was called for full triage with "no answer- walk out " notation. The patient was called 2 hours and 41 minutes after visual mini-triage. Subsequent calls were at 12:47 PM and again at 12:56 PM and "no answer-walk out" was recorded.

During the tour of the ED on 8/24/15, the area of the ED designated for pre-triage activity was observed. The pre-triage RN was seated at a table with a registration clerk next to her in the waiting room and patients were waiting for visual pre-triage assessment and initial "mini -registration" prior to full triage. During interview with the pre-triage RN on 8/24/15 at approximately 11:00 am, the nurse stated that she records the patients' complaints and makes a quick visual assessment (mini-triage) to determine the immediacy of the patient needs. Three options are possible: she determines if the patient needs to be transported immediately into the ED to see the MD, taken for immediate full triage assessment, or whether the patient can wait in the waiting room in the order of arrival time for full triage. There was a table set up for the taking of vital signs. The RN stated that taking vital signs is optional and dependent on whether immediate vital signs needed to be taken. This interview was conducted with the ED manager present who agreed with the nurse's answers.

Review of the Emergency Department (ED) Policy #38, titled,"Triage of Emergency Department Patients" effective 3/96 and revised 4/07/08 and 5/12 but not reviewed by the facility, states; "Walk in patients who present to the Emergency Department will be visually assessed by an RN who will assign priority. Then the patient will be triaged by an RN who will assign the ESI level (triage classification based upon Emergency Nurses Association (ENA) guidelines)." There was no standard as to expectations as to how long a patient can wait for triage after being "visually assessed" by the receiving RN.
The patients who walked out after "visual triage" were not triaged and assigned an ESI category as stated in the policy.

In addition, there were no policies and procedures to provide guidance for reassessment of patients who received "visual pre-triage assessment" but are awaiting full triage, and at what frequency this reassessment should be performed.