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.

CLEVELAND EMERGENCY HOSPITAL 1017 S TRAVIS AVE CLEVELAND, TX 77327 July 17, 2019
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on record review and interview, the facility failed to ensure that nursing staff who were caring for patients that were on cardiac drip medication had training and current competencies to administer and titrate cardiac medications in 2 (Staff #23 &29) of 2 staff reviewed.

It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients who needed cardiac Intravenous drips at risk for the likelihood of harm, serious injury, and possibly subsequently death.


Review of medical records on July 16, 2019 revealed the following:


PATIENT # 9

Review of the physician's orders for Patient #9 revealed the following:

6-14-2019 7:30 P.M.
"Ween Dobutamine to off keeping SBP (Systolic Blood Pressure) >100" There was no parameters listed for decreasing the amount of mcg or the intervals to decrease the Dobutamine for the nurse to follow.

Review of the Daily Nurse's Note revealed the following:

6-14-2019
8:00 P.M. Dobutamine decreased to 4.3 mcg/kg/minute - Vitals were documented as BP 118/60.
8:30 P.M. Dobutamine decreased to 3.4 mcg/kg/minute - Vitals were documented as BP 137/64.
9:05 P.M. Dobutamine decreased to 2.8 mcg/kg/minute - Vitals were documented as BP 131/60.
10:00 P.M. Dobutamine decreased to 2 mcg/kg/minute - Vitals were documented as BP 119/55.
10:51 P.M. Dobutamine discontinued. Vitals were documented as BP 119/55.

Staff #23 was noted as the nurse.

PATIENT #10

Review of the physician's order for Patient #10 revealed the following:

3-11-2019 9:15 P.M.
"Start Nicardipine drip at 5 mg/hr. Titrate to SBP (Systolic Blood Pressure) < 150 mmhg" There was no parameters listed for the milligrams or the intervals to decrease the Nicardipine for the nurse to follow.

Review of the Daily Nurse's Note revealed the following:
3-11-2019
10:15 P.M. Nicardipine drip started at 5 mg/hr.

3-12-2019
12:15 A.M. Nicardipine drip decreased to 2.5 mg/hr.
2:00 A.M. Nicardipine drip stopped at this time.
Staff # 29 was noted as the nurse.


An interview with Staff #24 on July 16, 2019 after 3:00 P.M. revealed the following:

Staff #24 was asked what the facility policy was on titrating medication drips, specifically cardiac medication drips. Staff #24 stated there was not a facility policy, as it was not allowed. Staff #24 was asked what training the nurses were given at the facility on IV Cardiac medication administration. Staff #24 stated there was no specific facility policy or training for staff. Staff #24 stated the nurses had extensive experience and they used that to determine competencies. Staff #24 stated the facility did not have any specific training or competencies relating to patients on cardiac medications or titrating medications.

Staff #24 confirmed the above findings.
VIOLATION: USE OF VERBAL ORDERS Tag No: A0407
Based on record review and interview, the facility (CEH) failed to:

A. ensure that verbal orders were completed with a date, time, and dosage.
B. ensure that verbal orders were clearly and accurately written to prevent medication errors and promote safe medication administration.
C. ensure that verbal orders were authenticated promptly by the ordering practitioner.
D. develop and implement a policy on verbal orders.

The above findings were noted in 2 (Patient #'s 9 & 10) of 10 patients reviewed.

It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients who needed cardiac Intravenous drips at risk for the likelihood of harm, serious injury, and possibly subsequently death.


Findings include:


PATIENT #9

Review of Physicians Orders revealed the following:

6-14-2019 7:30 P.M.

"Ween Dobutamine (Heart mediation used to increase cardiac output) to off keeping SBP (Systolic Blood Pressure) >100" There was no parameters listed for decreasing the amount of mcg or the intervals to decrease the Dobutamine for the nurse to follow.

6-14-2019
"VOTRB from Physician #39 - Start Dobutamine at 5 mcg/kg/min" - The order had not been authenticated as of 7-16-2019, over 1 month ago.

6-14-2019
"VOTRB From Physician #39 - Increase Dobutamine to 10 mcg/kg/min" - The order had not been authenticated as of 7-16-2019, over 1 month ago.

6-14-2019
"VOTRB - Pt can have Toradol (Narcotic pain medication used for moderate to severe pain) 30 mg IVP every 6 hours PRN Pain. The order did not list any parameters for pain levels. The order had not been authenticated as of 7-16-2019, over 1 month ago.,

6-14-2019
"O2 2 lpm Nasal Cannula - The order did not list any parameters for oxygen levels.
Dobutamine decrease to 5 mcg/kg/min. The order had not been authenticated as of 7-16-2019, over 1 month ago.


Review of Patient #9's medical record for TEH revealed a copy of the same order. The order had been initialed by an illegible signature. There was no date and time with the initials. There was no way to determine who signed the order and what time it was signed.



PATIENT #10

Review of the physician's order for Patient #10 revealed the following:

3-11-2019 3:40 P.M.
"V/O Physician # 39 - Tramadol (Narcotic Medication used to treat moderate to severe pain) 50 mg PO Q 6 hours PRN Pain- There was no parameters listed for pain levels.
Phenergan 12.5 mg IVP every 6 hours PRN nausea. D/C Zofran." VORB by illegible RN. The orders had been initialed by an illegible signature. There was no date and time with the initials. There was no way to determine who signed the order and what time it was signed.

3-11-2019 8:35 P.M.
"Mag Level- may use blood in lab. Hydralazine (Blood Pressure Medication) 20 mg IVP (Intravenous Push) x1 now" by illegible RN. The orders had been initialed by an illegible signature. There was no date and time with the initials. There was no way to determine who signed the order and what time it was signed.


3-11-2019 9:15 P.M.
"Transfer to overflow for 1:1 nursing. Start Nicardipine drip at 5 mg/hr. Titrate to SBP (Systolic Blood Pressure) < 150 mmhg" by illegible RN. There were no parameters listed for the milligrams or the intervals to decrease the Nicardipine for the nurse to follow. The orders had been initialed by an illegible signature. There was no date and time with the initials. There was no way to determine who signed the order and what time it was signed.

3-14-2019 6:00 A.M.
"TORBV Physician #39/Staff #40 -
1. Hold Lisinopril & Hydralazine for Systolic <110.
2. Discontinue Lasix
3. Imodium 2 mg PO every 6 hours PRN loose stools.
4. Normal Saline @ 75 ml/hr X 1 liter "

The orders had been initialed by an illegible signature. There was no date and time with the initials. There was no way to determine who signed the order and what time it was signed.

Staff #24 confirmed the above findings.

A request for a facility policy on verbal orders was made to Staff # 1. Staff 1 was not able to provide any policy on verbal orders as of the exit date of 7-17-2019.