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EAST LIVERPOOL CITY HOSPITAL 425 WEST 5TH STREET EAST LIVERPOOL, OH 43920 Feb. 20, 2020
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on document review and staff interviews, the facility failed to ensure medications were administered in accordance with physician orders and acceptable standard concentration and titration orders for intravenous (IV) medications. This affected one of three patients whose medical records were reviewed for IV medication administration, Patient #4. A total of 10 medical records were reviewed. The facility's census was 56.

Findings include:

Facility reference document Standard Concentration and Titration Orders for Commonly Used Intravenous Medications was reviewed with Staff A on 02/19/20 between 2:06 PM and 2:37 PM. Per the document, the initial dose of Propofol (Diprivan) was five (5) mcg/kg/minute. The maintenance dose was able to be titrated every 10 minutes by five mcg/kg/minute, with a maximum dose of 50 mcg/kg/minute.

The initial dose of Norepinehrine (Levophed) was 2 mcg/minute. The maintenance dose was able to be titrated every five (5) minutes by two mcg/minute to achieve the goal MAP (mean arterial pressure). The maximum dose was 30 mcg/minute.

Staff A also brought an infusion pump to demonstrate how rates were calculated and programmed for these IV medication drips.

1) Patient #4's medical record revealed a 02/16/20 order at 5:55 PM for Propofol as follows: initial rate 10 mcg/kg/minute, increase by five mcg/kg/minute every 15 minutes to a desired level of consciousness of -2 (light sedation). The dose was weight dependent, and Patient #4's only documented weight was 53 kg on 02/16/20.

The Propofol drip was initiated prior to the order at 3:40 PM at 10 mcg/kg/minute, which was 3.4 cc/hr on the infusion pump.

Per a Nurses Note at 7:13 PM the Propofol drip was increased to 25 mcg/kg/minute, which nursing documented was 8.4 cc/hr on the infusion pump.

Staff A confirmed the increase from 10 mcg/kg/minute to 25 mcg/kg/minute was not in accordance with physician's order and the Standard Concentration and Titration document. Staff A stated it should have been increase no more than five mcg/kg/minute. Staff A was also confirmed the rate on the infusion pump should have been eight cc/hr.

Per a Nurses Note at 8:52 PM the Propofol drip was now running at 30 mcg/kg/minute, which nursing documented was 10.1 cc/hr on the infusion pump.

Staff A was asked to confirm the infusion rate on the pump at 30 mcg/kg/minute. Per Staff A the rate was 9.5 cc/hr, not 10.1 as nursing documented.

Patient #4's medical record revealed a 02/16/20 order at 6:35 PM for Levophed as follows: five mcg/minute. At 7:13 PM, per a Nurses Note, the Levophed drip was started at six mcg/minute. This was not in accordance with the physician's order. The nurse then documented it was titrated to four mcg/minute.

Per Nurses Note at 8:52 PM the Levophed drip was now running at five mcg/minute, and at 10:51 PM the nurse noted the rate was increased to eight mcg/minute. There was no documented evidence of a gradual titration between the five mcg/minute and the eight mcg/minute.

Per Staff A and the Standard Concentration and Titration document, the Levophed should be increased by no more than two mcg/minute every five minutes. Staff A confirmed the increase from five mcg/minute to eight mcg/minute was not appropriate.

Staff B was also present and confirmed these findings at the time of the medical record review.
VIOLATION: REPORTING ADVERSE REACTIONS AND ERRORS Tag No: A0411
Based on medical record review, policy review, review of the facility's adverse event reports and interview, the facility failed to ensure an alleged medication error was reported to the physician and entered into the facility's adverse event reporting system immediately for one patient (Patient #3). Ten medical records were reviewed. The facility's census was 56.

Findings include:

The facility's Medication Errors policy (Directive 317, revised 11/15) stated all suspected or known medication errors will be reported to the physician. All medication errors will be reported by the Nursing Team Member who discovers the error immediately to the Clinical or Shift Director with completion of Medication Incident Report in its' entirety.

An adverse event report from 12/31/19 involving Patient #3 was reviewed. The adverse event was entered into the facility's adverse event reporting system on 01/21/20. The report alleged Staff D asked Staff C to increase Patient #3's Propofol due to increased agitation. Staff D alleged Staff C increased Patient #3's Levophed instead of the Propofol. Staff D reported he/she noticed the error about 15-20 minutes later and corrected the error. The report stated that there was nobody else who witnessed the error. The report stated the error was not brought to Staff C's attention at that time and was not reported to the nursing supervisor or Patient #3's physician

The medical record for Patient #3 was reviewed. The record did not contain documentation of the alleged medication error. The medical record did not contain physician notification of the alleged medication error.

Staff D was interviewed on 02/19/20 at 7:20 AM. Staff D reported Staff C increased the Patient #3's Levophed instead of the Propofol. Staff D stated she did not complete a Medication Incident Report.

Review of the personnel file of Staff D failed to reveal evidence of re-education regarding reporting medication errors after the incident.
VIOLATION: REPORTING ADVERSE EVENTS Tag No: A0508
Based on medical record review, policy review, review of the facility's adverse event reports and interview, the facility failed to ensure an alleged medication error was reported to the physician and entered into the facility's adverse event reporting system immediately for one patient (Patient #3). Ten medical records were reviewed. The facility's census was 56.

Findings include:

The facility's Medication Errors policy (Directive 317, revised 11/15) stated all suspected or known medication errors will be reported to the physician. All medication errors will be reported by the Nursing Team Member who discovers the error immediately to the Clinical or Shift Director with completion of Medication Incident Report in its' entirety.

An adverse event report from 12/31/19 involving the Patient #3 was reviewed. The adverse event was entered into the facility's adverse event reporting system on 01/21/20. The report alleged Staff D asked Staff C to increase Patient #3's Propofol due to increased agitation. Staff D alleged Staff C increased Patient #3's Levophed instead of the Propofol. Staff D reported he/she noticed the error about 15-20 minutes later and corrected the error. The report stated that there was nobody else who witnessed the error. The report stated the error was not brought to Staff C's attention at that time and was not reported to the nursing supervisor or Patient #3's physician

The medical record for Patient #3 was reviewed. The record did not contain documentation of the alleged medication error. The medical record did not contain physician notification of the alleged medication error.

Staff D was interviewed on 02/19/20 at 7:20 AM. Staff D reported Staff C increased Patient #3's Levophed instead of the Propofol. Staff D stated she did not complete a Medication Incident Report.

Review of the personnel file of Staff D failed to reveal evidence of re-education regarding reporting medication errors after the incident.