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.

METHODIST HOSPITAL 7700 FLOYD CURL DR SAN ANTONIO, TX 78229 June 12, 2019
VIOLATION: CARE OF PATIENTS Tag No: A0063
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interviews and policy review the hospital failed to meet the requirement because the hospital failed to ensure staff members followed federal hospital regulations in the administration of injectable medications as well as the reporting of medication errors identified while conducting a complaint survey for Patient #1.

Findings Include:

1. Medical Record Review:

a. The medical record for Patient #1 was reviewed in part on 06/11/19 at 3:40 p.m. in the office of the CEO and revealed a [AGE] year-old, pregnant, intubated patient in the Intensive Care unit with physician orders given on 02/13/19 at 0852 for an IV Fentanyl drip for sedation to be started at the initial rate of 25 mcg/hr, to be titrated by 25 mcg/hr every 30 minutes with a maximum rate of 200 mcg/hr. A flowsheet dated 02/13/19 noted under the "9A" column "Fentanyl 100 mcg @100mcg/hr" and noted under the "10A" column "150 mcg/hr."

b. The medical record was reviewed in part with Staff #3 on 06/12/19 at 11:33 a.m. in the office of the CEO and in the presence of Staff #1 and Staff #7 and revealed the following:

Staff #3 (nurse) reviewed and read out loud the physician order dated 02/13/19 as follows, "The order was entered by Dr. ... at 8:52 a.m. The order was written for Fentanyl volume 100 cc's to start at the initial rate of 25 mcg/hr. Titrate by 25 mcg/hr every 30 minutes. Maximum rate: 200 mcg/hr."

Staff #3 (nurse) reviewed the flowsheet dated 02/13/19 that noted under the "9A" column "Fentanyl @ 100 mcg/hr." Staff #3 read out loud the entry on the flowsheet as follows, "I have it listed at 100 mcg's/hr." Staff #3 could not provide an exact time.

2. Interviews:

a. During an interview of Staff #3 on 06/12/19 at 11:33 a.m. in the office of the CEO, Staff #3 confirmed that the order written by the physician was for 25 mcg's per hour but the Fentanyl was not started at 25 mcg's/hr. Staff #3 stated, "It was started at 100 mcg's which is what I wrote down." When asked why the 100 mcg's would have been started instead of 25 mcg's per hour according to the physician order, Staff #3 responded, "nurse discretion." Staff #3 was asked if she contacted the physician about increasing the rate from the order stated, "I don't remember talking to the physician after the order for Fentanyl was given." In addition Staff #3 confirmed that at some point before 10:30 a.m. and after the initial rate of the Fentanyl at 100 mcg/hr, the rate was titrated to 150 mcg/hr. Staff #3 was shown the order and confirmed that if the order had been followed according to the physician, the rate would have been 75 mcg/hr at 10:30 a.m. Neither Staff #1, Staff #3, nor Staff #7 could provide any documentation that the rate of a medication could be increased without contacting the physician. Staff #1, Staff #3, nor Staff #7 could provide standing orders or any other written documentation such as a policy or protocol referring to the use of "nurse discretion."

The word "discretion," is defined in the on-line Merriam-Webster dictionary in part as:
"1a: individual choice or judgment ..."

During an interview of Staff #3 on 06/12/19 at 3:54 p.m. in the office of the CEO in the presence of Staff #1, Staff #3 was asked if she remembered anyone in nursing leadership talking to her or counseling her after the medication event on 02/13/19 about her not starting the Fentanyl drip at the rate ordered by the physician at 25 mcg/hr but instead starting it at 100 mcg/hr. She responded that she did not remember anyone talking to her about that or counseling her about starting the Fentanyl drip at 100 mcg/hr instead of the rate of 25 mcg ordered by the physician.

b. Physician #1 and Physician #2 were interviewed in the presence of Staff #1 on 06/12/19 at 12:23 p.m. in a dictation room in ICU and revealed the following:

Physician #1 reviewed the order for the Fentanyl drip dated 02/13/19 and signed by a physician for a "Fentanyl drip, initial rate: 25 mcg/hr, titrate by: 25 mcg/hr every 30 minutes, goal: maintain RASS of -2 to 10, maximum rate: 200 mcg/hr." According to Physician #1, he stated, "I would expect the nurse to start it as ordered." Physician #2 reviewed the order and agreed with Physician #1.

According to Physician #1, he would expect the nurse to follow the order, to see if the patient was comfortable or not and every hour to increase the medication according to the parameters. At 6 hours it may be up to 200. If a nurse thinks a patient needs more medication, she will tell him and he will agree or disagree and put an order in. One of the intensivists is in the ICU unit 24 hours a day, seven days a week. An intensivist is always available for all patients if a nurse has a question.

According to Physician #2 the issue is communication. He expects the nurse to communicate. Physician #1 stated, "We don't want a nurse doing something and we don't know about it."

c. During an interview of Staff #6 on 06/12/19 at 4:02 p.m. in the office of the CEO in the presence of S#1, Staff #6 recalled that either Staff #2 or the former Chief Nursing Officer asked Staff #3 to to show them the original physician order for Fentanyl. According to Staff#6, whoever asked that question asked Staff #3 what she was running the rate at, it was at a higher number than the order was for and Staff #6 stated, "The whole group told her you can't be doing that."

Staff #6 was asked if Staff #3 was written up for administering the Fentanyl at a higher rate than ordered and Staff #6 admitted that she had not written Staff #3 up. Staff #6 stated, "The focus there was that everyone work within their scope." Staff #6 confirmed that Staff #3 did not follow the order as written to start the Fentanyl drip at 25 mcg/hr. Staff #6 acknowledged that it was not within Staff #3's scope to administer the Fentanyl drip at a higher rate than ordered by a physician.

Neither Staff #1 nor Staff #6 could provide written documentation that the hospital had identified, addressed and investigated the medication error that Staff #3 had not started the Fentanyl drip at 25 mcg/hr as ordered by the physician but had instead started the drip at 100mcg/hr.

3. Policy Review:

a. The hospital policy entitled, "Medication Administration," with a last revised date of "09/2015," was reviewed on 06/05/19 at 4:50 p.m. in the office of the CEO and stated the following in part:

POLICY: ...B. Medication is administered only with the written or verbal order from a licensed practitioner.

b. The hospital policy entitled, "Medication Variance Reporting," with a last revised date of "05/2018," was reviewed on 06/11/19 at 10:50 a.m. in the office of the CEO and stated the following in part:

PURPOSE: ...3. To establish a process for tracking and review of medication variances to facilitate the identification of cause, risk, and identify improvements needed in the medication process.

TYPES OF MEDICATION ERRORS
...Wrong Rate/Flow error: Administration an Injectable medication at a rate that is faster or slower than what was ordered or was appropriate for the medication that was being given.

REPORTING MEDICATION ERRORS
...4. Medication Variance Report - All medication errors must be reported using the risk management module (under medication event) in Meditceh by the employee involved or the employee who discovers the error before the shift is finished. If there is a serious adverse outcome the Director of Pharmacy, Nurse Director/Department Director, Director Quality/Risk Management will be notified immediately (in addition to the responsible physician).
5. Nurse/Department Director will complete screens for investigation and follow-up of the error.
6. Reports will be forwarded to the Director of Pharmacy for review, analysis and reporting.
7. Pharmacy will provide the Quality/Risk Management Department with information on medication variance reports in those cases where there is a serious adverse outcome (Category E-I).

REVIEW OF MEDICATION ERRORS
1. Medication errors will be reviewed promptly ...

c. The hospital policy entitled, "Tapering of Medications: Titration of Medications," with a last revised date of "07/2010," was reviewed on 06/12/19 at 1:45 p.m. and stated the following in part:

PURPOSE: To provide requirements of orders for titrating or tapering medications.

DEFINITIONS:
...Titration of medications is the progressive increase or decrease of the medication dose in response to the patient's clinical status.

POLICY:
...B. Titration orders must include the desired physiologic state the prescriber desires for the patient ... Specific drug dosage adjustment increments must be known before titrating. For titrated medications: Orders must include all five elements listed below:

1. Initial Dose
2. Incremental dose
3. Time interval for incremental dose
4. Maximum dose
5. Patient (response) goal ...
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interviews and policy review the hospital failed to meet the requirement because the hospital did not ensure that a nurse, Staff #3 administered an IV drip at the rate ordered by the physician for Patient #1 identified while conducting a complaint survey for Patient #1.

Findings Include:

1. Medical Record Review:

a. The medical record for Patient #1 was reviewed in part on 06/11/19 at 3:40 p.m. in the office of the CEO and revealed a [AGE] year-old, pregnant, intubated patient in the Intensive Care unit with physician orders given on 02/13/19 at 0852 for an IV Fentanyl drip for sedation to be started at the initial rate of 25 mcg/hr, to be titrated by 25 mcg/hr every 30 minutes with a maximum rate of 200 mcg/hr. A flowsheet dated 02/13/19 noted under the "9A" column "Fentanyl 100 mcg @100mcg/hr" and noted under the "10A" column "150 mcg/hr."

b. The medical record was reviewed in part with Staff #3 on 06/12/19 at 11:33 a.m. in the office of the CEO and in the presence of Staff #1 and Staff #7 and revealed the following:

Staff #3 (nurse) reviewed and read out loud the physician order dated 02/13/19 as follows, "The order was entered by Dr. ... at 8:52 a.m. The order was written for Fentanyl volume 100 cc's to start at the initial rate of 25 mcg/hr. Titrate by 25 mcg/hr every 30 minutes. Maximum rate: 200 mcg/hr."

Staff #3 (nurse) reviewed the flowsheet dated 02/13/19 that noted under the "9A" column "Fentanyl @ 100 mcg/hr." Staff #3 read out loud the entry on the flowsheet as follows, "I have it listed at 100 mcg's/hr." Staff #3 could not provide an exact time.

2. Interviews:

a. During an interview of Staff #3 on 06/12/19 at 11:33 a.m. in the office of the CEO, Staff #3 confirmed that the order written by the physician was for 25 mcg's per hour but the Fentanyl was not started at 25 mcg's/hr. Staff #3 stated, "It was started at 100 mcg's which is what I wrote down." When asked why the 100 mcg's would have been started instead of 25 mcg's per hour according to the physician order, Staff #3 responded, "nurse discretion." Staff #3 was asked if she contacted the physician about increasing the rate from the order stated, "I don't remember talking to the physician after the order for Fentanyl was given." In addition Staff #3 confirmed that at some point before 10:30 a.m. and after the initial rate of the Fentanyl at 100 mcg/hr, the rate was titrated to 150 mcg/hr. Staff #3 was shown the order and confirmed that if the order had been followed according to the physician, the rate would have been 75 mcg/hr at 10:30 a.m. Neither Staff #1, Staff #3, nor Staff #7 could provide any documentation that the rate of a medication could be increased without contacting the physician. Staff #1, Staff #3, nor Staff #7 could provide standing orders or any other written documentation such as a policy or protocol referring to the use of "nurse discretion."

The word "discretion," is defined in the on-line Merriam-Webster dictionary in part as:
"1a: individual choice or judgment ..."

During an interview of Staff #3 on 06/12/19 at 3:54 p.m. in the office of the CEO in the presence of Staff #1, Staff #3 was asked if she remembered anyone in nursing leadership talking to her or counseling her after the medication event on 02/13/19 about her not starting the Fentanyl drip at the rate ordered by the physician at 25 mcg/hr but instead starting it at 100 mcg/hr. She responded that she did not remember anyone talking to her about that or counseling her about starting the Fentanyl drip at 100 mcg/hr instead of the rate of 25 mcg ordered by the physician.

b. Physician #1 and Physician #2 were interviewed in the presence of Staff #1 on 06/12/19 at 12:23 p.m. in a dictation room in ICU and revealed the following:

Physician #1 reviewed the order for the Fentanyl drip dated 02/13/19 and signed by a physician for a "Fentanyl drip, initial rate: 25 mcg/hr, titrate by: 25 mcg/hr every 30 minutes, goal: maintain RASS of -2 to 10, maximum rate: 200 mcg/hr." According to Physician #1, he stated, "I would expect the nurse to start it as ordered." Physician #2 reviewed the order and agreed with Physician #1.

According to Physician #1, he would expect the nurse to follow the order, to see if the patient was comfortable or not and every hour to increase the medication according to the parameters. At 6 hours it may be up to 200. If a nurse thinks a patient needs more medication, she will tell him and he will agree or disagree and put an order in. One of the intensivists is in the ICU unit 24 hours a day, seven days a week. An intensivist is always available for all patients if a nurse has a question.

According to Physician #2 the issue is communication. He expects the nurse to communicate. Physician #1 stated, "We don't want a nurse doing something and we don't know about it."

c. During an interview of Staff #6 on 06/12/19 at 4:02 p.m. in the office of the CEO in the presence of S#1, Staff #6 recalled that either Staff #2 or the former Chief Nursing Officer asked Staff #3 to to show them the original physician order for Fentanyl. According to Staff#6, whoever asked that question asked Staff #3 what she was running the rate at, it was at a higher number than the order was for and Staff #6 stated, "The whole group told her you can't be doing that."

Staff #6 was asked if Staff #3 was written up for administering the Fentanyl at a higher rate than ordered and Staff #6 admitted that she had not written Staff #3 up. Staff #6 stated, "The focus there was that everyone work within their scope." Staff #6 confirmed that Staff #3 did not follow the order as written to start the Fentanyl drip at 25 mcg/hr. Staff #6 acknowledged that it was not within Staff #3's scope to administer the Fentanyl drip at a higher rate than ordered by a physician.

Neither Staff #1 nor Staff #6 could provide written documentation that the hospital had identified, addressed and investigated the medication error that Staff #3 had not started the Fentanyl drip at 25 mcg/hr as ordered by the physician but had instead started the drip at 100mcg/hr.

3. Policy Review:

a. The hospital policy entitled, "Medication Administration," with a last revised date of "09/2015," was reviewed on 06/05/19 at 4:50 p.m. in the office of the CEO and stated the following in part:

POLICY: ...B. Medication is administered only with the written or verbal order from a licensed practitioner.

b. The hospital policy entitled, "Medication Variance Reporting," with a last revised date of "05/2018," was reviewed on 06/11/19 at 10:50 a.m. in the office of the CEO and stated the following in part:

PURPOSE: ...3. To establish a process for tracking and review of medication variances to facilitate the identification of cause, risk, and identify improvements needed in the medication process.

TYPES OF MEDICATION ERRORS
...Wrong Rate/Flow error: Administration an Injectable medication at a rate that is faster or slower than what was ordered or was appropriate for the medication that was being given.

REPORTING MEDICATION ERRORS
...4. Medication Variance Report - All medication errors must be reported using the risk management module (under medication event) in Meditceh by the employee involved or the employee who discovers the error before the shift is finished. If there is a serious adverse outcome the Director of Pharmacy, Nurse Director/Department Director, Director Quality/Risk Management will be notified immediately (in addition to the responsible physician).
5. Nurse/Department Director will complete screens for investigation and follow-up of the error.
6. Reports will be forwarded to the Director of Pharmacy for review, analysis and reporting.
7. Pharmacy will provide the Quality/Risk Management Department with information on medication variance reports in those cases where there is a serious adverse outcome (Category E-I).

REVIEW OF MEDICATION ERRORS
1. Medication errors will be reviewed promptly ...

c. The hospital policy entitled, "Tapering of Medications: Titration of Medications," with a last revised date of "07/2010," was reviewed on 06/12/19 at 1:45 p.m. and stated the following in part:

PURPOSE: To provide requirements of orders for titrating or tapering medications.

DEFINITIONS:
...Titration of medications is the progressive increase or decrease of the medication dose in response to the patient's clinical status.

POLICY:
...B. Titration orders must include the desired physiologic state the prescriber desires for the patient ... Specific drug dosage adjustment increments must be known before titrating. For titrated medications: Orders must include all five elements listed below:

1. Initial Dose
2. Incremental dose
3. Time interval for incremental dose
4. Maximum dose
5. Patient (response) goal ...
VIOLATION: HOSPITAL PROCEDURES Tag No: A0410
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interviews and policy review the hospital failed to meet the requirement because the hospital failed to ensure staff members followed federal hospital regulations in the administration of injectable medications as well as the reporting of medication errors identified while conducting a complaint survey for Patient #1.

Findings Include:

1. Medical Record Review:

a. The medical record for Patient #1 was reviewed in part on 06/11/19 at 3:40 p.m. in the office of the CEO and revealed a [AGE] year-old, pregnant, intubated patient in the Intensive Care unit with physician orders given on 02/13/19 at 0852 for an IV Fentanyl drip for sedation to be started at the initial rate of 25 mcg/hr, to be titrated by 25 mcg/hr every 30 minutes with a maximum rate of 200 mcg/hr. A flowsheet dated 02/13/19 noted under the "9A" column "Fentanyl 100 mcg @100mcg/hr" and noted under the "10A" column "150 mcg/hr."

b. The medical record was reviewed in part with Staff #3 on 06/12/19 at 11:33 a.m. in the office of the CEO and in the presence of Staff #1 and Staff #7 and revealed the following:

Staff #3 (nurse) reviewed and read out loud the physician order dated 02/13/19 as follows, "The order was entered by Dr. ... at 8:52 a.m. The order was written for Fentanyl volume 100 cc's to start at the initial rate of 25 mcg/hr. Titrate by 25 mcg/hr every 30 minutes. Maximum rate: 200 mcg/hr."

Staff #3 (nurse) reviewed the flowsheet dated 02/13/19 that noted under the "9A" column "Fentanyl @ 100 mcg/hr." Staff #3 read out loud the entry on the flowsheet as follows, "I have it listed at 100 mcg's/hr." Staff #3 could not provide an exact time.

2. Interviews:

a. During an interview of Staff #3 on 06/12/19 at 11:33 a.m. in the office of the CEO, Staff #3 confirmed that the order written by the physician was for 25 mcg's per hour but the Fentanyl was not started at 25 mcg's/hr. Staff #3 stated, "It was started at 100 mcg's which is what I wrote down." When asked why the 100 mcg's would have been started instead of 25 mcg's per hour according to the physician order, Staff #3 responded, "nurse discretion." Staff #3 was asked if she contacted the physician about increasing the rate from the order stated, "I don't remember talking to the physician after the order for Fentanyl was given." In addition Staff #3 confirmed that at some point before 10:30 a.m. and after the initial rate of the Fentanyl at 100 mcg/hr, the rate was titrated to 150 mcg/hr. Staff #3 was shown the order and confirmed that if the order had been followed according to the physician, the rate would have been 75 mcg/hr at 10:30 a.m. Neither Staff #1, Staff #3, nor Staff #7 could provide any documentation that the rate of a medication could be increased without contacting the physician. Staff #1, Staff #3, nor Staff #7 could provide standing orders or any other written documentation such as a policy or protocol referring to the use of "nurse discretion."

The word "discretion," is defined in the on-line Merriam-Webster dictionary in part as:
"1a: individual choice or judgment ..."

During an interview of Staff #3 on 06/12/19 at 3:54 p.m. in the office of the CEO in the presence of Staff #1, Staff #3 was asked if she remembered anyone in nursing leadership talking to her or counseling her on 02/13/19 about her not starting the Fentanyl drip at the rate ordered by the physician at 25 mcg/hr but instead starting it at 100 mcg/hr. Staff #3 responded that she did not remember anyone talking to her about that or counseling her about starting the Fentanyl drip at 100 mcg/hr instead of the rate of 25 mcg ordered by the physician.

b. During an interview of Staff #6 on 06/12/19 at 4:02 p.m. in the office of the CEO in the presence of Staff #1, Staff #6 recalled that either Staff #2 or the former Chief Nursing Officer asked Staff #3 to show them the original physician order for Fentanyl. According to Staff#6, whoever asked that question asked Staff #3 what she was running the rate at, it was at a higher number than the order was for and Staff #6 stated, "The whole group told her you can't be doing that."

Staff #6 was asked if Staff #3 was written up for administering the Fentanyl at a higher rate than ordered and Staff #6 admitted that she had not written Staff #3 up. Staff #6 stated, "The focus there was that everyone work within their scope." Staff #6 confirmed that Staff #3 did not follow the order as written to start the Fentanyl drip at 25 mcg/hr. Staff #6 acknowledged that it was not within Staff #3's scope to administer the Fentanyl drip at a higher rate than ordered by a physician.

Neither Staff #1 nor Staff #6 could provide written documentation that the hospital had identified, addressed and investigated the medication error that Staff #3 had not started the Fentanyl drip at 25 mcg/hr as ordered by the physician but had instead started the drip at 100mcg/hr.

c. During an interview of Staff #1 on 06/12/19 at 3:11 p.m. in the office of the CEO, according to Staff #1 it was noticed that the order was not followed for the rate ordered and Staff #2 had talked to Staff #3 about her not following the physician order for starting the Fentanyl at 25 mcg/hr but Staff #1 could not provide any written documentation that the hospital had identified and addressed the drug error made by the nurse, Staff #3.

3. Policy Review:

The hospital policy entitled, "Medication Variance Reporting," with a last revised date of "05/2018," was reviewed on 06/11/19 at 10:50 a.m. in the office of the CEO and stated the following in part:

PURPOSE: ...3. To establish a process for tracking and review of medication variances to facilitate the identification of cause, risk, and identify improvements needed in the medication process.

TYPES OF MEDICATION ERRORS
...Wrong Rate/Flow error: Administration an Injectable medication at a rate that is faster or slower than what was ordered or was appropriate for the medication that was being given.

REPORTING MEDICATION ERRORS
...4. Medication Variance Report - All medication errors must be reported using the risk management module (under medication event) in Meditceh by the employee involved or the employee who discovers the error before the shift is finished. If there is a serious adverse outcome the Director of Pharmacy, Nurse Director/Department Director, Director Quality/Risk Management will be notified immediately (in addition to the responsible physician).
5. Nurse/Department Director will complete screens for investigation and follow-up of the error.
6. Reports will be forwarded to the Director of Pharmacy for review, analysis and reporting.
7. Pharmacy will provide the Quality/Risk Management Department with information on medication variance reports in those cases where there is a serious adverse outcome (Category E-I).

REVIEW OF MEDICATION ERRORS
1. Medication errors will be reviewed promptly ...