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Based on record review and interview the hospital failed to ensure physicians credentialing files were maintained by failing to have documented proof of current licensure, DEA (drug enforcement agency) license, CDS (controlled dangerous substance) license, and proof of liability insurance for 5 of 5 physicians credentialing files reviewed. (S5, S6, S7, S8, S9)
Findings:

Review of the credentialing file for S5, MD, Internal medicine, revealed the following:
Louisiana State Board of Medical Examiners License- Expired 12/31/2009;
Louisiana Board of Pharmacy Controlled Dangerous Substance- Expired 07/01/2009;
Professional Liability Insurance- Expired 07/13/2009.

Review of the credentialing file for S6, MD, Nephrology, revealed the following:
Professional Liability Insurance- Expired 06/30/2009.

Review of the credentialing file for S7, MD, Internal Medicine, revealed the following:
Louisiana State Board of Medical Examiners License- Expired 10/31/2009;
United States Department of Justice Drug Enforcement Administration Certificate- Expired 03/31/2009;
Louisiana Board of Pharmacy Controlled Dangerous Substance- Expired 06/01/2009;
Professional Liability Insurance- Expired 12/31/2009.

Review of the credentialing file for S8, MD, Pulmonology, revealed the following:
Professional Liability Insurance- Expired 01/01/2010.

Review of the credentialing file for S9, MD, Cardiologist, revealed the following:
Louisiana State Board of Medical Examiners License- Expired 01/31/2010;
United States Department of Justice Drug Enforcement Administration Certificate- Expired 11/30/2009;
Professional Liability Insurance- Expired 01/10/2010.

In interview on 02/24/10 at 12:30 p.m. S1, Administrator, indicated there was a breakdown in the physician's credentialing process. S1 indicated that the updated licenses and proof of liability insurance were sent to the credentialing department via e-mail, but the current licenses were never printed and placed in the physician's files.

Review of the Medical Staff Bylaws revealed, in part, "Article IV- Appointment To The Medical Staff- 4.1 General: (c) To be eligible to apply for appointment to the medical staff, each individual must: (1) have a current, unrestricted license to practice in the State of Louisiana; (3) possess current, valid professional liability insurance coverage in a form and in amounts satisfactory to the Governing Board of the Hospital".

20177



Based on record review (medical record, hospital policy) and interview the hospital failed to ensure a registered nurse supervise and evaluate the nursing care of each patient by:

1) failing to ensure a patient's condition was monitored after being assessed as having an episode of low blood pressure for 1 of 1 record reviewed of a patient experiencing low blood pressure and failing to ensure the physician was notified when the Blood Pressure medication was held for 1 of 21 sampled patients (Patient #9).
2) failing to follow their policy and procedure for patients on telemetry monitors as evidenced by no documented evidence the rhythm strip had been assessed for heart rate, rhythm, and identification of any ectopy and the signature of the nurse or tech analyzing the strip for 4 of 4 patients who had been monitored on telemetry (#5, #6, #10, #15) of 21 sampled patients.
3) Failing to ensure a patient's blood pressure and pulse were assessed as ordered prior to the administration of Oxycodone (Patient #11).
4) Failed to ensure patient's were weighed as ordered for 3 of 21 sampled patients (Patient #7, #13, #19).

1)failing to ensure a patient's condition was monitored after being assessed as having an episode of low blood pressure
Patient #9
The medical record for Patient #9 was reviewed. Patient #9 was admitted 01/22/10 with diagnoses of S/P CABG, Seizues, UTI, ARF, GI Bleed, Respiratory Failure, Trach and was vent dependent. Review of the Physician's Orders dated 01/22/10 revealed Metoprolol (Lopressor) 25 mg Peg Bid :(twice daily). Review of the Medication Administration Record (MAR) dated 02/23/10 thru 02/24/10 revealed the Lopressor was circled as not given 02/23/10 at 2100. (9pm) with reason documented as "BP (blood pressure) too low." Review of the Nurses Daily Flow Sheet dated 02/23/10 revealed no documented evidence of Patient #9's Blood pressure reading prior to holding the Lopressor. There was no documented evidence the physician was notified of the low blood pressure. There was no documented evidence the patient as reassessed 1 hour after the change in condition as per the hospital policy.

S2, Director of Nurses was interviewed 02/25/10 at 9:45am. She reviewed the record for Patient #9. S2 confirmed the Lopressor had been held for low blood pressure and there was no documented evidence in the nurse's narrative notes the patient was reassessed within 1 hour after the significant change in the patient's blood pressure reading. Further S2 confirmed there was no documented evidence the physician was notified of Patient #9's low blood pressure.

The policy entitled "Patient Assessment/Reassessment" presented as the hospitals's current policy was reviewed. Documentation revealed in part, "Patient Reassessment" Any significant change in the patient's condition should elicit a reassessment of the patient (documented in the narrative notes) within one hour. The registered nurse is responsible for ensuring that the physician is notified of all significant changes in the patient's condition.


2) failing to follow their policy and procedure for patients on telemetry monitors as evidenced by no documented evidence the rhythm strip had been assessed for heart rate, rhythm, and identification of any ectopy and the signature of the nurse or tech analyzing the strip

Patient #5
Review of the Physician's Order form dated 01/19/10 revealed Patient #5 had been admitted to the hospital with a diagnosis of debility due to abdominal surgery and had an order to be placed on telemetry. Review of the telemetry strips for Patient #5 revealed no documented evidence the strips had been evaluated by a nurse on the following dates/times: 02/23/10 at 0559 (5:59am); 02/22/10 at 0559 (5:59am); 02/18/10 at 0559 (5:59am); 02/17/10 at 0559 (5:59am); 02/16/10 at 1759 (5:59pm); and 02/15/10 at 1759 (5:59pm).

Patient #6
Review of the Physician's Admit Orders dated 01/12/10 revealed Patient #6 had been admitted to the hospital with a diagnosis of respiratory failure/ventilator dependent and had an order to be placed on telemetry. Review of the telemetry strips for Patient #6 revealed no documented evidence the rhythm strips had been evaluated by a nurse on the following dates/times: 02/22/10 at 0559 (5:59am); 02/23/10 at 0559 (5:59am); 02/18/10 at 0559 (5:59am); 02/17/10 at 0559 (5:59am); 02/16/10 at 1759 (5:59pm); 02/15/10 at 1759 (5:59pm); 02/14/10 at 0827 (8:27am); 02/14/10 at 0827 (8:25am); 02/14/10 at 0559 (5:59am); 02/13/10 at 0559 (5:59pm);02/13/10 at 0559 (5:59am); 02/12/10 at 0559 (5:59am); 02/11/10 at 1759 (5:59pm); 02/09/10 at 0559 (5:59am); 02/08/10 at 0559 (5:59am); 02/03/10 at 1759 (5:59pm); 02/04/10 at 0559 (5:59am); 02/03/10 at 0559 (5:59am); 02/02/10 at 1759 (5:59pm); 02/02/10 at 0559 (5:59am); 01/31/10 at 1759 (5:59pm); 02/01/10 at 1759 (5:59pm); 01/31/10 at 0559 (5:59am); 01/30/10 at 0559 (5:59am); 01/29/10 at 1759 (5:59pm); 01/29/10 at 1759 (7:59pm); 01/29/10 at 1136 (11:36am); 01/29/10 at 0559 (5:59am); 01/28/10 at 1759 (5:59am); 01/27/10 at 2037 (8:27pm); 01/26/10 at 2023 (8:23pm); 01/26/10 at 0559 (5:59am); 01/25/10 at 2024 (8:24pm); 01/25/10 at 0559 (5:59am); 01/24/10 at 1759 (5:57pm); 01/23/10 at 1559 (5:59pm); 01/23/10 at 0559 (5:59am); 01/22/10 at 2143 (9:23pm); 01/21/10 0600 (6:00am) 01/21/10 0600 (6:00am); 01/21/10 at 2247 (10:22pm); 01/21/10 0600 (6:00am); 01/20/10 at 1759 (5:59pm); 01/17/10 at 1559 (5:59pm); 01/17/10 at 1759 (5:59am); 01/16/10 at 1759 (5:59pm); 01/16/10 at 559 (5:59am); 01/15/10 at 1759 (5:59pm) and 01/15/10 at 1759 (5:59am).

Patient #10
Review of the Physician's Admit Orders dated 02/08/10 revealed Patient #10 had been admitted to the hospital with a diagnosis of a CVA (Cerebral Vascular Accident) and had an order to be placed on telemetry. Review of the telemetry strips for Patient #10 revealed no documented evidence the rhythm strips had been evaluated by a nurse on the following dates/times: 02/23/10 at 0600 (6:00am); 02/22/10 at 5:59 (5:59am); 02/17/10 at 5:59 (5:59am); 02/18/10 at 0600 (6:00am); 02/16/10 at 1800 (6:00pm); 02/15/10 at 1759 (5:59pm); 02/14/10 at 0559 (5:59am); 02/13/10 at 1759 (5:59pm); 02/12/10 at 0600 (6:00pm); and 02/11/10 at 1759 (5:59pm).

Patient #15
Review of the Physician's Admit Orders dated 12/02/09 revealed Patient #15 had been admitted to the hospital with a diagnosis of failure to thrive and respiratory arrest and had an order to be placed on telemetry. Review of the telemetry strips for Patient #15 revealed no documented evidence the rhythm strips had been evaluated by a nurse on the following dates and times: 01/29/10 at 2023 (8:23pm); 01/26/10 at 0559 (5:59am); 01/25/0 at 2024 (8:24pm); 01/25/10 at 0559 (5:59am); 01/24/10 at 0559 (5:59am); 01/24/10 at 1758 (5:58pm); 01/23/10 at 1759 (5:59pm); 01/23/10 at 0559 (5:59am); 01/22/10 at 2143 (9:43pm); 01/21/10 at 2246 (9:46pm); 01/21/10 at 0559 (5:59am); 01/20/10 at 1759 (5:59pm); 01/17/10 ay 1759 (5:59pm); 01/17/10 at 0559 (5:59am); 01/16/10 at 1759 (5:59pm); 01/16/10 at 0559 (5:59am); 01/15/10 at 1759 (5:59pm); 01/15/10 at 0559 (5:59am); 01/11/10 at 0558 (5:58am); 01/10/10 at 1759 (5:59pm); 01/10/10 at 0559 (5:59am); 01/09/10 at 1759 (5:59pm); 01/09/10 at 0559 (5:59am); 01/08/10 at 1800 (6:00pm); 01/08/10 at 0559 (5:59am); 01/07/10 at 1758 (5:58pm); 01/07/10 at 0559 (5:59am); 01/06/10 at 1800 (6:00pm); 01/06/10 at 0600 (6:00am); 01/05/10 at 1759 (5:59pm); 01/03/10 at 0559 (5:59am); and 01/02/10 at 0600 (6:00am).

Review of Policy Number 9-6.14.0 titled "Telemetry and Cardiac Monitoring" last revised 05/09 and submitted as the one currently in use revealed .... "Procedure: Shift assessment will include a documented strip with a description of the tracing including heart rate, rhythm, and identification of any ectopy and the signature of the nurse or tech analyzing the strip ....".


3) Failing to ensure a patient's #11 blood pressure and pulse were assessed as ordered prior to the administration of Oxycodone to Patient #11.

Review of Patient #11's Medication Administration Record revealed Oxycodone was administered at the following dates and times:
12/07/2009 at 13:00 (1:00 p.m.), 21:00 (9:00 p.m.);
12/08/2009 at 13:00 (1:00 p.m.), 21:00 (9:00 p.m.);
12/09/2009 at 05:00 (5:00 a.m.), 13:00 (1:00 p.m.), 21:00 (9:00 p.m.);
12/10/2009 at 05:00 (5:00 a.m.), 13:00 (1:00 p.m.), 21:00 (9:00 p.m.);
12/14/2009 at 13:00 (1:00 p.m.), 21:00 (9:00 p.m.).

Review of the Graphic/I&O vital signs revealed no documented evidence the patient's pulse and systolic blood pressure were assessed prior to adminstration of Oxycodone at the above times listed.

In interview on 02/25/10 at 2:00 p.m. S2, Director of Nursing, could provide no explanation as to why the nurses were not documenting systolic blood pressure and pulse prior to administering Oxycodone to Patient #11.

4. Failed to ensure patient's were weighed as ordered for 3 of 21 sampled patients (Patient #7, #13, #19).
Patient #7
Review of the Physician ' s Orders dated 02/09/10 revealed Patient #7 had been admitted to the hospital on 02/09/10 with the diagnosis of third degree burns of the bilateral lower extremities with skin grafts. Further review of the orders revealed #7 was to be weighed upon admit and weekly.

Review of the Physician ' s Admit Orders dated 02/09/10 revealed no documentation Patient #7 had been weighed upon admit as evidenced by a blank in the space provided for weight.

Review of the Weight Flow Sheet for Patient #7 revealed he had been weighed 02/10/10 and again on 02/14/10. Further review of the medical record revealed no changes in the weekly weight order had been documented.

Patient #13
Review of the medical record revealed Patient #13 had been admitted to the hospital on 02/12/2010 with the diagnosis of sacral decubiti, cervical spine fusion, incomplete quadriplegic, orosepsis and neurogenic bladder review of the Physician ' s Orders dated 02/10/10 revealed an order to weigh the #13 on admit and weekly

Review of the " Weight Flow Sheet " form dated 02/12/10 for Patient #13 revealed he had been weighed on 02/12/10; however there was no documented evidence he had been weighed seven days later as evidenced by a blank space provided for the weekly weight.

Patient #19
Review of Patient #19's Admit Orders dated 08/21/09 at 8:02 p.m. revealed, in part, "Check all that apply and draw a line thru all orders that do not apply: Weight on admission and weekly". Further review revealed that Patient #19 was discharged from the hospital on 09/16/09 at 2:00 p.m.

Review of Patient #19's records revealed the patient weighed 250 pounds on 08/21/09 at 8:02 p.m. the day of admission. Further review of the medical record revealed the only other recorded weight was 265 pounds done on 09/04/09. Review of the entire medical record revealed no other documented assessment of weights for Patient #19.

In interview on 02/25/10 at 2:10 p.m. S2, Director of Nursing, indicated she had identified that weights were not being obtained as ordered. S2 further indicated that a weight log book had been created in order to maintain accurate records of weights that were being done. S2 further indicated that the problem with obtaining weights as ordered had not been corrected.




25892

Based on record review (patient medical records, hospital policy) Medical Staff Bylaws) and interview, the hospital failed to ensure medical record entries were dated and timed for 1) Progress Notes for 5 of 21 sampled patients (#3, #4, #5, #6, #9) and 2) Physician Orders were dated/timed 3 of 21 sampled patients (#5, #6, #15).
Findings:

1) Progress Notes

Patient #3
Review of Patient #3's "Physician Progress Notes" revealed notes written 02/19/10, 02/20/10 and 02/21/10 had no documented evidence of the time the note was written.

Patient #4
Review of Patient #4's "Physician Progress Notes" revealed notes written 02/04/10, 02/09/10 and 02/19/10 had no documented evidence of the time the note was written.

Patient #5
Review of the Physician's Progress Notes for Patient #5 revealed no times had been documented for the following entries: 02/23 (no year documented), 02/19/10, 2/17 (no year documented), 02/12/10, 02/10 (no year documented), 02/09/10, 02/3 (no year documented), 02/02/10, 01/31 (no year documented), 01/30/10, 01/29/10, 01/27/10, and 01/26 (no year documented) by Cardiology Services and no date or time times 3 (sometime before or on 02/11/10), 02/08 (no year documented), 02/04/10, 02/03/10, 2/02 (no year documented), 02/02/10 by Renal Services.
.
Patient #6
Review of the Physician's Progress Notes for Patient #6 revealed no times had been documented for the following entries: 02/24 (no year documented), 02/23/10, 02/20/10, 02/19 (no year documented), 02/17 (no year documented), 02/16 (no year documented), 02/15 (no year documented), 02/10 (no year documented), 02/09 (no year documented), 02/08 (no year documented), 02/05/10, 01/27/10, and 01/26/10 by Cardiology
Review of the Physician ' s Progress Notes for Patient #15 revealed no times had been documented for the following entries: 01/11/10, 01/08/10, 01/07/10, 01/06/10, 01/05/10, 01/02/10, 12/31/09, 12/28(no year documented), 12/30 (no year documented), 12/26 (no year documented), 12/25 (no year documented), 12/24 (no year documented), 12/23 (no year documented), 12/22(no year documented), 12/15 (no year documented), 12/14 (no year documented), 12/13/09, 12/12/09. 12/22/09, 12/09 (no year documented), 12/08 (no year documented) and 12/07 (no year documented) by Cardiology Services; 01/09/10, 01/06/10, 01/02/10, 12/24/09, 12/20/09, 12/17/09, 12/16/09, and 12/08/09 by Surgery Services; and
01/08/10, 01/06/10, 01/04/10, 12/28 (no year documented), 12/11(no year documented), 12/10 (no year documented) 12/09 (no year documented), 12/11 (no year documented), and 12/8 (no year documented) by Renal Services.

Patient #9
Review of Patient #9's "Physician Progress Notes" revealed notes written 02/08/10, 02/15/10 and 02/20/10 had no documented evidence of the time the note was written.



2) Physician Orders not dated/timed
Patient #5
Review of the Physician ' s Orders for Patient #5 revealed the following had no documented time and or date for the order: 02/12/10 for Potassium levels; 02/12/10 orders for Potassium labs and Bumex; 2/11/10 for IV fluids, CXR, and lab work; 02/10/10 epogen orders; 02/10/10 lab work; 02/09/10 for IV fluids and lab work; 2/08/10 for IV fluids and lab work; 02/07/10 for Potassium Chloride (KCL); 2/04/10 for KCL;
02/03/10 Bumex and KCL; and 02/01/10 blood transfusion, Bumex and CXR.

Patient #6
Review of the Physician ' s Orders for Patient #6 revealed the following had no documented time and or date for the order: 02/10/10 for wound care; 02/09 10 for pre-op orders; 02/09/10 for stat PT/PTT; 01/31/10 for irrigation of Foley catheter; 01/31/10 for suture set to the bedside; and01/17/10 for HCTZ, Tylenol and Lisinoprin.

Patient #15
Review of the Physician ' s Orders for Patient #15 revealed the following had no documented time and or date for the order: 01/27 (year left blank) no time documented for dialysis orders 01/21/10 no time documented for wound care orders; 01/06/10 no time documented for wound care orders; 01/06/10 no time documented for Bumex IV order; 01/04/10 no time documented for a 24-hour urine; 01/02/10 no time documented for wound care orders; 01/30 (year left blank) no time documented for discontinuing Transderm Nitro; 12/28/09 no time documented for order for UA and Potassium; 12/23/10 no time documented for dialysis; 12/23/10 no time documented for CBC; 12/22/10 no time documented for EKG order; 12/21/09 no time documented for discontinuing of Bumex and Zaroxolyn; 12/17/09 no time documented for labs (BMP Magnesium level); 12/17/09 no time documented for wound care orders; 12/14/09 no time documented for ventilator settings; 12/12/09 no time documented for dialysis orders
12/11/09 no time documented for dialysis orders; 12/10/10 no time documented for a trach collar order; no documented date or time for an order to decrease Bumex; no date or time documented for urinalysis orders; 12/09/09 no time lab work ordered; 12/08/09 no time for order for Nitrodur with parameters; 12/08/09 no time for dialysis orders; 12/05/09 no time for dialysis orders; 12/05/09 no time for EKG orders; 12/04/09 no time for transfusion orders; 12/04 09 no time for dialysis orders; and12/03/09 no time lab work had been ordered.

Based on record review and interview the hospital failed to ensure all verbal/telephone orders were authenticated by the physician within 10 days according to hospital policy for 6 of 21 medical records reviewed (#5, #6, #10, #11, #15, #21).
Findings:

Patient #5
Review of the Physician ' s Orders for Patient #5 revealed the following verbal orders had not been dated, timed and/or signed by the physician: 02/22/10 for KCL, 02/17/10 for clarification of CT scan, and 02/16/10 for a blood administration order. Further review revealed no physician signature for the following orders: 02/11/10 to cancel order for Magnesium Sulfate; 02/10/10 for blood transfusion; 02/09/10 normal saline bolus and stat labs; 02/09/10 post op orders; 02/08/10 for Vancomycin; 02/02/10 to hold blood transfusion; and 02/02/10 for blood cultures.

Patient #6
Review of the Physician ' s Orders for Patient #6 revealed the following verbal orders had not been dated, r timed and/or signed by the physician: 02/09/10 @1455 (2:55pm) for orders for endotracheal suction and no physician signature for 2/11/10 @0850 (8:50am) orders for Foley Catheter and irrigation and 01/12/10 admit orders.

Patient #10
Review of the Physician ' s Orders for Patient #10 revealed the following verbal orders had not been dated, timed and/or signed by the physician: 02/09/10 verbal orders for ABG in AM no signature of the physician.

Patient #11
Review of Patient #11's Physician's Routine Orders revealed the following verbal orders written: 1. 12/04/09 at 2100 (9:00 p.m.) OK to use Central line. 2. 12/08/09 at 1735 (5:35 p.m.) to change wound vac every other day. 3. 12/21/09 at 1015 (10:15 a.m.) for STAT (NOW) KUB to verify line placement. 4. 01/16/10 at 1600 (4:00 p.m.) Patient NPO (nothing by mouth) after midnight for cystoscope and Retrograde Pyelogram on tomorrow. Further review revealed no documented evidence the physician signed and dated the verbal orders as per hospital policy.

Patient #15
Review of the Physician ' s Orders for Patient #15 revealed the following verbal orders had not been dated, timed and/or signed by the physician: 01/27/10 @ 1520 (3:20pm) OK to TPA catheters; 01/27/10 @ 0655 (6:55am) orders for insulin; 01/27/10 @ 0945 (9:45am) post-op orders no MD signature; 12/18/09 orders for T-piece as tolerated with vent no signature of MD; 12/16/09 orders to hold Bumex; 12/30/09 orders for dialysis@ 0830 (8:30am); 12/26/09 orders for stat potassium; 12/13/09 order for Bumex and Zaroxolyn with parameters; 12/03/09 lab work; and 12/02/09 admit orders all with no documented signature of the physician. Further review revealed date/time documented when physician signed the verbal orders on: 12/21/09 orders for dialysis; 12/18/09 orders for dialysis; 12/13/09 orders to continue Bumex; 12/11/ orders for stat CXR; 12/03/09 for lab work; and12/03/09 for blood transfusion.

Patient #21
Review of the Physician ' s Orders for Patient #21 revealed the following verbal orders had not been dated, timed and/or signed by the physician: 06/29/09 @ 1300 (1:00pm) Discharge planning; 06/29/09 @1400 (4:00pm) orders for Durable Medical Equipment (DME); 06/27/09 Coumadin orders; and 06/28/09 PT-INR none which had documented evidence of the date and time the physician had signed the orders.

In a face to face interview on 02/25/10 at 11:00am the S1 Administrator indicated he is aware of the medical record problem including the names of those physicians who are continually non-compliant. Further S1 indicated there is only the RHIA working in medical records at the present time and she is responsible for the medical records department, gathering and reeporting of statistics and the credentialing process.

Review of the hospital policy titled: "Orders: Verbal, Policy Number: 10-14.1.0, last revised: 01/06" revealed, in part, "Procedure: Recording Verbal Orders- 1. The physician identifies self, specifies the patient's name, and communicates the order. 2. The receiver: documents the order immediately on the physician's order form including the date, time, physician's name, receiver's name, status, and signature repeats the order back to the physician including the: patient name, drug name and spelling of the drug to avoid error due to sound alike drugs, dosage, frequency, requests the indication for the medication to assist in avoiding errors, questions the physician if there is any uncertainty regarding the order". Further review revealed, in part, "Authentication (verification) of verbal orders- Orders that are not written by the prescriber (e.g. verbal orders) shall be subsequently authenticated (verified) and countersigned by the prescribing practitioner or other responsible practitioner within 10 days of receipt".

Based on record review and interview the hospital failed to follow their policy and procedure for reporting of medication variances by failing to initiate a Medication Variance Report for 9 identified medication variances involving 3 of 21 sampled patients (#9, #15, #16).
Findings:

The medical record for Patient #9 was reviewed. Patient #9 was admitted 01/22/10 with diagnoses of S/P CABG, Seizues, UTI, ARF, GI Bleed, Respiratory Failure, Trach and was vent dependent. Review of the Physician's Orders dated 01/22/10 revealed Metoprolol (Lopressor) 25 mg Peg Bid :(twice daily). Review of the Medication Administration Record (MAR) dated 02/23/10 thru 02/24/10 revealed the Lopressor was circled as not given 02/23/10 at 2100. (9pm) with reason documented as "BP (blood pressure) too low." Review of the Nurses Daily Flow Sheet dated 02/23/10 revealed no documented evidence of Patient #9's Blood pressure reading prior to holding the Lopressor. There was no documented evidence the physician was notified of the low blood pressure. There was no documented evidence the patient as reassessed 1 hour after the change in condition as per the hospital policy.

S2, Director of Nurses was interviewed 02/25/10 at 9:45am. She reviewed the record for Patient #9. S2 confirmed the Lopressor had been held for low blood pressure and there was no documented evidence in the nurse's narrative notes the patient was reassessed within 1 hour after the significant change in the patient's blood pressure reading. Further S2 confirmed there was no documented evidence the physician was notified of Patient #9's low blood pressure.


Review of the medical record for Patient #15 revealed he had been admitted to the hospital on 12/02/09 with the diagnosis of failure to thrive and respiratory failure. Review of the MAR (medication Administration Record) dated 01/21/10 @7:00am through 01/22/10 @6:59am revealed an order for Reglan injection 5mg/ml every 6 hours, Haldol 2mg tablets twice daily at 9A and 9P, Bumex 0,25mgmg/ml intravenous every 8 hours at 5am, 1pm, and 9pm, and Mucinex 600mg 2 tablets every 12 hours. Further review of the MAR revealed the following medications were not administered to Patient #15 due to " the med tech out " (The Med Tech is the automated medication dispensing unit): Reglan 5mg @ 300 (3:00am), Haldol 2mg tablet at 2100 (9:00pm), Bumex 0.25mg/ml intravenous @ 0500 (5:00am) and Mucinex 600mg po (by mouth) @ 0224 (2:00am).

In a telephone interview on 02/25/10 at 9:20am Pharmacist S3 indicated that " medicine not available in Med Tech " should not be used as an excuse not to administer a scheduled dose of medication. Further he indicated a pharmacist is on call and available 24/7 and that all a nurse has to do is call the pharmacist and he will arrange to obtain the medication from the host hospital, call the nurse back and have he arrange for someone to pick up the medication.


Review of Patient #16's Medication Administration Record dated 12/08/09 revealed "Topamax 25mg, Give: 100mg = 4 Tablets". Further review revealed that at 9:00am the nurse administered 2 tablets = 50mg and documented only 2 available given. Review of the entire medical record revealed no documented evidence that the patient was administered Topamax 100mg as ordered.

Review of Patient #16's Medication Administration Record dated 12/09/09 revealed "Neurontin 100mg Capsule, Give: 100mg = 1 Capsule". Further review revealed that the dose scheduled for 17:00 (5:00 p.m.) was not documented as administered. Review of the entire medical record revealed no documented evidence that the patient was administered Neurontin 100mg as ordered.

Review of Patient #16's Medication Administration Record dated 12/10/09 revealed "Oxycodone 5mg, Give: 10mg = 2 Capsules". Further review revealed that the dose scheduled for 05:00 (5:00 a.m.) was not documented as administered. Further review of Patient #16's Medication Administration Record dated 12/14/09 revealed, "Oxycodone 5mg, Give: 10mg = 2 Capsules". Further review revealed that the dose scheduled for 05:00 (5:00 a.m.) was not documented as administered. Review of the entire medical record revealed no documented evidence that the patient was administered Oxycodone as ordered.

In interview on 02/24/10 at 2:30 p.m. S2, Director of Nursing, indicated that she could provide no explanation as to why the medications were not documented as administered. S2 further indicated that there were no medication variances reported for the above medication omissions.

In a telephone interview on 02/25/10 at 9:15 a.m. S3, Pharmacist, indicated that he was not aware of the missed medication doses for Patient #16. S3 further indicated that the pharmacy depends on the nursing staff to report medication variances. S3 indicated the pharmacy would have to start conducting chart audits to identify medication variances.

Review of the hospital policy titled: "Medication Variances, Policy Number: 9-4.15.0, Revised Date: 10/08" revealed, in part, "Policy: To establish a policy and procedure to define and report medication variances. Protocol for reporting medication variances- When a medication variance is discovered, (whether or not patient injury has occurred), the incident must be reported immediately to the charge RN and/or the Director of Nursing and/or the employee's supervisor. The variance should be reported to the physician as soon as possible. The drug administered in error/omitted in error and the action taken should be documented in the patient's medical record. The medication variance will be documented thru the on-line occurrence reporting system. Performance Improvement and Safety/Risk- Medication variances will be reported at the safety/risk committee meeting. Plans of correction will be instituted in accordance with the Performance Improvement Plan. MAR (Medication Administration Records) will be faxed by nursing to the pharmacy daily. The director of Pharmacy, or designee, will monitor MAR corrections and report pharmacy involvement at the Safety/Risk Committee meeting and/or Performance Improvement meetings".

Based on record review and interview the hospital failed to have a full time employee who serves as the director of the food and dietetic services.
Findings:

Review of the facility employee census revealed no documented evidence that a full time employee was designated as the director of food and dietetic services.

In interview on 02/24/10 at 11:30 a.m. S1, Administrator, indicated the dietary manager was an employee of the company who was contracted for food service. S1 further indicated the dietary manager was available full time in the kitchen for Hospital A. S1 further verified there was no full time employee at the hospital designated as the director of food and dietetic services.

Based on record review and interview the hospital failed develop and implement a process for identifying medication variances as evidenced by medication variances identified during the survey process and no documented medication variances of the identified incidents. Findings:

Review of Organizational Performance Improvement Plan last revised 05/09 and submitted as the one currently in use revealed ..... A. The scope of the Organizational Performance Improvement Program includes performance of the following medical staff functions: .... medication use monitoring 1. Identify medical errors and adverse events...." Further review of the plan revealed the hospital used the plan do check act philosophy for performance improvement.

Review of the Performance Improvement statistics from January 2009 through October 2009 submitteed to the survey team as the only information available at the present time revealed there had been no reported medication variances or adverse drug reactions for this time period.

See findings at Tag A0404 for medication variances and interviews.

Based on record review and interview the hospital failed to develop and implement performance improvement activities to track medical errors as evidenced by relying on nurses reporting medication variances as the sole tool in which to collect data and failing to investigate further when no medication variances were reported when greater than 25,000 medications are administered on a monthly basis. Finding

Review of the Performance Improvement statistics from January 2009 through October 2009 submitted to the survey team as the only information available at the present time revealed there had been no reported medication variances or adverse drug reactions for this time period.

In a face to face interview Pharmacist S3 indicated he does not participate in any chart audits as part of monitoring the safe administration of drugs.

In a face to face interview on 02/25/10 at 11:00 S2 the Director of Nursing (DON) indicated self-reporting by the nursing staff was the means for data collection of medication variances. Further she indicated no chart checks were being performed to monitor drug administration. S2 indicated there was no actions taken because she did not think medication administration was a problem.

Based on record review (hospital policy, medical record) and interview the hospital failed to ensure medications were given as ordered for 3 of 21 sampled patients by: 1) failing to ensure physicians' orders were clarified when there were no parameters indicated for holding Lopressor for a patient's low blood pressure (Patient #9); 2)failing to notify the pharmacist to obtain ordered medications not available in the medication administration system (Medi Tech) (Patient #15) and 3) failing to ensure Topamax, Neurontin, and Oxycodone were administered as ordered (Patient #16). Findings:

1) failing to ensure physicians' orders were clarified when there were no parameters indicated for holding Lopressor for a patient's low blood pressure.

Patient #9
The medical record for Patient #9 was reviewed. Review of the Physician's Orders dated 01/22/10 reveled Metoprolol (Lopressor) 25 mg Peg Bid :(twice daily). Review of the Medication Administration Record (MAR) dated 02/23/10 thru 02/24/10 revealed the Lopressor was circled as not given 02/23/10 at 2100. (9pm) with reason documented as "BP (blood pressure) too low." Review of the Nurses Daily Flow Sheet dated 02/23/10 revealed no documented evidence of Patient #9's Blood pressure reading prior to holding the Lopressor. There was no documented evidence the physician was notified of the low blood pressure. There was no documented evidence the Lopressor order was clarified for parameters to hold the Lopressor.

S4, RN was interviewed face to face 02/23/10 at 9:30am. She reviewed the record for Patient #9. S4 confirmed there were no parameters for the physician's order to hold the Lopressor and no documentation of the blood pressure reading.

S2, Director of Nurses was interviewed 02/25/10 at 9:45am. She reviewed the record for Patient #9. S2 confirmed the Lopressor had been held for low blood pressure without a physician's order for parameters to hold the Lopressor.

The policy entitled "Medication Administration" presented as the hospital's current policy was reviewed. Documentation revealed in part, "C. Withholding Medication and/or treatments * Any drug that is withheld shall be circled and initialed on the MAR. * The nurse shall document on the MAR on in the nurse's narrative notes the reason the drug was not given, if applicable, that the physician was notified."


2) Failing to obtain unavilable drugs.
Review of the medical record for Patient #15 revealed he had been admitted to the hospital on 12/02/09 with the diagnosis of failure to thrive and respiratory failure. Review of the MAR (medication Administration Record) dated 01/21/10 @7:00am through 01/22/10 @6:59am revealed an order for Reglan injection 5mg/ml every 6 hours, Haldol 2mg tablets twice daily at 9A and 9P, Bumex 0,25mgmg/ml intravenous every 8 hours at 5am, 1pm, and 9pm, and Mucinex 600mg 2 tablets every 12 hours. Further review of the MAR revealed the following medications were not administered to Patient #15 due to " the med tech out " (The Med Tech is the automated medication dispensing unit): Reglan 5mg @ 300 (3:00am), Haldol 2mg tablet at 2100 (9:00pm), Bumex 0.25mg/ml intravenous @ 0500 (5:00am) and Mucinex 600mg po (by mouth) @ 0224 (2:00am).

In a telephone interview on 02/25/10 at 9:20am Pharmacist S3 indicated that " medicine not available in Med Tech " should not be used as an excuse not to administer a scheduled dose of medication. Further he indicated a pharmacist is on call and available 24/7 and that all a nurse has to do is call the pharmacist and he will arrange to obtain the medication from the host hospital, call the nurse back and have he arrange for someone to pick up the medication.

Review of policy number 9-4.15.0 titled "Medication Variances" last revision date 10/08 and submitted as the one currently in use by the hospital revealed no documented evidence unavailable drugs had been addressed.


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3) failed to ensure medications Topamax, Neurontin, and Oxycodone were administered as ordered by the physician (#16).

Review Patient #16's Physician's Orders dated 12/04/09 revealed, in part, "Neurontin 400mg PO (by mouth) QID (four times daily) and Topamax 100mg PO (by mouth) BID (two times daily)." Further review of the Physician's Orders dated 12/05/09 revealed, "Oxycodone 10mg PO Q8hrs (by mouth every 8 hours) hold for sedation, SBP < 100 (Systolic blood pressure less than or equal to 100) or heart rate < 60 (heart rate less than 60)".

Review of Patient #16's Medication Administration Record dated 12/08/09 revealed "Topamax 25mg, Give: 100mg = 4 Tablets". Further review revealed that at 9:00am the nurse administered 2 tablets = 50mg and documented only 2 available given. Review of the entire medical record revealed no documented evidence that the patient was administered Topamax 100mg as ordered.

Review of Patient #16's Medication Administration Record dated 12/09/09 revealed "Neurontin 100mg Capsule, Give: 100mg = 1 Capsule". Further review revealed that the dose scheduled for 17:00 (5:00 p.m.) was not documented as administered. Review of the entire medical record revealed no documented evidence that the patient was administered Neurontin 100mg as ordered.

Review of Patient #16's Medication Administration Record dated 12/10/09 revealed "Oxycodone 5mg, Give: 10mg = 2 Capsules". Further review revealed that the dose scheduled for 05:00 (5:00 a.m.) was not documented as administered. Further review of Patient #16's Medication Administration Record dated 12/14/09 revealed, "Oxycodone 5mg, Give: 10mg = 2 Capsules". Further review revealed that the dose scheduled for 05:00 (5:00 a.m.) was not documented as administered. Review of the entire medical record revealed no documented evidence that the patient was administered Oxycodone as ordered.

In interview on 02/24/10 at 2:30 p.m. S2, Director of Nursing, indicated that she could provide no explanation as to why the medications were not documented as administered. S2 further indicated that there were no medication variances reported for the above medication omissions.

In a telephone interview on 02/25/10 at 9:15 a.m. S3, Pharmacist, indicated that he was not aware of the missed medication doses for Patient #16. S3 further indicated that the pharmacy depends on the nursing staff to report medication variances. S3 indicated the pharmacy would have to start conducting chart audits to identify medication variances.

Review of the hospital policy titled: "Medication Administration, Effective Date: May 2009" revealed, in part, "Policy: All patient medications will administered per a physician's order and documented on a Medication Administration Record (MAR). Procedure: A. Administering Medication- MARs are pre-printed by the pharmacy and shall reflect the correct MD orders for medications. The nurse who administers the medication (medications, IV fluids, Saline or Heparin Flushes, etc.) shall document such by initialing the time on the MAR as soon as possible following administration. Draw a line through the time. C. Withholding Medications and/or Treatments- Any drug that is withheld shall be circled and initialed on the MAR. The nurse shall document on the MAR or in the nurses' narrative notes the reason the drug was not given and, if applicable, that the physician was notified".