HospitalInspections.org

Based on observation, interview, record review and policy review, the facility failed to:
- Ensure staff followed facility policy, as well as recommendations from Speech Therapy (ST), to reduce the risks of aspiration (to choke or inhale liquids into lungs) for five patients (#1, #13, #17, #18 and #19) of seven patients who were on aspiration precautions (measures taken to reduce the risk of aspiration).
- Coordinate meal delivery with insulin (a hormone that regulates the blood sugar) and/or diabetic medication administration (timing of medication delivery can reduce insulin requirements) for two (#3, #34) of six patients reviewed with diabetes.
- Immediately administer oxygen to one patient (#35) of one patient reviewed with oxygen ordered "STAT" (immediately) by a physician. These failures had the potential to lead to poor outcomes, and could affect all patients in the hospital. The facility census was 339.

Findings included:
Record review of the facility's policy titled, "Aspiration Precautions for Adult and Pediatric Patients," dated 09/2012, showed that all patients at risk for aspiration of secretions (saliva) or nourishment (food or drink) should have suction equipment set up at the bedside and that patient specific strategies generated by the speech pathologist should be followed.
Observation on 09/19/16 at 3:05 PM, showed Patient #1 with a cervical collar (c-collar, used to stabilize the neck if broken or suspected to be broken) around her neck. In the patient's room was a posted sign titled, "Swallowing Guide" (documented measures to take when a patient is at risk for aspiration) which showed that the patient strategies were to "sit in chair to eat". Further observation showed that there was no suction equipment readily available in the patient's room.

Record review of Patient #1's medical record showed:
- A History and Physical (H&P) dated 09/16/16, with a diagnosis of cervical spine fracture which required the use of a c-collar.
- A Clinical Swallow Evaluation dated 09/16/16 which indicated that the patient was at increased risk of aspiration due to advanced age and poor positioning due to the c-collar.
- A Kardex (paper or electronic list of pertinent patient information) which indicated that the patient was on aspiration precautions with interventions that included sitting up in a chair for all meals.

During an interview on 09/19/16 at 3:05 PM, Patient #1 stated that she had extreme difficulty swallowing, and at times could not swallow due to her injury, position and weakened neck muscles. Patient #1 and her family member both stated that she experienced coughing while eating and drinking (sign of aspiration), that the patient was not always placed in a chair to eat her meals and that suction tubing was never available in her room.

During an interview on 09/19/16 at 3:30 PM, Staff D, Registered Nurse (RN), stated that suction equipment should be available for patients on aspiration precautions, and confirmed that Patient #1 did not have suction equipment available in her room.

Observation on 09/19/16 at 4:00 PM, showed Patients #17, #18 and #19 without suction equipment readily available in their room.

Record review on 09/19/16 at 4:00 PM of Kardexes, showed Patients #17, #18 and #19 were on aspiration precautions, as per physician orders, which were verified by Staff C, RN, Team Lead (TL).

Record review of Patient #13's H&P dated 09/18/16, showed the patient was admitted on that date with recent history of a stroke (when circulation to the brain is interrupted, causing some brain cell death-09/15/16) with left-sided weakness (strokes can cause swallowing difficulty).

Record review of the patient's care plan dated 09/18/16, showed the patient was on aspiration precautions.

Record review of a Clinical Swallow Evaluation dated 09/19/16, at 6:16 PM, showed the following:
- Patient at severe risk of aspiration.
- Required maximum encouragement to swallow, after holding liquid and/or applesauce in his mouth for over five minutes.
- Suction set-up initiated with assistance of nursing staff.

During an observation and concurrent interview, on 09/20/16 at 1:45 PM, Patient #13's family members stated that the patient had been having trouble swallowing his medications that were not crushed since admission. Family members stated that staff had just installed the suction canister and tubing on 09/19/16, it was not there before that time.

During an interview on 09/21/16 at 11:53 AM, Staff A, Vice President of Nursing/Chief Nursing Officer (CNO), stated that maintaining a patient's airway should be of utmost importance and because of this, House Supervisors (Registered Nurses who supervise nursing care throughout the hospital) were made aware of "high risk" patients, for example, patients on aspiration precautions daily.

During an interview on 09/21/16 at 12:38 PM, Staff FF, Nursing Director, stated that:
- Recommendations (located on the "Swallowing Guide" posted in patient rooms) from ST should be followed by nursing staff when they provided care to patients on aspiration precautions;
- Recommendations from ST should be followed until the physician discontinued the order for aspiration precautions; and
- Suction equipment should be available at the patient's bedside for all patients on aspiration precautions.

Even though requested, the facility failed to provide a specific policy related to meal delivery for diabetic patients.

Record review of the facility's policy titled, "Medication Administration," revised 5/2014, showed the following:
- The licensed professional administering any medication must understand the dose, side effects, appropriateness and purpose.
- Verify medications against the original order and/or the Medication Administration Record (MAR) immediately prior to administration, including the right time.
- Time critical scheduled medications should be given within 30 minutes of the scheduled time (before or after).

Record review of a standardized insulin order entry example (a facility print-out of an example/template of an order for insulin that showed instructions), dated 09/20/16, showed insulin may be given immediately before meal, during meal, or immediately after meal is eaten. Meal must be present before administration.

During an interview on 09/20/16 at 11:05 AM, Staff G, Interim Dietary Team Leader, stated that the dietary department had experienced challenges in delivering meals to patients within 45 minutes of their order. Staff G stated that the patient ordered their meal via telephone, a ticket printed out when the tray was ready, dietary staff notified the nurse responsible for the patient to see if the insulin and/or diabetic medications had been given so the tray could be delivered to the patient.

During an interview on 09/19/16 at 4:17 PM, Patient #3 stated that staff failed to coordinate her blood sugar monitoring, insulin administration and meal delivery causing her blood sugar to fluctuate a great deal (requiring more insulin). Patient #3 stated that her meal was, at times, delivered as long as three to four hours after order.

During an interview on 09/21/16 at 9:41 AM, Patient #34, a pre-diabetic patient, stated that she was on a medication called Metformin (lowers blood sugar levels). The patient stated that her nurse would ask her if she had ordered her meal, and if she had, the nurse would give her the Metformin, irregardless of when the meal tray came, usually about an hour later.

Record review of Patient #34's MAR, dated 09/21/16, showed the Metformin was to be given twice daily with meals.

During an interview on 09/21/16 at 9:56 AM, Staff HH, RN stated that Metformin should be administered 30 minutes before or after a meal.

During an interview on 09/21/16 at 12:44 PM, Staff HH, Director of 1 West, stated that since the institution of "At your request," meal service, insulin and/or diabetic medication may not be given within 30 minutes of meal.

Record review of the undated facility's protocol titled, "Emergency Department (ED) Chest Pain," showed that oxygen should be administered "STAT" (immediately) at two liters per minute (L/min, unit of measure) by nasal cannula (NC, plastic tubing that delivers oxygen into the nasal passages).

Record review of the facility's list of approved abbreviations, showed that "STAT" meant at once or immediately.

Record review of Patient #35's ED record dated 09/21/16 showed:
- The patient arrived to the ED at 9:23 AM;
- Oxygen two L/NC was ordered "STAT" at 9:30 AM; and
- The patient was diagnosed with a ST Elevated MI (STEMI, heart attack caused by the complete blockage of an artery, a vessel that supplies blood to the heart muscle) and was taken to the Cardiac Catherization Lab (department where procedures are done related to the heart).

Observation on 09/21/16 at 9:32 AM, showed Patient #35 in the ED with complaints of chest pain. The patient did not have oxygen on, and oxygen was not placed on the patient until 9:45 AM.

During an interview on 09/21/16 at 10:45 AM, Staff GG, RN, stated that although "STAT" meant "right away", she didn't believe the oxygen administration was delayed, that oxygen administration was not one of "the first things that we do", and added that if the patient's oxygen level was low, oxygen would have been administered immediately.

During an interview on 09/21/16 at 11:53 AM, Staff A, Vice President of Nursing/CNO, stated that the American Heart Association (AHA) recommended oxygen administration for patients with chest pain even if the patient's oxygen isn't low. Staff A stated that the patient's oxygen should have been applied as soon as the oxygen was ordered by the physician.



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Based on observation, interview, record review, and policy review the facility failed to ensure staff:
- Followed facility procedures for medication administration through an oral gastric (OG, type of feeding tube placed through the mouth and into the stomach) tube for one of one patient (#16) observed who received medication through an OG tube.
- Followed facility procedures for medication administration for one of one patient (#24) observed who received medication through a gastric tube (a tube inserted through a small incision in the abdomen into the stomach used for long-term nutrition).
- Followed facility procedures for medication administration through a central line (CL, small plastic tube inserted through the skin in the arm or chest, and into a large vein to administer medications, nutrients or blood over a long period of time) to two Patients
(#16 and #43) of two patients observed who received medications through a CL.
- Followed facility policy for administration of medications in the right form (crushed, liquid, etc) in a timely manner; and, failed to submit an event report (a report that identifies an unusual event or error) when medications were administered three hours late for one (#13) of four patients observed with oral medications administered.
These failures had the potential to cause medications to enter the lungs (causing pneumonia), rather than the stomach, for all patients with feeding/gastric tubes, could cause too much medication to reach the patient too quickly for patients with CLs, and could cause choking and/or aspiration for all patients requiring crushed or liquid forms of medication. The facility census was 339.

Findings included:

Record review of an undated Mosby's Clinical Skills for "Feeding Tube Medication Administration", showed the following:
- Prepare tablet medications by crushing the tablet and mixing it in at least 30 milliliters (ml, unit of measure) of sterile water.
- Use sterile water, because tap water may contain medication residue (left over or remaining) or heavy metals (invisible metals that may be dangerous to a person's health) that may combine with crushed medication and decrease the active effects of the medication.
- Before administering medications, verify the placement of the feeding tube by withdrawing and inspecting aspirate (fluid or tissue withdrawn from the body).
- If tube is gastric (in the stomach), check for residual volume (amount of fluid or nutrients that remain in the stomach and have not been digested).

Observation on 09/20/16 at 9:00 AM, showed Staff K, Registered Nurse (RN), administered a crushed aspirin (medication used to relieve mild or moderate pain, and reduce fever and inflammation) mixed with tap water to Patient #16 through an OG tube. Staff K failed to verify the OG tube placement, failed to used sterile water and failed to check for residual volume before he administered the patient's medication. Staff K then flushed (administer solution through the OG tube, to ensure all medication was administered, and prevents clogging of the tube) the OG tube with tap water.

During an interview on 09/20/16 at 9:23 AM, Staff K stated that the staff used tap water to mix mediations and flush the tube, and that he had already verified Patient #16's tube placement and residual earlier in morning.

Observation on 09/21/16 at 9:15 AM, showed Staff L, RN, administered Keppra (used to treat seizures), Pepcid (used to treat and prevent ulcers in the stomach and intestines) and Primidone (used to treat certain types of seizures) to Patient #24 through a gastric tube. Staff L failed to verify the tube placement before he administered the patient's medication.

During an interview on 09/21/16 at 9:19 AM, Staff L stated that he had already verified Patient #24's tube placement earlier in morning. He stated that at 7:50 AM he checked the tube placement by auscultation (instilling air into the feeding tube with a syringe while using a stethoscope placed over the stomach to listen for rushing air).

Record review of an undated Mosby's Clinical Skills for "Medication Administration: Intravenous (IV, in the vein) Bolus (all at once)", showed that prior to administering IV push medications, staff should:
- Connect a syringe to the IV line (tube or connection port);
- Pull back gently on the syringe's plunger (flat end of the syringe)and aspirate for blood return before administering the medication; and
- Administer the medication within the amount of time recommended by the organization's practice, pharmacist, medication reference manual or manufacturer.

Record review of the facility's guideline titled, "Adult IV Medication Guidelines for In-Patient Care Units and Emergency Departments," dated 09/2016, showed that Pepcid IV should be administered over two minutes.

Observation on 09/20/16 at 9:00 AM, showed Staff K, administer Pepcid, 20 milligrams (mg, unit of measure) IV to Patient #16 through a CL. Staff K failed to pull back on the syringe's plunger and aspirate for blood return before he pushed the medication into the CL over a period of less than 10 seconds.

During an interview on 09/20/16 at approximately 9:15 AM, Staff K stated that he checked the CL placement (aspirated for blood return) earlier in the shift, and acknowledged that the Pepcid should have been administered over a period of two minutes.

Observation on 09/21/16 at approximately 12:00 PM, showed Staff CC, RN failed to pull back on the syringe's plunger and aspirate for blood return before she administered Solu-Cortef (anti-inflammatory medication) 50 mg IV, through Patient #43's CL.

Record review of the facility's policy titled, "Medication Administration," revised 5/2014, showed the following:
- The licensed professional administering any medication must understand the dose, side effects, appropriateness and purpose.
- Staff must verify medications against the original order and/or the Medication Administration Record (MAR) immediately prior to administration, including the right time.
- Time critical scheduled medications should be given within 30 minutes of the scheduled time (before or after).
- Non-time critical scheduled medications include all other medications, and should be given within 60 minutes of the scheduled time, for a total time window of two hours.
- Errors that are the result of missed or late dose administration that result in significant alteration or therapeutic effect will be reported via the online event reporting system.

Record review of Patient #13's History & Physical dated 09/18/16, showed the patient was admitted on that date with recent history of a stroke (when circulation to the brain is interrupted, causing some brain cell death-09/15/16) with left-sided weakness (strokes can cause swallowing difficulty).

Record review of the patient's care plan dated 09/18/16, showed the patient was on aspiration precautions (to choke or inhale liquids into lungs).

Record review of physician's orders dated 09/18/16, timed at 4:00 PM, showed an order for continuous aspiration precautions.

Record review of a Clinical Swallow Evaluation dated 09/19/16, at 6:16 PM, showed the following:
- Patient at severe risk of aspiration.
- Required maximum encouragement to swallow, after holding liquid and/or applesauce in his mouth for over five minutes.
- Severe swallow level.
- Recommend crushed medications with puree.

During an interview on 09/20/16 at 1:45 PM, Patient #13's two family members stated the following:
- They had experienced poor medication administration and/or consistency from nurse to nurse.
- Nurses were not administering the patient's medications crushed, or in a form he could swallow.
- The patient's 9:00 AM medications were not given until around 12:00 (noon).
- They were afraid to leave the patient without family representation for fear staff would try to give him something he could not swallow.

During an interview on 09/20/16 at 2:10 PM, Staff H, Team Leader, stated that pills that can be crushed are, others require physician input for a substitute or liquid form. Staff H stated that "crushed," can appear on the MAR, but patients with swallowing problems or aspiration risk, speech therapy recommendations guide the medication form.

During an interview on 09/20/16 at 2:31 PM, Staff I, RN, stated that medications ordered daily were due at 9:00 AM, twice daily- 9:00 AM and 9:00 PM. Staff I stated that medications should be crushed if the patient was on aspiration precautions; however, a few medications could not be crushed, so the doctor usually held them or ordered an alternative form of the drug. Staff I stated that swallow evaluation recommendations should appear on the MAR as "Administration Instructions." The nurse responsible for the patient at the time of the speech therapy recommendation should call the pharmacy so the MAR could be changed to show crushed medications. Staff I stated that she was late giving Patient #13's medications because she was caring for another patient.

Record review of the patient's MAR dated 09/20/16 showed the following:
- Norvasc (for blood pressure) 10 mg daily (a tablet), administered at 11:37 AM.
- Lisinopril (for blood pressure or heart failure) 20 mg daily (a tablet), administered at 10:38 AM.
- Eliquis (blood thinner) 5 mg twice daily (a tablet), administered at 11:54 AM.
- Aspirin 325 mg daily (a tablet), administered at 11:37 AM.
- Ferrous Sulfate (iron) 300 mg daily with breakfast (a liquid), administered at 11:36 AM.
- Isordil (for heart pain) 20 mg three times daily, (a tablet), administered at 11:37 AM, and again at 2:00 PM (only two hours later).
- Keppra (anti-seizure) 500 mg twice daily, (a liquid), administered at 11:36 AM.
- Lopressor (for blood pressure) 12.5 mg twice daily, (a tablet), administered at 11:54 AM.
- Potassium Chloride (a potassium supplement) 20 milliequivalents (mEq) daily with breakfast, (a liquid), administered at 11:36 AM.
- Maxzide-25 (for blood pressure) daily, (a tablet), administered at 11:42 AM.
- None of the tablet form medications were shown to be given as "crushed" under the "Administration Instructions."
All of the above medications, but one - Maxzide, can be crushed, be delivered sublingual (under the tongue), or come in liquid form. Staff failed to follow the speech therapy recommendations, the pharmacy failed to change the MAR to show "crushed or liquid" medications, Staff I failed to administer Patient #13's medications timely, and then failed to file an event report related to them being late.

During an interview on 09/21/16 at 9:32 AM, Staff B, Regulatory Compliance, stated that staff should have filed an event report regarding Patient #13's late medications. Staff B confirmed an event report was not filed.














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