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Based on record review, interview and observation the facility failed to meet the Condition of Participation for nursing services. Staff failed to followed standards of practice for medication administration and the facility failed to show that medication errors were handled appropriately. These deficient practices could lead to increased medication errors.

The findings are:

A. Refer to Tag A-0405 for not following standards of practice for medication administration.

B. Refer to Tag A-0508 for not ensuring medication errors were handled appropriately.

Based on record review, observation, and interview the facility failed to ensure staff were following standards of practice for medication administration for 1 (P [patient] 1) out of 3 (P1-P3) reviewed for medication administration. This deficient practice can lead to an increase in medication errors which could possibly cause patient harm.

The findings are:

A. Record review of the facility's policy titled, "Controlled Substances" dated 11/9/2023 under, "Administration and Documentation" stated, "8.4 At the time the medication is due for administration, the nurse or other appropriate healthcare professional will remove the medication from the AMMS [automated medication management system, locked medication dispensing cabinet] under the correct patient profile and administer the dose to the patient following the rights [right patient, right drug, right dose, right time, right route, right indication, right documentation] of medication administration. 8.4.1 Staff removing the controlled substance from the AMMS will always refer to the medication administration record (MAR) when removing the medication."

B. Record review of P1's medical record for admission dated 11/15/2024 through 11/27/2024 revealed the following:

1. Review of "Orders" revealed an order for hydromorphone (opioid pain medication) 0.25 mg (milligrams) ordered on 11/25/2024 at 6:27 PM and discontinued on 11/27/2024 at 6:09 PM.

2. Review of the medication administration record revealed hydromorphone 2 mg was administered on 11/27/2024 at 2:09 PM.

3. Review of a "History + Physical" note dated 11/27/2024 at 5:48 PM under, "Assessment/Plan" stated, ". . . # Metabolic encephalopathy [confusion related to issues of metabolism], acute. # Likely [secondary to] opioid overdose. Patient with acute AMS [altered mental status] and respiratory distress after undergoing IR [interventional radiology] drain exchange earlier today. She is fairly petite, received 50 mcg [micrograms] of fentanyl [opioid pain medication] and 2.0 mg of hydromorphone in close proximity. Upon arrival to MICU [medical intensive care unit], she became more responsive and able to speak with additional pushes of Narcan [drug used to reverse effects of opioid pain medication]. Her acute metabolic encephalopathy most likely in the setting of opioid overdose. . ."

4. Review of "Death Forms" revealed that the patient's date and time of death was 11/27/2024 at 11:20 PM.

C. During an interview on 12/11/2024 at 9:46 AM with S (staff) 8, clinical, S8 explained that the AMMS located on Unit A has a non-profile setting (a setting that doesn't require each patient to have an individual profile in the machine). The non-profile setting does not limit the available medications to the patient profile but allows staff to have access to all the medications in the AMMS for all patients.

D. During an interview on 12/11/2024 at 10:20 AM with S6, clinical it was confirmed that the dose provided to P1 was an error. It was explained that the 2 mg order for hydromorphone came from a different patient's chart.

E. Record review of the facility's policy titled, "Medication Error, Potential Adverse Drug Events and Adverse Drug Reaction Reporting" dated 11/8/2023, under "Procedure" stated "5. The Medication Safety Committee reviews PSP [Patient Safety Portal, incident reports] and PSP trends on a bimonthly basis, or more frequently based on the committee meeting schedule. Medication use improvements and recommendations are made based on PSP review, medication safety literature, and best practice recommendations. 6. Medication error prevention strategies will be developed based on review of PSP data, medication safety literature, and best practice guidelines and implemented for areas of the medication use system including selection and procurement, storage, ordering, preparing, dispensing, administration, monitoring, and evaluation of medications/medication therapy.

F. During an observation on 12/10/2024 at 11:00 AM at the nurse's station on Unit A, three medical records were opened in the electronic medical record system allowing access to more than one patient's information.

G. During an interview on 12/10/2024 at 11:00 AM with S10, clinical, it was confirmed that staff have not received any education regarding medication administration or having multiple charts open since the incident on 11/27/2024 involving P1.

Based on record review and interview the facility failed to ensure medication errors were handled appropriately for all patients receiving care in the hospital. This deficient practice could possibly lead to persistent issues when medication errors happen.

The findings are:

A. Record review of the facility's policy titled, "Medication Error, Potential Adverse Drug Events and Adverse Drug Reaction Reporting" dated 11/8/2023, under "Procedure" stated ". . . 1.4. Report the event through the Patient Safety Portal (PSP) system. Medication errors, incompatibilities, or other medication related events that do not reach the patient are considered "Unsafe conditions" or a "Near Miss" and should be reported through the PSP system. . . 6. Medication error prevention strategies will be developed based on review of PSP data, medication safety literature, and best practice guidelines and implemented for areas of the medication use system including selection and procurement, storage, ordering, preparing, dispensing, administration, monitoring, and evaluation of medications/medication therapy."

B. Record review of an untitled and undated document provided by the facility when an incident log was requested revealed a list of file names and then a list of files with dates. One of the file names included, "Medication Related [sic]". Unable to verify with this information if medication related incidents were appropriately reported, investigated and taken to the hospitals quality assessment and performance improvement program when needed.

C. During an interview on 12/10/2024 at 1:46 PM with S(staff)1, non-clinical, it was explained that the facility would not be providing an incident log.