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Based on clincal record reviews and interviews with facility personnel for one of four sampled patients (Patient #22), the facility failed to ensure that patients undergoing radiology procedures were medically managed and/or monitored appropriately after a procedure. Patient #22 was admitted to the hospital on 4/26/10 for an ultrasound guided thoracentesis related to a diagnosis of pleural effusion. Although the patient experienced a potential complication during the procedure, the patient was discharged without continued monitoring and/or a physicican evalutation in accordance with facility policy. The patient returned to hospital six hours later in distress and was transferred to another facility where he/she expired.
See (A 347)

THE CONDITION IS NOT MET: Based on clincal record reviews and interviews with facility personnel, the facility failed to ensure that patients undergoing radiology procedures were medically managed and/or monitored appropriately after a procedure. Patient #22 was admitted to the hospital on 4/26/10 for an ultrasound guided thoracentesis related to a diagnosis of pleural effusion. Although the patient experienced a potential complication during the procedure, the patient was discharged without continued monitoring and/or a physicican evalutation in accordance with facility policy. The patient returned to hospital six hours later in distress and was transferred to another facility where he/she expired.
See ( A546)

Based on clincal record reviews and interviews with facility personnel, for one of four sampled patients (Patient #22), the facility failed to ensure that the quality of care was provided to the patient.

The findings include:

1. Patient #22 was admitted to the hospital on 4/26/10 for an ultrasound guided thoracentesis related to a diagnosis of pleural effusion. Patient #22 had a history of pulmonary fibrosis and pulmonary hypertension. Review of the pre-procedure checklist identified that no imaging studies were completed prior to the procedure. During the procedure, only a small crescent of heterogeneous hypoechoic material was seen in the lower lateral left chest. Under direct visualization, a catheter was introduced into the region and a small amount of blood (30cc) which quickly coagulated was obtained. MD# 22 (Radiologist) identified that when he had aspirated the blood, he thought that he may have punctured a blood vessel or an organ. After the thoracentesis, Patient #22 had a follow-up chest x-ray which revealed no pneumothorax. Futher review failed to indicate that any other diagnostic study was obtained to rule out any other complications. Patient #22 was kept in the radiology department for one hour following the procedure with vital signs monitored by Radiology staff. Patient #22 was not transferred to the Emergency Department (ED) for close monitoring after a suspected complication. Patient #22 was discharged to home one hour post procedure. Review of hospital policy identified that in the event of complications requiring urgent medical treatment, the patient is immediately transferred to the ED and the referring physician is notified. Upon interview, MD #22 (Radiologist) stated he/she never examined the patient and/or called any consulting physician prior to the patient being discharged even though he thought he may have punctured a blood vessel or an organ. MD # 22 indicated that he went to do another procedure while Patient #22 was in the radiology department. Interview with MD #23, (Medical Director of Radiology) identified that prior to the procedure, imaging studies need to be obtained. Further interview with MD #23 identified that a CT scan post procedure and more close monitoring should have been done to ensure no complications existed due to a suspected injury. Subsequently, 6 hours later, Patient #22 was brought into the ED with complaints of dyspnea and severe abdominal pain. Review of the CT scan report dated 4/27/10 identified that the patient had a large volume intraperitoneal hemorrhage, likely of splenic origin. Patient #22 was transferred to Hospital #2 for further intervention and expired on 4/29/10.

Based on clincal record reviews and interviews with facility personnel, for one of four sampled patients (Patient #22), the facility failed to ensure that the quality of care was provided to the patient.

The findings include:

1. Patient #22 was admitted to the hospital on 4/26/10 for an ultrasound guided thoracentesis related to a diagnosis of pleural effusion. Patient #22 had a history of pulmonary fibrosis and pulmonary hypertension. Review of the pre-procedure checklist identified that no imaging studies were completed prior to the procedure. During the procedure, only a small crescent of heterogeneous hypoechoic material was seen in the lower lateral left chest. Under direct visualization, a catheter was introduced into the region and a small amount of blood (30cc) which quickly coagulated was obtained. Interview with MD #22 (Radiologist) identified that when he aspirated the blood, he thought that he may have had punctured a blood vessel or an organ. Further interview identified that MD #22 (Radiologist) never examined the patient and/or called any consulting physician prior to the patient being discharged. MD # 22 indicated that he went to do another procedure while Patient #22 was in the radiology department. Although Patient #22 had a follow-up chest x-ray which revealed no pneumothorax no further diagnostic studies were obtained. Patient #22 was kept in the radiology department for one hour following the procedure with vital signs monitored by Radiology staff and was discharged home one hour post procedure. Patient #22 was not transferred to the Emergency Department (ED) for close monitoring after a suspected complication. Review of hospital policy identified that in the event of complications requiring urgent medical treatment, the patient is immediately transferred to the ED and the referring physician is notified. Interview with MD #23, (Medical Director of Radiology) identified that prior to the procedure, imaging studies need to be obtained. Further interview identified that a CT scan post procedure and closer monitoring should have been done to ensure no complication due to a suspected injury. Subsequently, 6 hours later, Patient #22 was brought into the ED with complaints of dyspnea and severe abdominal pain. Review of the CT scan report dated 4/27/10 identified that the patient had a large volume intraperitoneal hemorrhage, likely of splenic origin. Patient #22 was transferred to Hospital #2 for further intervention and expired on 4/29/10.

Based on clinical record review and interviews with staff, the Hospital failed to ensure that for 2 of 3 patients (Patients #20 and #27), the patient's pain level was assessed and/or evaluated following administration of a pain medication. The findings include:

a. Patient #20 was admitted to the emergency department on 8/20/09 at 9:15 AM after falling at home the night before (8/19/09) and being found on the floor on the morning of 8/20/09. The patient had a history of congestive heart failure, chronic obstructive pulmonary disease (COPD), and Alzheimer ' s disease. The patient was noted to be alert, diaphoretic, pale, cyanotic, had labored breathing, and a blood oxygen level was identified in the 60 ' s. Patient #20 complained of back, hip, and leg pain, and RN #20 administered Dilaudid 2 mg IV. The clinical record failed to reflect that RN #20 reassessed the patient ' s pain after receiving the pain medication.
Interview with RN #20 on 5/27/10 at 10 AM identified that he/she obtained vital signs following the pain medication administration, however, did not identify the patient ' s pain level, per policy.

b. Patient #27 was admitted to the labor and delivery unit on 5/21/10 and underwent a C-section. The patient's clinical record was reviewed with the Nurse Manager on 5/24/10 at 10:30 AM. Patient #27 received pain medications on 5/24/10 at 12:30 AM and again at 6:00 AM, and staff failed to perform a reassessment of the patient's pain following each of the pain medication administrations.




19907

Based on clinical record reviews and interviews with facility personnel, for one of two sampled patients (Patient # 36), the facility failed to ensure that neurological checks were completed per physician's order.

The findings include:

1. Patient #36 was admitted to the hospital on 5/23/10 with mental status changes after a previous fall. Review of the physician's orders dated 5/23/10 identified that the patient was to have neurological checks every two hours. Review of nursing documentation dated 5/24/10 from 5:00am-11:00am identified that neurological checks were not completed per physician order. Subsequent to surveyor inquiry on 5/24/10 at 11:00am, neurological checks were documented from 7:00am-11:00am by the nurse assigned to the patient, however neuro-vital signs for 5:00 a.m. were still lacking. Interview with the ICU Nurse Manager on 5/24/10 identified that the physician 's order was not followed.


2. Patient #36 was admitted to the hospital on 5/23/10 with mental status changes after a previous fall at home. Patient #36 was disorientated and had a left orbital floor fracture and contusion. Review of the admission fall assessment dated 5/24/10 identified that the patient was assessed as a low risk for falls. Further review failed to identify that the patient was accurately assessed for fall risk since the patient had previous falls at home. Review of hospital policy identified that the nurse assesses all inpatient's risk for falls using the Schmid Fall Risk Assessment Tool on admission. Interview with the Nurse Manager on 5/24/10 identified that the patient was not accurately assessed for fall risk on admission.

Based on clinical record reviews and interviews for one sampled patient (Patient #29) with a history of behavioral dyscontrol, the clinical record lacked a comprehensive care plan to address these behaviors. The findings include:

Patient #29 was admitted on 5/6/10 with diagnoses that included cerebral vascular accident, seizure disorder and pneumonia. During a tour of the 3 East nursing unit with the Nurse Manager on 5/24/10 at 9:45AM it was identified that Patient #29 was in a private room with the door closed due to his history of yelling and using profanity towards staff and visitors. A review of the nurse's notes dated 5/12/10, 5/23/10 and 5/24/10 identified Patient #29 refusing medication, yelling at staff and visitors and refusing care. Interview and review of the clinical record with the Nurse Manager on 5/24/10 at 11:15AM failed to provide evidence that the care plan reflected the behaviors and/or interventions to address these behaviors.

Based on clinical record reviews and interviews with facility personnel for two of three sampled patients (Patient #38, Patient #39), the facility failed to ensure that the informed consent was reviewed and/or signed by a radiologist prior to procedure.

The findings include:

1. Patient #38 was admitted to the hospital on 5/25/10 for a CT scan of the chest/pelvis/abdomen with contrast. Review of the consent form dated 5/25/10 identified that that although the patient signed the consent, the procedure was not reviewed and/or signed by the radiologist. Review of hospital policy identified that a consent must be obtained and signed prior to commencement of treatment. Interview with the Director of Radiology on 5/25/10 identified that that the Radiology Technician reviews the procedure and/or risks and benefits with the patient. At the end of the procedure, the radiologist signs the consent.

2. Patient #39 was admitted to the hospital on 5/25/10 for a CT scan of the abdomen and pelvis with contrast. Review of the consent form dated 5/25/10 identified although the patient signed the consent, the procedure was not reviewed and/or signed by the radiologist. Review of hospital policy identified that a consent must be obtained and signed prior to commencement of treatment. Interview with the Director of Radiology on 5/25/10 identified that the Radiology Technician reviews the procedure and/or risks and benefits with the patient. At the end of the procedure, the radiologist signs the consent.

Based on a tour of the pharmacy department, review of hospital plicies and interviews the pharmacist failed to adequately supervise intravenous (IV) admixtures prepared by the certified technician. The findings include:

A tour of the pharmacy department was conducted on 5/25/10 at 9:30 AM. Observation identified a self-contained isolation barrier hood in the IV admixing room. Interview with the Director of Pharmacy on 5/25/10 at 9:45 AM noted that a certified pharmacy technician or pharmacist prepared IV admixtures. He/she further indicated that after the certified pharmacy technician injected the medications into the IV bag, the technician would leave the vials of the medication with an empty syringe pulled back to the amount of medication that had been injected for pharmacist accuracy review. The Director of Pharmacy also indicated that, at times, multi- dose medication vials were utilized and the pharmacist did not verify that the proper dosage of medication was in the syringe prior to mixing. The hospital medication preparation policy identified that any medication prepared by the technician is reviewed for dosing accuracy and integrity by a licensed pharmacist.

Based on observations and interviews with facility personnel, the facility failed to ensure that medications and biologicals were kept in a secure area.

The findings include:

1. During tour of the Radiology Department on 5/25/10, it was observed that in Exam Room #1, the medication cabinet was broken and remained unlocked. Interview with the Director of Radiology on 5/25/10 identified that she was not aware that the medication cabinet could be opened without a key and would have it repaired.

2. During tour of the Echo Room on 5/25/10, it was observed that Xylocaine and Citacaine Spray were located in an unsecured location. Interview with the Director of Radiology on 5/25/10 identified that those medications were to be in a locked cabinet.

Based on observation and interviews with facility personnel, the facility failed to ensure that outdated biologicals were discarded.

The findings include:

1. During tour of the Radiology Department on 5/25/10, it was observed that Betadine Solution was outdated (2/2005). Interview with the Director of Radiology on 5/25/10 identfied that she did not know why the Betadine was in the cabinet since they don't use it anymore for procedures.

On June 10, 2010, as part of the periodic federal survey, the Radiology and Nuclear Medicine Departments of New Milford Hospital was inspected for compliance with CFR 482.26 and 482.53.

The inspection consisted of a review of records, procedures, equipment and facilities, including the following: (a) in-house physics reports and follow-up corrective actions; (b) personnel dosimetry records; (c) and of area surveys; and (d) records of calibration.

In the Radiology Department, one item of non-compliance was identified within the scope of the inspection.

Under CFR 482.26(b)(1) interpretative guideline for adequate shielding for patients, personnel and facilities - requires in part that an evaluation of the radiation hazards incident to the use of sources of radiation under a specific set of conditions be performed.

Contrary to the above, surveys of the radiation hazard were not performed for diagnostic x-ray equipment in the radiology department and were not available upon request.

Based on observation, interview of staff and review of Hospital documentation for the Radiology Department, the Hospital failed to ensure that clinical and diagnostic equipment was inspected, tested and maintained according to facility policy and NFPA 99 " Health Care Facilities " The findings include:

During documentation review on 05/24/10 and 05/25/10 it was found that the annual certification of the facility ' s CT scanner and the Stereotactic unit had not been completed since January 2009.

Based on clincal record reviews and interviews with facility personnel, for one of four sampled patients (Patient #22), the facility failed to ensure that the quality of care was provided to the patient.

The findings include:

1a. Patient #22 was admitted to the hospital on 4/26/10 for a ultrasound guided thoracentesis related to a diagnosis of pleural effusion. Patient #22 had a history of pulmonary fibrosis and pulmonary hypertension. Review of the pre-procedure checklist identified that no imaging studies were completed prior to the procedure. During the procedure, only a small crescent of heterogeneous hypoechoic material was seen in the lower lateral left chest. Under direct visualization, a catheter was introduced into the region and a small amount of blood (30cc) which quickly coagulated was obtained. After the thoracentesis, Patient #22 had a follow-up chest x-ray which revealed no pneumothorax, however, no additional diagnostic studies were obtained to rule out suspected complications. Patient #22 was kept in the radiology department for one hour later with vital signs monitored by Radiology staff and was discharged home one hour post procedure.. Patient #22 was not transferred to the Emergency Department (ED) for close monitoring after a suspected complication. Review of hospital policy identified that in the event of complications requiring urgent medical treatment, the patient is immediately transferred to the ED and the referring physician is notified. Upon interview, MD #22 (Radiologist) identified that when he aspirated the blood, he thought that he may have had punctured a blood vessel or an organ. Further interview identified that MD #22 (Radiologist) never examined the patient and/or called any consulting physician prior to the patient being discharged. MD # 22 indicated that he went to do another procedure while Patient #22 was in the radiology department. Interview with MD #23, (Medical Director of Radiology) identified that prior to the procedure, imaging studies need to be obtained. Further interview identified that a CT scan post procedure and more close monitoring needed to be done to ensure no complication with a suspected injury. Subsequently, 6 hours later, Patient #22 was brought into the ED with complaints of dyspnea, severe abdominal pain. Review of the CT scan report dated 4/27/10 identified that the patient had a large volume intraperitoneal hemorrhage, likely of splenic origin. Patient #22 was transferred to Hospital #2 for further intervention and expired on 4/29/10.

1b. Review of the clincal record dated 4/26/10 identified that Patient #22 was kept in the radiology department for one hour post-procedure. Review of the vital signs sheet dated 4/26/10 identified that although vital signs were completed post procedure, a nursing assessment and/or respiratory rate was not completed either pre-procedure or post-procedure for the patient despite a suspected complication. Further review failed to identify that a registered nurse was monitoring the patient post procedure. Interview with RN #23 on 6/2/10 identified that MD #22 had informed her during the procedure that the patient may have a splenic injury. Interview with RN #24 identified that she was not informed that Patient #22 may have had a splenic injury by RN #23 during change of shift. RN #23 identified that she left to assist with another procedure and a Radiology Technician monitored Patient #22's vital signs. She then went back to discharge the patient. RN #23 indicated that MD #22 never examined the patient prior to discharge. Review of hospital policy identified that vital signs including pulse oximetry and blood pressure are monitored and documented throughout procedure until discharge. Review of hospital policy identified that in the event of complications requiring urgent medical treatment, the patient is immediately transferred to the ED and the referring physician is notified.

Based on a tour of the dietary department, review of hospital policy, observations and interviews the hospital failed to ensure that one of four dietary staff served food in a safe manner. The findings include:

A tour of the dietary department was conducted with the Director of Nutritional Services on 5/25/10 at 10:35 AM. Observations on 5/25/10 at 11:40 AM identified three Cooks prepared food and one Dietary Assistant checked the plates for accuracy, cover the plates and placed the plates of food as well as other food items on the serving trays. The Dietary Assistant was observed with long hair, hair net covered 3/4 of his/her head and wisps of hair had been tucked behind each ear with a large strand of hair sticking out from the back of the hair net. The Dietary Assistant was observed with the Director of Food Services to work on the tray line with the uncovered food and partially contained hair from 11:40 AM to 11:50 AM. Interview with the Director of Food Services on 5/25/10 at 11:50 AM noted that dietary staff was expected to have all hair covered when in the kitchen. Although the Dietary Director directed the Dietary Assistant to properly replace the hair net at 5/25/10 at 11:50 AM, the Dietary Assistant had left the long wisps of hair behind each ear that stuck out at the sides and required further direction from the Director of Food Services to properly don the hairnet. The personal hygiene policy for the food and nutrition department identified that associates will practice good personal hygiene to prevent the spread of food borne illness to include hairnets or caps worn at all times.



19907

Based on observations and interviews with facility personnel, the facility failed to ensure that food utilized for patients was labeled with expiration dates to ensure safety.

The findings include:

1. During tour of the ICU and Cancer Center on 5/24/10, it was observed that food and juices utilized for patients was not labeled with expiration dates. Review of hospital policy identified that all food items must have a date it was put in the refrigerator. Interview with the Nurse Manager on 5/24/10 identified that food/juices in patient refrigerators needs to labeled.

Based on observations of the facility and interviews with facility personnel, the facility failed to ensure that equipment used to produce ice for patients was maintained in a safe and sanitary manner.
The findings include:
During tour of the facility it was observed that the ice machines on the 3E unit , the Labor & Delivery Family Room, and the Intensive Care Unit had rusting and calcium buildup within the hopper of the ice machine that stored ice to be utilized for patient drinking and treatment uses.

Based on observations and interviews with facility personnel, the facility failed to maintain equipment to ensure safety.

The findings include:

1. During tour of the Cancer Center on 5/24/10, it was identified that a blanket warmer temperature was set at 205 degrees. Further review failed to identify that the temperature was being monitored and/or that the hospital had a policy regarding monitoring blanket warmers. Review of manufacturers manual identified that the ambient temperature range of the blanket warming cabinet is not to exceed 159 degrees. Interview with the Nurse Manager on 5/25/10 identified that they had a problem with maintaining the temperature of the blanket warmer and that is why it was set high. Further interview identified that they were not monitoring the temperatures.

Based on observation and interviews with staff, the Hospital failed to ensure that patient care supplies and equipment were stored in a manner consistent with appropriate infection control practices and/or ensure that medications are not expired. The findings include:

a. A tour of the labor and delivery area was conducted on 5/24/10 at 9:50 AM with the Nurse Manager. In the soiled utility room, a clean medication administration pump was stored on the dirty work counter, compromising the integrity of the machine.
b. A tour of the emergency department ' s medication room was conducted on 5/24/10 at 1:00 PM with the Nurse Manager. The sink and surrounding counter area was heavily soiled with a white and brown substance. Patient care supplies that included IV bags, IV flush syringes, and IV equipment, and blood draw supplies were placed within 6 inches of the dirty sink and contained splash/splatter marks, compromising the integrity of the supplies
c. Further review of the emergency department on 5/24/10 identified a tackle box with supplies to treat patients with cardiac problems. In the tackle box, multiple injectable medications were out dated since 3/2009.



19907

Based on clinical record reviews and interviews with facility personnel, the facility failed to ensure that equipment was cleaned to maintain appropriate appropriate infection control practices and/or that staff followed appropriate infection control practices.


The findings include:



1. During tour of the ICU on 5/24/10, it was observed that a nurse exited a patient room with gloves hand and a urine sample. The nurse was observed coming to the nurses station, opening the medication cart, return the patient's eye drops and continue to carry the urine sample in her hand and place it on the nurses station counter. Further review failed to identify that the handling of urine specimens was followed. Review of hospital policy identified that lab specimens are placed in a container that prevents leakage, handled and transported in a biohazard symbol bag. In addition, remove gloves and perform hand hygiene promptly before touching non-contaminated items and environmental surfaces. Interview with the ICU Nurse Manager on 5/24/10 identified that the handling of lab specimems was not followed.

2. During tour of the Cancer Center on 5/24/10, it was observed that in the soiled utility room contained a file cabinet on wheels, multiple items utilized for patient being stored. Interview with the Nurse Manager on 5/24/10 identified that they were utilizing the soiled utility room for storing of items and that they would remove them.

3. During tour of the ICU and the Cancer Center on 5/24/10, it was observed that a box on top of the code cart contained laryngoscopes that were not being stored in a clean self-seal pouch. Review of hospital policy identified that laryngoscopes are sent to central sterile for cleaning and are returned to the units. Interview with the Director of Central Sterile on 5/25/10 identified that the laryngoscopes are cleaned and sent to the units in a self-seal pouch that states that they are clean, not sterile. Interview with the ICU Nurse Manager on 5/24/10 identified that the staff removes the laryngoscopes from the pouches and places them in the respiratory emergency box. Further interview identified that she could not guarantee that they were a clean item.




20361

Based on observation, interviews and review of facility documentation for one newly admitted patient (Patient # 30) with a history of MRSA, infection control measures were not implemented. The findings include:

Observation on 5/24/10 at 10:25AM during a tour of 3 East with the Nurse Manager identified a new admission (Patient #30) who was just transported from the Emergency Department by RN#20 without the benefit of personal protective equipment. RN#22 was outside of the room providing family education as they entered the room regarding the need to implement precautions according to hospital policy as the patient had a history of MRSA( Methicillin Resistant Staphylococcus Aureus). Interview with RN#22 on 5/24/10 at 11:30AM identified that she reviewed Patient #30's previous history prior to arrival on the nursing unit and initiated precautions as there was a history of MRSA in the past . RN#22 further identified that it is hospital policy to implement precautions until additional testing can be completed to determine if the MRSA is still active. RN#22 indicated that she informed RN#20 of this history when she obtained a nursing report from her prior to transfer to the nursing unit. Interview with RN#20 on 5/27/10 at10:20AM identified that she was notified of the patient's history by RN#22, however she did not utilize personal protective equipment as precautions are not utilized until they are on the inpatient unit. A review of the Prevention of Transmission of Infections Policy and Procedure directs staff to utilize the recommended precautions with all suspect patients until a definitive diagnosis ruling out the infection/condition has been determined.

Based on clinical record review, observation, and interviews with staff, the Hospital failed to ensure that staff administered medications as ordered for 1 patient (Patient #20) who was given the wrong intravenous medication. The findings include:

Patient #20 was admitted to the emergency department on 8/20/09 at 9:15 AM after falling at home the night before (8/19/09) and being found on the floor that morning (8/20/09). The patient had a history of congestive heart failure, chronic obstructive pulmonary disease (COPD), and Alzheimer ' s disease. The patient was noted to be alert, diaphoretic, pale, cyanotic, and had labored breathing. A blood oxygen level was identified in the 60 ' s throughout the admission. Patient #20 complained of back, hip, and leg pain, and MD #20 ordered Morphine 2 mg IV. Although RN #20 documented that the Morphine was administered at 10:20 AM, the patient actually received Dilaudid 2 mg IV, in error. Following the administration of the pain medication, Patient #20 had a series of X-rays and returned to the emergency department. On return at 11:00 AM, the patient ' s blood pressure, pulse, and respirations were elevated, and the blood oxygen level continued in the 60 ' s. Additional medications were administered to treat the patient ' s respiratory problem, and the patient was admitted to the hospital. Admission orders identified that the patient was in end stage COPD and end of life measures were to be initiated, including not to resuscitate if breathing ceased. Patient #20 was identified as unresponsive and unable to follow commands when moved from the emergency department stretcher onto a hospital bed between 12:32 and 12:54 PM. At approximately 1:06 PM, the patient ceased to breathe and was pronounced deceased. Interview with RN #20 on 5/27/10 at 10 AM identified that he/she inadvertently reached for, and administered Dilaudid instead of Morphine on 8/20/09 at 10:20 AM. Interview with Pharmacist #20 on 5/26/10 at 12 PM identified that Dilaudid was 7 times stronger than Morphine and could cause a " respiratory slow-down. " Interview with MD #20 on 5/27/10 at 11:05 PM identified that he/she ordered Morphine to be administered to Patient #20 for pain. MD #20 identified that Patient #20 had significant health problems, including chronic respiratory problems and was not doing well when admitted to the hospital. MD #20 and the patient ' s family had discussed the patient ' s condition at length and determined that the patient would be a DNR (do not resuscitate) should the patient stop breathing. MD #20 identified that Patient #20 was chronically hypoxic and felt that the patient ' s end of life would occur that same day. MD #20 identified that he/she was unable to speculate if the medication error precipitated the patient ' s death due to the patient ' s other disease processes. In addition, MD #20 identified that if the patient ' s pain was not relieved with the Morphine that was originally ordered, he/she would probably have ordered Dilaudid.