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Based on record review and interview, the hospital failed to ensure that a registered nurse must supervise and evaluate the nursing care for each patient as evidenced by failing to titrate a Precedex drip as ordered by the physician for 2 (#13, #25) of 2 patients reviewed on Precedex drips in a total sample of 30.
Findings:

Review of the hospital policy titled, Analgesia and Sedation, revealed in part that sedatives will be administered and/or titrated per a physicians order. The Richmond Agitation Sedation Scale (RASS) is used to determine the level of sedation, anxiety, or agitation in patient. The target level of sedation is a calm patient who is easily aroused and has a normal sleep-wake cycle (RASS 0 to -2).

Patient #13
Review of the medical record revealed an order set titled Sedation Analgesia Orders (dated 09/25/20 at 7:00 a.m.) with the medication Dexmedetomidine (Precedex) checked as ordered. Further review of the order revealed to titrate infusion rate per protocol below:
RASS = +4 to +1; increase Precedex by 0.2mcg/kg/hr and reassess in 5 minutes after each adjustment
RASS= 0 to -2; reduce RASS assessment to every hour
RASS= -3 to -5; decrease Precedex by 0.2mcg/kg/hr and reassess in 5 minutes after each adjustment

Review of the Medication Titration Flow Sheet and Sedation Flow Sheet dated 09/25/20 revealed the following:
7:00 a.m. - Precedex infusing at 0.6mcg/kg/min; RASS score of +1 (indicating patient was restless). Per titration orders, Precedex rate should have been increased by 0.2mcg/kg/hr
8:00 a.m. - Precedex infusing at 0.7mcg/kg/min; RASS score of 0 (indicating patient alert and calm). Per titration orders, Precedex rate should have remained the same.
9:00 a.m. - Precedex infusing at 0.8mcg/kg/min; RASS score of -1 (indicating patient drowsy). Per titration orders, Precedex rate should have remained the same.
10:00 a.m. - Precedex infusing at 0.9mcg/kg/min; RASS score of 0. Per titration orders, Precedex rate should have remained the same.
11:00 a.m. - Precedex infusing at 1.0mcg/kg/min; RASS score of 0. Per titration orders, Precedex rate should have remained the same.

On 10/21/20 at 8:30 a.m., S3DON reviewed the above medical record and confirmed that the Precedex infusion was not titrated per physicians orders.

Patient #25
Review of the medical record revealed an order set titled Sedation Analgesia Orders (dated 07/24/20 at 1:00 p.m.) with the medication Dexmedetomidine (Precedex) checked as ordered. Further review of the order revealed to titrate infusion rate per protocol below:
RASS = +4 to +1; increase Precedex by 0.2mcg/kg/hr and reassess in 5 minutes after each adjustment
RASS= 0 to -2; reduce RASS assessment to every hour
RASS= -3 to -5; decrease Precedex by 0.2mcg/kg/hr and reassess in 5 minutes after each adjustment

Review of the Medication Titration Flow Sheet and Sedation Flow Sheet dated 07/24/20 revealed the following:
7:35 p.m. - Precedex infusing at 0.2mcg/kg/min; RASS score of -1 (indicating patient was drowsy). Per titration orders, Precedix rate should have remained the same.
8:30 p.m. - Precedex infusing at 0.4mcg/kg/min; RASS score of -1. Per titration orders, Precedix rate should have remained the same.
9:00 p.m. - Precedex infusing at 0.6mcg/kg/min; RASS score of -1. Per titration orders, Precedix rate should have remained the same.
10:00 p.m. - Precedex infusing at 0.8mcg/kg/min; RASS score of -2 (indicating light sedation). Per titration orders, Precedix rate shold have remained the same.

Further review revealed the rate remained at 0.8mcg/kg/min until 07/25/20 at 3:00 a.m. when it was decreased to 0.6mcg/kg.min. The RASS score at that time was documented as -2 (indicating light sedation). Per titration orders, the rate should not have been decreased, but remained the same.

On 10/21/20 at 11:40 a.m., S3DON reviewed the above medical record and confirmed that the Precedex infusion was not titrated per physicians orders.

Based on record review and interview, the hospital failed to ensure that H&Ps (history and physical) were completed within 24 hours after admission for 5 of 30 (Patient #2, 5, 23, 27, 29) patients reviewed.
Findings:

Patient #2
Review of the medical record for patient #2 revealed an admit date of 10/07/20. Review of the H&P revealed it was dictated on 10/09/20.
On 10/20/20 at 1:00 p.m., an interview with S4HIM confirmed that the H&P should have been dictated within 24 hours after admission.

Patient #5
Review of the medical record for patient #5 revealed an admit date of 09/10/20. Review of the H&P revealed it was dated 10/15/20.
On 10/19/20 at 3:45 p.m., an interview with S4HIM confirmed that the H&P was completed greater than 24 hours after admit.

Patient #23
Review of the medical record for patient #23 revealed an admit date of 10/07/20. Review of the H&P revealed it was dictated and signed on 10/20/20.
On 10/20/20 at 2:30 p.m., an interview with S4HIM confirmed the physician had completed the H&P earlier that day.

Patient #27
Review of the medical record for patient #27 revealed an admit date of 10/13/20. Further review of the record revealed no evidence of a completed H&P.
On 10/21/20 at 11:10 a.m., an interview with S4HIM confirmed that the H&P had not been completed.

Patient #29
Review of the medical record for patient #29 revealed an admit date of 09/09/20. Further review of the record revealed an H&P but it was not dated.
On 10/21/20 at 11:15 a.m., S4HIM reviewed the H&P and confirmed that it was not dated and she was unsure when it was completed.


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Based on record review and interview, the hospital failed to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed (review for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications).
Findings:

Review of the Louisiana Administrative Code, Title 46 Professional and Occupational Standards, Part LIII Pharmacist, Chapter 15 Hospital Pharmacy, Section: 1511: Prescription Drug Orders, Item A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

Review of the hospital policy titled, Drug Therapy Monitoring, Policy Number 10-14.11.0, dated January 2004 revealed in part: A pharmacist shall review the prescriber's original order, or a direct copy thereof, before the initial dose is dispensed (with the exception of emergency orders when time does not permit).

Review of the hospitals Override Transaction Profile report dated 07/19/20 - 10/19/20 revealed 171 medications were on the report, indicating that they had been overridden and removed from the automated medication dispensing system prior to a pharmacist review.

Interview on 10/20/2020 at 2:20 p.m. with S2CAA confirmed that in reviewing the override report, there were 39 medications that were not stat or emergency doses that should have been reviewed by pharmacy. S2CAA further stated that she was aware of the issue that nurses are overriding the automated medication dispensing system in order to administer new medications prior to a first dose review by a pharmacist.

Based on record review and interview, the hospital failed to ensure all dispensing of drugs and biologicals was under the supervision of a pharmacist as evidenced by failing to ensure an antibiotic medication was provided to a patient in a timely manner (Patient #19).
Findings:

Review of the hospital's policy titled, Medication Administration, revealed in part that if medication is not readily available for administration to patients, the following procedure will be followed: The pharmacist will explore all options to secure the medication including contacting a local pharmacy or contacting the host facility to secure the medication.

Review of the medical record for Patient #19 revealed a physician order dated 10/06/20 at 4:01 p.m. for Vancomycin (antibiotic) 150mg every 6 hours. Review of the medication administration record (MAR) revealed the patient did not receive the first dose of the antibiotic until the next day, 10/07/20 at 9:00 a.m. Further review of the MAR revealed documentation on 10/07/20 at 12:00 a.m. and 6:00 a.m. that the medication was unavailable.

On 10/20/20 at 3:30 p.m., interview with S3DON revealed that the patient's Vancomycin oral medication had to be mixed by a pharmacist and a pharmacist was not available to mix the medication until the next day after it was ordered.

On 10/21/20 at 10:00 a.m., interview with S1Administrator confirmed that the medication should have been made available on the day it was ordered by the physician. S1Administrator confirmed the patient's Vancomycin medication was not provided timely by the pharmacist.

Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of 30 of 30 patient beds.
Findings:

On 10/19/2020 at 10:45 a.m., an observation of one unoccupied inpatient room revealed that the patient bed in Room a had a non-functional nurse call feature (a red cross symbol) on the siderail of the bed. The red cross symbol was pressed during the observation and no alert of any type was generated when it was pressed.

An interview with S3DON on 10/19/20 at 11:00 a.m. confirmed the red cross nurse call feature on the siderail of the inpatient bed was not functional. She reported patients/patient families were instructed to use the nurse call feature on the corded call light located at the patient's bedside to call for staff assistance. The surveyor discussed the possibility of patient/patient family/visitor confusion with having the non-functional nurse call feature available for use as well as the nurse call feature on the corded call light and the potential of the non-functional nurse call feature being pressed to summon help from staff. S3DON agreed that having the non-functional nurse call feature available for use could result in potential confusion when calling for staff assistance.

On 10/19/2020 at 1:30 p.m., a follow-up interview with S3DON confirmed all 30 of the hospital's inpatient beds had a non-functional nurse call feature on the bed side rails.

Based on observation and interview, the hospital failed to employ methods for preventing and controlling the transmission of infections within the hospital as evidenced by failing to ensure patient rooms and the medication room was clean.
Findings:

On 10/19/20 at 10:45 a.m., observation of Room a revealed the overbed table tray had dried drips of a brown substance on it. Obsevations further revealed multiple dried brown splatters on the wall (near the thrermostat) and the air vent was coated with a thick build up of lint and debris. On 10/19/20 at 11:05 a.m., S3DON confirmed Room a was clean and available for a new admit.

On 10/19/20 at 10:55 a.m., observation of the medication room (next to Room a) revealed the cabinets that contained the intravenous fluids were coated with a thick build up of dust and debris.

On 10/20/20 at 10:20 a.m., observation of Room b revealed old tape was stuck to the IV pole, brown splatters were on the wall behind the bed, the overbed table had a dried brown substance on it and the air vent was coated with lint and debris. On 10/20/20 at 10:45 a.m., interview with S3DON confirmed this room was clean and available for a new admit.