HospitalInspections.org

Based on record reviews, observations, and interviews, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:
1) failure of the RN to properly label laboratory specimens for 2 (#2, #9) of 5 (#1, #2, #3, #4, #9) patient records reviewed for laboratory orders from a sample of 9 patients (See findings under tag A-0395);
2) failure of the RN to ensure antibiotic orders were clarified before omitting antibiotic on an NPO patient for 1 (#3) of 2 (#3, #7) patient records reviewed for medication errors from a sample of 9 patients (See findings under tag A-0395); and
3) failure of the RN to follow physician laboratory orders for 1 (#3) of 5 (#1, #2, #3, #4, #9) patient records reviewed for laboratory orders from a sample of 9 patients (See findings under tag A-0395).

Based on record reviews and interviews, the hospital failed to ensure the patient or his/her family/representative had the right to make informed decisions regarding his/her care. This deficient practice was evidenced by failing to have documented evidence of a discussion with a patient and/or his/her family/representative regarding a DNR order and the decision to have the DNR order written in accordance with hospital policy for 1 (#6) of 2 (#5, #6) patient record reviewed with an order for DNR from a sample of 9 patients.
Findings:

Review of the hospital policy titled, "Do Not Resuscitate (DNR) Orders", presented as current, revealed it is the responsibility of the attending physician to address the question of a "Do Not Resuscitation" order with the patient and/or family/significant other. A nurse may take a verbal or telephone order for a DNR/Limited DNR status. All DNR/Limited DNR telephone orders require a second nurse witness. Further review revealed the decision to "Do Not Attempt Resuscitation (DNR)" or to add Additional Limitations must be discussed with the patient and/or legitimate surrogate and must be documented in the patient's Progress Notes by the attending physician or physician designee.

Review of the hospital policy titled, "Advance Directives", presented as current, revealed in part: The purpose of the policy is to help assure that any patient that has executed an Advance Directive is encouraged to provide the directive information to the hospital staff so that their wishes may be adhered to in regards to their healthcare. Further review revealed the directive should indicate someone has been designated to carry out their healthcare wishes/make decisions for them in the event that they are not able to make those decisions. The procedure indicated the patient has the right to, and may, at any point, make clarifications, modifications or revocations of the directive and such conversations will be documented in the patient medical record and the patient/resident's physician will be informed of the change. It further indicates nursing staff will ask the patient to sign a "Resuscitation Order/Consent" Form. The Resuscitation Order/Consent Form will become a part of the permanent medical record. This executed form will also serve as the physician order, once the attending physician or designee has signed the form.

On 07/09/19 at 11:20 a.m. a review of Patient #6's electronic medical record, with the guidance of S5RT, revealed a the patient was a 58 year old male, admitted on 05/23/19, with an admitting diagnosis of post-reconstructive surgery the right neck with post-operative complications. Further review revealed Patient #6 had a tracheostomy and a gastrostomy tube.

Additional review of the medical record of Patient #6 revealed a form titled, "Patient Self Determination Act of 1990 Acknowledgement Consent for Advance Directive" and this document had printed handwriting at the bottom which indicated, "I have a living will to "Do Not Resuscitate". Patient #6's signature was noted under this statement. "DNR" was written on the side of this statement in a different handwriting. This document is dated 05/23/19 and signed by one Registered Nurse.

Review of Patient #6's orders revealed a DNR telephone order co-signed by S6MD on 05/24/19 at 10:52 a.m.

Review of Patient #6's History and Physical, dated 05/24/19 at 10:52 a.m., completed by S6MD, revealed documentation indicating the patient's code status was "full resuscitation."

In an interview on 07/09/19 at 11:45 a.m. with S2COO, he verified no DNR progress
note was in medical record for Patient #6.

In an interview on 07/10/19 at 9:50 a.m. with S3DQM, she verified there was no "Resuscitation Order/Consent" Form for Patient #6 in his record. She confirmed there was no progress note, in the patient's medical record, to indicate a discussion related to the patient's DNR status had taken place between the physician and the patient and/or the patient's family/representative

Based on record review, observation, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:

1) failure of the RN to properly label laboratory specimens for 2 (#2, #9) of 5 (#1, #2, #3, #4, #9) patient records reviewed for laboratory orders from a sample of 9 patients;

2) failure of the RN to ensure antibiotic orders were clarified before omitting antibiotic on an NPO patient for 1 (#3) of 2 (#3, #7) patient records reviewed for medication errors from a sample of 9 patients;

3) failure of the RN to follow physician laboratory orders for 1 (#3) of 5 (#1, #2, #3, #4, #9) patient records reviewed for laboratory orders from a sample of 9 patients; and

4) failure of the RN to follow the hospital policy for checking the code cart daily for 1 of 2 code carts observed for contents and for review of documentation of daily checks.

Findings:

1) Failing to properly label laboratory specimens:

Review of the hospital policy titled, "Specimen Collection Policy and Procedure", presented as current policy, revealed in part: It is critical that specimens for laboratory testing are submitted with proper specimen and patient identification. Most patient care errors involving laboratory testing occur because of patient/specimen identification or labeling error. Therefore: ....The person obtaining specimens must perform dual identification using two patient identifiers - full name and date of birth for patients ....When there is a discovery of error in patient identification, or specimen labeling, the specimen must be discarded. The procedure must be repeated following the patient identification and specimen labeling policy. Document the occurrence.


Patient #9
Review of the medical record for Patient #9 revealed he was a 75 year old admitted on 04/02/19 with a diagnosis of non-pressure chronic ulcer of the left foot.

Review of lab results in Patient #9's medical record revealed a left hip culture collection dated 04/10/19 at 3:00 p.m. which was determined on 4/13/19 to actually be lab results for Patient #2. Patient #9 had no hip wounds.

Review of Patient #9's physician's orders revealed there was no order for a hip culture for Patient #9 on 04/10/19.

Further review of Patient #9's labs revealed the culture collected on 04/10/19 was resulted on 04/13/19 at 9:41 a.m. The culture was positive for growth of Pseudomonas Aeruginosa (lab resulting from Patient #2's left hip wound).

Review of Patient #9's orders revealed an order dated 04/13/19 at 12:44 p.m. by S6MD for Meropenem IVPB 1 gram three times a day for diabetic foot infection. (Progress note by S6MD indicates this antibiotic was started based on the culture results for Patient #2's wound that were mislabeled with Patient #9's information).

Review of a nursing note, dated 04/13/19 at 10:44 a.m. by S8LPN, revealed the following:
10:00-nurse noted new order for Fortaz 2 grams IVPB every 8 hours by S11MDInfDis. Further review revealed the nurse documented the right hip wound culture was positive for Pseudomonas. Additional review revealed the nurse had assessed the patient's left and right hips and the patient did not have wounds.
10:30-called S7WNP and asked about hip wound cultures. He said, "No, we did not collect cultures on him. He does not have wounds to his hips."
11:00-S11MDInfDis made aware culture results were mislabeled. Order to discontinue Fortaz.

Review of a physician's progress note, dated 04/13/19 at 12:12 p.m., by S6MD revealed the following: "4/13 pt. asleep-tissue cultures growing pseudomonas R"

Review of physician's progress note, dated 04/13/19 at 1:29 p.m., by S11MDInfDis revealed the following: "Right hip wound - wound culture with pseudomonas".

Review of Patient #9's MAR revealed Meropenem 1 gram IVPB three times a day administered at the following times:
a. 04/13/19 at 1:47 p.m.
b. 04/13/19 at 9:46 p.m.
c. 04/14/19 at 5:29 a.m.
*(Patient #9 was treated with 3 doses of antibiotics based on the culture results of Patient #2's wound).

Review of a physician's progress note, dated 04/14/19 at 12:25 p.m., by S11MDInfDis revealed the following: "On Mero per primary. Culture wrong in EPIC. Will d/c".

Review of a physician's progress note, dated 04/14/19 at 1:53 p.m., by S6MD revealed the following: "Patient doesn't have any wounds on his right or left hip, tissue cultures were mislabeled with his name but were actually for the patient in the same room, other bed".

Review of discharge summary dated 04/29/19 at 11:27 a.m. by S6MD revealed in part, "Patient went to the LTAC completed a course of antibiotics, we added meropenem because of multi-drug-resistant Pseudomonas.

In an interview on 07/10/19 at 2:45 p.m. with S7WNP, he verified he mislabeled the wound culture labs for Patient #2 with Patient #9's name. He stated he did not know Patient #9 received 3 doses of antibiotics for the mislabeled specimen.

In an interview on 07/10/19 at 3:00 p.m. with S8LPN, she verified she notified S11MDInfDis that he ordered antibiotics for Patient #9 for a wound she did not observe and he discontinued the antibiotic.

Patient #2
Review of Patient #2's electronic medical record on 07/09/19 at 12:15 p.m., with the guidance of S5RT, revealed Patient #2 was a 61 year old admitted on 03/13/19 with diagnoses of osteomyelitis of the right foot and pressure ulcers. Patient #2 was transferred for a higher level of care on 04/29/19.

Review of Patient #2's physician's orders revealed an order for a hip culture on 04/10/19. Further review of Patient #2's medical record revealed the ordered hip culture had not been completed.

Further review of Patient #2's physician's orders revealed an order written 04/14/19 for Fortaz 2 grams IVPB every 8 hours for wound.

In an interview on 07/10/19 at 2:45 p.m. with S7WNP, he verified he mislabeled the wound culture labs for Patient #2 with Patient #9's name. He stated he did not know Patient #9 received 3 doses of antibiotics based on the culture results from the mislabeled specimen. He further stated he made the decision not to repeat the wound culture and did not discontinue the wound culture and started to treat him based on the lab results.


2) Failing to ensure an antibiotic order was clarified with the physician before omitting antibiotic on an NPO patient:

Review of the hospital policy titled, "Medication Error Reporting", presented as current, revealed in part: Drugs administered in error and doses omitted shall be reported and reviewed in accordance with this policy.
Among the types of error is omission which is described as failure to administer an ordered dose to a patient before the next scheduled dose, if any.
Further review revealed if the error resulted in no harm or is insignificant the error does not require immediate reporting to the prescribing practitioner and can be reported the next day during regular physician rounding hours .....If the practitioner who orders the drug is unavailable, the error shall be reported to the attending practitioner or another responsible practitioner.
All medication variances shall be entered into the patient's medical record notes as a Medication Error/Adverse Drug Event.

Patient #3
Review of Patient #3's electronic medical record with the guidance of S5RT, on 07/09/19 at 10:40 a.m., revealed the patient was a 55 year old admitted on 06/19/19 with a complex left foot fracture with MRSA (antibiotic resistant bacteria) infection.

Review of Patient #3's orders revealed an order was entered on 06/13/19 for Metronidazole 500 mg PO every 8 hours.

Review of Patient #3's MAR Audit revealed Metronidazole doses were documented as "Not Given" on the following days:
06/21/19 at 6:00 a.m.
06/23/19 at 2:00 p.m.
06/23/19 at 10:00 p.m.
06/24/19 at 6:00 a.m.

Review of Patient #3's nursing notes revealed no documented evidence that the physician was notified of the above omitted doses of Metronidazole.

In an interview on 07/09/19 at 8:40 a.m. with S3DQM, she verified Patient #3 had missed 4 doses of Metronidazole after reviewing the MAR Audit Report. She stated the reason the Metronidazole was not given was because Patient #3 was NPO. She further revealed no occurrence/event report was written and the physician was not notified because the patient was NPO.

In an interview on 07/10/19 at 3:20 p.m. with S9LPN, she reported if a patient is NPO and is receiving oral medications, you must notify the physician before omitting the dose.

In an interview on 07/11/19 at 3:00 p.m. with S10LPN, she reported if a patient is NPO and oral medications are ordered you would not give the medication and you would not notify the physician about not administering the medications.


3) Failing to follow physician laboratory orders:

Patient #3
Review of Patient #3's electronic medical record on 07/09/19 at 10:40 a.m., with the guidance of S5RT, revealed the patient was a 55 year old admitted on 06/19/19 with a complex left foot fracture with MRSA (antibiotic resistant bacteria) infection.

Review of Patient #3's orders revealed an order written 06/16/19 at 8:59 a.m. for random Vancomycin Trough weekly, on Wednesday, while the patient was receiving Vancomycin.

Review of Patient #3's laboratory results revealed a random Vancomycin Trough had not been done on Wednesday, June 26, 2019 nor Wednesday, July 3, 2019.

In an interview on 07/09/19 at 11:10 a.m. with S3DQM, she called S4Pharm and verified the above Vancomycin Troughs were not drawn as ordered for Patient #3.

In an interview on 07/09/19 at 11:45 a.m. with S2CCO, he verified the Vancomycin Troughs were not drawn as ordered for Patient #3.

Review of the hospital event reports revealed an event report, dated 07/09/19, was initiated by S4Pharm and completed by S3DQM and S2CCO related to staff failure to draw vancomycin troughs as ordered.

Review of Patient #3's labs revealed the following Vancomycin troughs had been performed:
07/10/19 at 6:48 a.m. Vancomycin Trough resulted 28.8 (10-15); and
07/10/19 at 4:55 p.m. Vancomycin Trough resulted 16.1 (10-15).


4) Failed to ensure one of the code carts was checked daily.

Review of the hospital policy titled, "Code Cart Checking", presented as current, revealed in part: The purpose is to ensure a properly stocked and functional code cart is available to respond appropriately to patient code situations. Code carts will be checked daily.

Review of the crash cart daily checklist for the crash cart located on the odd hallway revealed the crash cart was not checked on 07/05/19.

On 07/08/19 at 9:00 a.m. S3DQM verified the crash cart was not checked on 07/05/19.

Based on record reviews and interviews, the hospital failed to ensure drugs and biologicals were prepared and administered in accordance with Federal and State laws and regulations, the orders of the practitioner or practitioners responsible for the patient's care, and in accordance with the approved medical staff policies and procedures. This deficient practice was evidenced by failure to ensure drugs and biologicals were administered in accordance with the physician's order for 2 (#3, #7) of 2 patient records reviewed for medication errors from a sample of 9 patients.
Findings:

Review of the hospital policy titled, "Medication Error Reporting", presented as current, revealed in part: Drugs administered in error and doses omitted shall be reported and reviewed in accordance with this policy.
Among the types of error is omission which is described as failure to administer an ordered dose to a patient before the next scheduled dose, if any.

Patient #3
Review of Patient #3's electronic medical record on 07/09/19 at 10:40 a.m., with the guidance of S5RT, revealed the patient was a 55 year old admitted on 06/19/19 with diagnoses of complex left foot fracture with MRSA (antibiotic resistant bacteria) infection.

Review of Patient #3's orders revealed an order dated 06/13/19 for Flagyl 500 mg PO every 8 hours.

Review of a MAR Audit revealed Metronidazole doses were documented as "Not Given" on the following dates:
06/21/19 at 6:00 a.m.
06/23/19 at 2:00 p.m.
06/23/19 at 10:00 p.m.
06/24/19 at 6:00 a.m.

In an interview on 07/09/19 at 8:40 a.m. with S3DQM, she verified, according to the MAR Audit Report, that Patient #3 had missed 4 doses of Metronidazole. She stated the reason the Metronidazole had not been given was because Patient #3 was NPO. She reported no occurrence/event report had been written and indicated the physician was not notified about the missed doses because the patient was NPO.

In an interview on 07/09/19 at 9:30 a.m. with S4Pharm regarding the MAR Audit Report, he confirmed Patient #4 had missed 4 doses of metronidazole and the nurses had written in the comment section that the patient was NPO. S4Pharm indicated he does not follow up on this and the missed doses were considered "excused". S4Pharm explained the investigation into the missed medication doses had ended after being told, by staff, that the patient was NPO.

In an interview on 07/10/19 at 3:20 p.m. with S9LPN, she reported if a patient is NPO and is on oral medication, you must notify the physician before omitting the dose.

In an interview on 07/11/19 at 3:00 p.m. with S10LPN, she reported if a patient is NPO and on ordered oral medications, you do not give the medication, and you do not notify the physician.


Patient #7
Review of Patient #7's electronic medical record on 07/09/19 at 1:10 p.m., with the guidance of S5RT, revealed the patient was a 43 year old admitted on 02/11/19 with admission diagnoses of Osteomyelitis and MRSA. Further review revealed the patient was discharged on 03/18/19.

Review of Patient #7's physican's orders revealed an order on 02/22/19 for Ancef IVPB every 8 hours for infection.

Review of the hospital's Medication Event Report revealed Patient #7 had missed a dose of Ancef on 03/14/19 at 6:00 a.m. Further review revealed S2CCO had completed an event report notifying the nurse whom omitted the antibiotic. Additional review revealed no documented evidence that the physician was notified of the missed medication dose on 03/14/19 at 6:00 a.m.

In an interview on 07/09/19 at 9:35 a.m. with S4Pharm regarding Patient #7 missing a dose of antibiotic, he stated he identifies the medication was omitted and he notifies S2CCO. He further stated S2CCO handles the event report after this point. S4Pharm stated he did not know if the physician was notified of the omitted dose of antibiotic.