HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure all entries into the medical record were accurate, promptly completed, timed, dated and authenticated by the person making the entry in one of one code record reviewed, (MR1)

Findings include:

Review of facility provided document on October 18, 2021, at approximatley 2:45 PM revealed, "Lippincott Procedures - Cardiopulmonary resuscitation (CPR), two person ... Assess the patient for unresponsiveness by tapping the patient on the shoulder and shouting 'Are you all right? ... Documentation ... If the patient also received [Advanced Cardiac Life Support] ACLS measures, document the interventions performed, the person who performed them and when, equipment used, and the results. ..."

1. Review of MR1 on October 18, 2021, at approximately 2:00 PM revealed a "Code Blue Flowsheet" which indicated, "Date 8/26/21 ... Time 0226 ... Brady ... ECG Brady ... BP [Blood Pressure] 113/139 ... CPR [Cardiopulmonary Resuscitation] [check mark] ... Time ... 0230 Asystole ... Epi [Epinephrine] [check mark] ... 0235 Epi [check mark] 0240 ... Epi [check mark] 0241 Lido [Lidocaine] [check mark] ... 0245 Epi [check mark] ..."

There were no initials after each entry, or after the documentation of the administration of the Epinephrine or the Lidocaine. It could not be determined who initiated the CPR, and there were no comments next to each entry on the 'Code Blue Flowsheet".

Interview with EMP1 on October 18, 2021, at approximately 2:15 PM confirmed that there were no initials next to each entry. When asked who administered the Epinephrine, and the Lidocaine EMP1 indicated, "It would have been the RN."

Cross Reference:
482.24(c) Content of Record
482.24(c)(1) Medical Record Services
482.24(c)(4)(vi) Content of Record: Orders, notes, reports

Based on review of facility policies and procedures, medical records (MR), and interviews with staff (EMP), it was determined the facility failed to describe the patient's progress and response to physician ordered interventions, medications and services according to facility policies and procedures for one of 10 medical records reviewed (MR1).

Findings include:

Review on November 4, 2021, of facility policy "High Observation Standard of Care," last approved January 2021, revealed "C. ONGOING ASSESSMENT/MONITORING...2. Vital Sign guidelines: a. Includes Temperature, Pulse, Respiratory Rate and BP...c. unstable/change in condition as indicated by condition to evaluate effectiveness of interventions...E. RESPIRATORY MANAGEMENT...3. Respiratory status is evaluated by the Respiratory Therapist every 2 hours or as needed with any changes...4. Continuous pulse oximetry monitoring is in place...F. REPORTING CHANGE IN CONDITION...1. All changes in patient condition will be reported to the MD utilizing SBAR format. 2. Changes in condition will be recorded in the nursing or RT flow sheets. 3. All changes in condition will be reported to the nursing supervisor."

Review on November 4, 2021, of facility policy "Orders for Medication", last approved 6/2021, revealed "PROCEDURE:...d. Now medication orders will be administered within 1 hour of the time the order is written or verbalized..."

Review of MR1 revealed as follows:

1. "Twenty-four Hour VS Graphic Sheet...August 25, 2021, ... 0800 Temp 97.7, Pulse 81, Resp 16, BP 97/68... 1600 Temp 97.2, Pulse 82, Resp 18, BP 99/62...2000 Temp 97.8, Pulse 84, Resp 20, BP 102/65". The twenty-four hour VS Graphic Sheet did not contain further documentation of vital signs.

2. Review on November 3, 2021, of "RESPIRATORY THERAPY Shift Assessment/Treatment/Therapy" revealed "8/25/2021 2350 HR:120 RR:48...SpO2 UNABLE TO OBTAIN...8/26/2021 0307 CTB". Documentation within the respiratory therapy record did not indicate nursing was made aware of abnormal respiratory assessment. No further respiratory therapy interventions were documented.

3. Review on November 3, 2021, of nursing documentation for MR1 dated August 25, 2021, revealed "8/25/2021 2030 Patient RR up to 40/min, temp 101.3, 92% 2L NC. Very lethargic no longer responding with words. Dr.....called, new orders given to supervisor...8/25/2021 2240 Wife notified of change of condition...". Nursing documentation did not indicate physician was made aware or updated to change of condition. No updated vital signs were documented within MR1.

4. Review on November 3, 2021, of "PHYSICIAN'S ORDER SHEET" revealed
"8/25/21 2010 Blvd. cx. x2 sites...dc all sedatives/narcotics if on sedatives/narcotics...give narcan & romazicon if on sedatives...Vancomycin 1Gm IV now...02 4LPM...duonebs QID TORB....8/25/21 2015 Hold narcan/romazicon (not on sedation/narcotics)...Cefipime 2GMS IV Q12...CXR,abg's-call results of abg's... TORB....8/25/21 2055 TORB... ^02 to 4 Liters NC...Duoneb 0.5mg/3ml QID SOB...8/25/21 2055 D5W 3 amps HC03 @ 100 cc/hr...am lactic acid, procalcitonin, serum acetone, cmp, mg, phos, cbc with diff...8 am abg's TORB..."

5. Review of the medication administration record (MAR) did not indicate the physician ordered "now" medication of Vancomycin 1GM was administered.

Interview with EMP7 on November 4, 2021, at approximately 11:23 AM confirmed there was no documentation to indicate the nursing supervisor was made aware of abnormal respiratory assessment and no further respiratory interventions were documented within MR1.

Telephone interview with EMP10 on November 4, 2021, at approximately 1:25 PM confirmed there was no documented evidence in MR1 that the physician was notified about the change in patient condition or futher documentation indicating medical interventions were completed as ordered. There was no further documentation related to patient's progress or response to physician ordered treatments.

Cross Reference:
482.24(b) Form and Retention Of Records
482.24(c)(1) Medical Record Services
482.24(c)(4)(vi) Content of Record: Orders, notes, reports

Based on review of facility documents, review of medical records (MR), and staff interviews (EMP), it was determined that the nursing record was not complete or authenticated consistent with facility policies and procedures for one of one code medical records reviewed (MR1).

Findings include:

Review on November 4, 2021, of facility documentation "... "ACLS...2015...Drug...Epinephrine...Cardiac arrest: VF [ventricular fibrillation], pulseless VT [ventricular tachycardia], asystole, PEA...Symptomatic bradycardia: can be considered after atropine as an alternative infusion to dopamine...Lidocaine Alternative to Amiodarone in cardiac arrest from VF/pVT...Cardiac Arrest From VF/pVT...Initial dose: 1 to 1.5 mg/kg IV/IO...For refractory VF, may give additional 0.5 to 0.75 mg/kg IV push, repeat in 5 to 10 minutes; maximum 3 doses or total of 3 mg/kg..."

Review of facility standard of care policy on November 4, 2021, "High Observation Standard Of Care" last approved 09/2021 revealed "C. ONGOING ASSESSMENT/MONITORING 1. A full physical assessment will be conducted and recorded in the record by the Registered Nurse minimally every shift (12 hours), more frequently as condition warrants or with changes in condition. 2. Vital Sign guidelines a. Includes Temperature, Pulse, Respiratory Rate and BP. c. Unstable/change in condition as indicated by condition to evaluate effectiveness of interventions...D: PATIENT CARDIAC MONITORING...7. The patient's record reflects documentation of a rhythm strip every shift (12 hours) and with any acute changes...".

1. Review of MR1 on November 4, 2021, of "CODE BLUE FLOWSHEET...8/26/2021 0226...Summary of Events Preceding Code/Precipitating Factors: Cardiac Rhythm Change...Altered Mental Status...Lab Abnormalities Identified....Initial Signs of Arrest: Apnea...Absence of Pulse...Unconsciousness...Time: 0226 ECG Rhythm: Brady [Intervention] CPR...Time:0230 ECG Rhythm: Asystole [Intervention] Epe..Time: 0235 ECG Rhythm: Asystole[Intervention] Epe...Time:0240 ECG Rhythm: Asystole [Intervention] Epe...Time: 0241 ECG Rhythm: Asystole [Intervention] Lido...0245 ECG Rhythm: Asystole [Intervention] Epe...0246 EMT arrived...CPR Stopped: Death Time Pronounced: 03:07 ...". The "CODE BLUE FLOWSHEET" did not contain corresponding rhythm strips indicating cardiac rhythm changes immediately before or during event to justify deviation from ACLS interventions. "Epe" and "Lido" were checked off on code blue flowsheet but did not indicate dosing of medication administered based on patient weight (mg/kg) or who administered the medication. The code blue sheet was not signed by a physician at the time of review.

2. Further review of MR1 revealed a "Daily Nursing Assessment" with "Daily Nursing Note" and "Daily Care Sheet" dated August 25, 2021. The last entry made on the daily nursing assessment, dated August 25, 2021, was at "1900" by "TF". No further nursing assessment was documented on the daily nursing assessment sheet. Review of "Daily Care Sheet" dated August 25, 2021 revealed a blank form with no documentation related to care of "HYGIENE...ACTIVITY...SAFETY".

Telephone interview with EMP10 confirmed the above findings, "I don't recall using lidocaine...may have given a dose." When asked why ACLS protocol was not followed related to use of lidocaine as there was no documentation within MR1 of ventricular fibrillation or ventricular tachycardia, EMP10 replied, "... You can't kill dead." EMP10 futher revealed rhythm strips were obtained and printed after the code to show asystole, however no rhythm strips were obtained or printed during the event. EMP10 interview continued indicating, "the arrest prevented getting it filled out...usually the nursing assistant would complete it", when asked about the blank "Daily Care Sheet" within MR1.

Cross Reference:
482.24(b) Form and Retention Of Records
482.24(c) Content of Record
482.24(c)(4)(vi) Content of Record: Orders, notes, reports

Based on a review of facility documents and medical records (MR), as well as employee interviews (EMP), it was determined the facility failed to document medication administration in accordance with hospital policies for six of 10 medical records reviewed. (MR1, MR2 MR6, MR7, MR8 and MR10)

Findings include:

Review on October 19, 2021, at 2:48 PM of "MAR [Medication Administration Record]-Paper Policy" last approved on May 2021, revealed, "...C. Administration Documentation. ...When not administered, circle the time, initial and document the reason the medication was not administered on the MAR. If additional space is needed, write 'see nurse's note' and make appropriate documentation in nurse's notes. ..."

Review on October 28, 2021, at approximatley 2:15 PM revealed, "High Alert Medications" dated April 2021, revealed, "... Policy ... The Director of Pharmacy is responsible for maintaining a list of hign-risk medications available ... for use in the Hospital ... Insulin (SubQ and IV) and anticoagulants (oral, SubQ and IV are High Risk (Alert) Medications within the Hospital. Their ordering, dispensing and administration are covered in specific policies. ... Components: ... Insulin must require a second nurse verification ... If a High-Alert medication requires a second nurse verification, that verification must be documented in the patient's medical record. ..."

Review of a facility document provided on November 5, 2021, at approximatley 1:00 PM revealed, "Curahealth - Pittsburgh HIGH ALERT DRUG LIST Concentrated Electrolytes: Premix Magnesium Sulfate 1gm/100ml; 3% Sodium Chloride ... 23.4% Sodium Chloride Anticoagulants, (e.g. Enoxaparin, Fondaparinux, Warfarin, Apixaban, Rivaroxaban, Argatroban) Propofol Insulin."

Review of facility policy on November 4, 2021, revealed "Orders for Medication", last approved 6/2021, revealed "PROCEDURE:...d. Now medication orders will be administered within 1 hour of the time the order is written or verbalized...routine medications within 1 hour before or after scheduled dose..."

1. Review on October 18, 2021, at approximately 11:00 AM, of MR1 revealed the patient was admitted on August 20, 2021, and expired on August 26, 2021, at 03:07 AM. Review at approximately 11:05 AM, of the MAR revealed an order dated August 24, 2021, at 6:00 PM, which indicated, "... Diltiazem, ...45mg nasogastric every six hours." Further review of the MAR revealed that Diltiazem was not administered at 6:00 PM or 00:00 as per order.

2.Review on October 18, 2021, at approximately 11:15 AM, of MR1 revealed the patient was ordered a NovoLog sliding scale. The MAR indicated, "High Alert Medication- requires a second nurse verification." Review of the MAR revealed that only one nurse initialed the MAR.

3. Continued review of MR1 on November 3, 2021, of "PHYSICIAN'S ORDER SHEET" revealed "8/25/21 2010 Bld. cx. x2 sites...dc all sedatives/narcotics if on sedatives/narcotics...give Narcan & romazicon if on sedatives...Vancomycin 1 Gm IV now...02 4 LPM...Duonebs QID TORB...." Further review of medication administration record (MAR) indicated "Vancomycin 1 GM IV now" and "Duonebs QID" were not administered to the patient. The MAR did not contain a documented reason medication was not administered.

4. Review on October 18, 2021, at approximately 11:20 AM, of the MAR for MR2 revealed a medication was ordered to be administered orally by mouth [chlorhexidine] 12 hours at 9:00 AM, and at 2100. The MAR for MR2 was blank for the medication at 9:00 AM on September 7, 2021.

5. Review on October 18, 2021, at approximately 11:30 AM, of the MAR for MR2 revealed a topical medication was ordered [benzoyl peroxide topical gel] to be applied once a day at 9:00 AM. The medication was not documented as being applied at 9:00 AM on September 7, 2021.

6. Review of MR6 on November 5, 2021, of MAR revealed orders for " triamcinolone topical 0.025% CREA 15 GM....emollients Oint 0.75 GM (AQUAPHOR) Topical ONCE A DAY...apply with wound care to R/L LE closed areas". Scheduled administrations within the MAR for 8/25 at 0900, 08/27 at 0900, and 8/28 at 0900 did not indicate medication was administered to patient. The MAR did not contain a documented reason medication was not adminstered.

7. Review of MR7 on November 5, 2021, of MAR revealed orders for " budesonide 0.5mg/2mL SUSP (PULMICORT RESPULES) Inhalation TWICE A DAY RESPIRATORY...levalbuterol 0.63mg/3 ml SOLN (XOPENEX) Inhalation EVERY 8 HOURS...tiotropium 18mcg CAP (SPIRIVA) Inhalation DAILY RESPIRATORY...". Scheduled administrations within the MAR for 8/27 at 0800 did not indicate budesonide, levalbuterol, or tiotropium were administered to the patient. Scheduled administration on 8/27 at 1600 did not indicate levalbuterol was administered. The MAR did not contain a documented reason medication was not administered.

8. Review of MR8 on November 5, 2021, of "PHYSICIAN'S ORDER SHEET" revealed "9/15/2021 1100 1)D/C current IVF 2) 1/2 N/S IVF @ 70ml/hr 3) ^free water flushes via tube to 250 cc q 6 hr 4) Kayexalate 30 g x 1 via g tube 5) Bicarb 1 amp IV X1 6)Regular insulin 10 units IV X 1 7) D50 1 amp IV x1....TORB...". Further review of MAR within MR8 did not indicate medications ordered were administered to patient. The MAR did not contain a documented reason medication was not administered.

9. Review on November 5, 2021, at approximatley 11:30 PM of the MAR for MR10 revealed a blood thinner medication [Lovenox- Subcutaneous] was ordered to be given once daily. The MAR indicated "High Alert". The MAR for August 30, 2021, at 9:00 revealed only one nurse documented the medication on the MAR, not two as required by facility policy.

10. Continued review on November 5, 2021, from 11:00 AM of a telephone order for MR10 revealed, "09/10/21/11:20 ... Magnesium Oxide 800 mg po . 1 stat.". Review of the medical record at this time revealed that the Magnesium Oxide was not transcribed to the MAR and the medication was not documented as given.

11. Continued review on November 5, 2021, at approximatley 11:35 PM of the MAR for MR10 revealed a stat order which indicated, "1740 ...Magnesium sulfate 3mgs IV X 1 now." This medication was not documented as given.

12. Continued review on November 5, 2021, at approximatley 12:30 PM of the MAR for MR10 revealed that a pain reliever [acetaminophen] medication ordered to be given every six hours was not documented as given on Septerber 10, 2021, at 18:00.

13. Continued review on November 5, 2021, at approximatley 12:40 PM of the MAR for MR10 revealed that [Diphenhydramine] was ordered to be given twice a day was not documented as administered on September 2, 2021, at 9:00 AM or September 10, 2021, at 9:00 AM.

14. Continued review on November 5, 2021, at approximatley 12:45 PM of the MAR for MR10 revealed that a topical cream [Hydrocortisone] was ordered to be given twice a day was not documented as applied on September 2, 2021, at 9:00 AM.

15. Review of MR10 on November 5, 2021, at approximatley 1:30 PM of the MAR revealed a blood thinner [Lovenox] was ordered and administered on September 1, 2021, at 9:00 AM. The MAR indicated that the medication was a "High Alert Medication." Only one nurse documented the medication on the MAR, not two as required by facility policy.

During an interview on October 18, 2021, at approximately 2:45 PM, EMP2 confirmed the above findings for MR1 and MR2.

During an interview on November 5, 2021, at approximately 1:10 PM, EMP2 confirmed the above findings for MR10.

Interview with EMP1 & EMP10 on November 5, 2021, at approximately 1:00 confirmed the above findings for MR1, MR6, MR7, and MR8.

Cross Reference:
482.24(b) Form and Retention Of Records
482.24(c) Content of Record
482.24(c)(1) Medical Record Services

Based on a review of facility documents and medical records (MR), as well as employee interviews (EMP), it was determined the facility pharmacy failed to maintain documentation and tracking of drugs dispensed from the pharmacy in accordance with hospital policies and accepted professional principles for one of one code medical records reviewed. (MR1)

Review on November 4, 2021, at 1:30 PM of facility policy, "Patient Safety Plan" revealed, "... Quality Council. The Quality Council functions as the oversight committee for the Patient Safety Committee, and in this capacity is responsible for the design, implementation and management of the hospital-wide patient safety program at Curahealth Hospital Pittsburgh. ... Quality Council Committee duties include: ... Develops and recommends policies and procedures to support an effective patient safety program. ... Designs and performs an organization assessment to determine risks to patient safety and the organization's current rate of medical errors. Identifies and prioritizes opportunities to improve patient safety. ... Ensures that mechanisms exist for internal and external reporting of information relating to medical errors. Patient Safety Committee ... Other members as appropriate Pharmacy Respiratory ...Department Managers are responsible for developing and measuring performance indicators reflective of patient safety, within the scope of services of their departments. ..."

1. When asked on November 5, 2021, at approximatley 2:00 PM for records regarding mediation(s) removed from the emergency medication cart on August 26, 2021, EMP13 indicated that drugs on the cart are not tracked by pharmacy. EMP13 indicated that medications that are missing from the tray are sent to billing.

2. When asked on November 5, 2021, at 2:15 PM which medications were removed from the emergency medication/crash cart, EMP12 indicated that the billing person would know which medications were charged for the code of August 26, 2021. EMP12 further indicated that the billing person would not be working until Monday November 15th.

3. On November 10, 2021, at 4:49 PM via email, EMP12 provided the billing information for the code for MR1 which indicated, "This charge is a bulk crash cart charge. Our billing does not charge for each item. If the staff uses one or all of the supplies in there, it doesn't matter. Once it's opened it gets a bulk charge. ..."

There was no record of specific medications used for MR1's code of August 26, 2021.