HospitalInspections.org

30420

Based on record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:
1) failure to ensure all patient admission orders were obtained from a licensed provider for 1(#FR3) of 6 sampled patients (see findings tag A-0395); and
2) failure to ensure complete and accurate skin and wound assessments of patients and wound care were documented by nursing for 4 (#F1, #F2, #F3, #F5) of 6 sampled patients (see findings tag A-0395).





17450

Based on record review and interview, the hospital failed to ensure that drugs and biologicals were prepared and administered in accordance with the orders of the practitioner by failing to properly document medication errors according to policy. This deficient practice is evidenced by:
1) failing to accurately document medication administration times on the Medication Administration Record for 5 (#FR6, #FR3, #FR5, #F5, #FR2) of 5 current patients observed receiving medications; and
2) failing to accurately document all medications given, reasons for holding medications, or physician notifications of medications not administered for 3 (#F2, #F4, #F5) of 6 sampled patients.

Findings:

A review of the hospital policy titled Medication Administration last approved 05/21/2020 revealed in part:
- If a medication is held or refused, a notation is made on the patient's medication record.

A review of the hospital policy titled Medication Policy and Procedure last reviewed 07/20/2015 revealed in part:
The time parameters of when a medication can be given before or after the ordered time is 60 minutes.
The nurse will document the exact time the medication is given on the MAR.
Any medication that is not given within the 60 minutes parameter will require completion of a Pharmacy Variance Report and if deemed necessary notification of the physician for potential adjustment of the administration time for further doses.

A review of the hospital policy titled Medication Management last revised 10/24/2019 revealed in part:
Types of medication variances include:
Wrong: drug, dose, route or time.
When a medication variance occurs, the following should occur in this order.
a) Notify the physician and evaluate the patient.
b) Perform any necessary clinical interventions, within the patient care provider's scope of practice to reduce the negative effects of the identified variance.
c) Record the medication as given in the medical record.
d) Record the observed and assessed outcome of the patient in the medical record.
e) Record notification of the physician in the medical record with any resultant orders.
f) Record any actions and clinical interventions taken and the patient's response.
Report the variance in detail on a medication variance report.
The practitioner who identifies a variance will document all relevant particulars on the incident report form.

1) Failing to accurately document medication administration times on the Medication Administration Record.

On 10/14/2020 at 9:34 a.m. an observation of SF8LPN administering medications to Patient #F1 revealed the medications were ordered for 8:00 a.m.

On 10/14/2020 at 9:50 a.m. in an interview SF8LPN stated she was late passing medications because morning report lasted till 8:00 a.m. She also stated they have 1 hour before and 1 hour after the order time for administering medications. She further stated she had the following patients remaining to administer the 8:00 a.m. medications to: Patient #FR6, Patient #FR3, Patient #FR5, Patient #F5 and Patient #FR2.

On 10/14/2020 at 1:00 p.m. a review of the above patient's medical records failed to reveal documentation related to the medication errors. Further review revealed the 8:00 a.m. medications were documented as given at 8:00 a.m. when they were either administered or held until after 9:34 a.m.

On 10/14/2020 at 1:00 p.m. in an interview SF8LPN verified she had documented the medications for the time they were ordered to be given and not when they were given.

On 10/14/2020 at 1:10 p.m. in an interview SF3ADON confirmed the medications were documented as given at 8:00 a.m. and the medical record failed to have documentation related to the medication errors. Lastly she confirmed a Medication Variance Report had not yet been completed because she was not aware of the error until this surveyor brought it to her attention.

2) Failing to accurately document all ordered medications given, reasons for holding medications, or physician notifications of medications not administered.

Patient #F2
Review of Patient #F2's medication administration record revealed the following:
On 10/07/2020 and 10/12/2020 - Lantus 42 units SQ daily 8:00 a.m. - Documented as held but no explanation why the medication had not been administered or documentation of physician notification.

On 10/08/2020 at 11:00 a.m. the blood glucose was documented as 203 which required 2 units of insulin per sliding scale. The dose was documented as held with no explanation or documentation of physician notification.

On 10/12/2020 Levothyroxine 25 mcg po q day was not documented as having been given.

In an interview on 10/13/20 at 1:25 p.m. with SF2DON, she said holding medications without an order or documentation as to why the medications were held was a medication error.

Patient #F4
A review of the MAR for Patient #F4 revealed an order for Vistaril 25 mg po TID PRN for anxiety ordered on 10/05/2020.

On 10/13/2020 at 2:00 p.m. in an interview SF2DON provided the medication bubble pack for Patient #F4's Vistaril and it was noted to have 2 capsules missing.

Review of Patient #F4's MAR from 10/05/2020 when the order was written through the date of the survey 10/13/2020 failed to reveal any documentation for the administration of the missing Vistaril.

On 10/13/2020 at 2:20 p.m. in an interview SF2DON verified Patient #F4's MAR failed to contain documentation for the missing Vistaril.

On 10/ 14/2020 at 1:10 p.m. in an interview SF3ADON confirmed a Medication Variance was not completed for the missing Vistaril.

Patient #F5
Review of Patient #F5's medication administration record revealed the following:
On 10/07/2020 - Levothyroxin 175 mcg 6:00 a.m. dose held with no documentation why or documentation of physician notification.

On 10/08/2020 - Eliquis 5mg, Vitamin C 1000 mg, Aspirin 81 mg, Vitamin B complex and Tamusulin 0.4 mg 8:00 a.m. doses held with no documentation as to why or documentation of physician notification.

On 10/09/2020 and 10/10/2020- 8:00 a.m. doses of Hydrochlorothiazide 25mg ½ tablet doses held with no documentation as to why or documentation of physician notification.

In an interview on 10/14/2020 at 10:30 a.m. with SF1CEO, she said if medications not administered there should be documentation of an explanation and physician notification. She said she would consider those a medication error.






17450




20310

Based on record review and interview, the hospital failed to ensure that drugs and biologicals were controlled and distributed in accordance with applicable standards of practice and hospital policy by failing to ensure that the pharmacist conducted a review of all medication orders for appropriateness prior to dispensing the first dose as evidenced by the nurse failing to indicate either in writing or via use of approved stamp that the medication in question has had a first dose review by pharmacist within the medical record per hospital policy.
Findings:

A review of the hospital's policy titled Medication Administration, Policy ID: MM 11001- FD effective date 05/21/2020 reads in part:

1. When an order is received from the physician for a new medication or to resume a home medication or any new admission medications, the nurse will take a picture of the order on the Netsfere and post to the "first dose review" thread. She may also fax this order to the Pharmacy. Either method is appropriate, and the pharmacist will respond in the same manner to either communication.
2. The nurse will also call the pharmacist if fax method is utilized.
3. Within 1 hour, the Pharmacist will review each medication to include:
a. therapeutic appropriateness
b. duplication of a medication regimen
c. appropriateness of drug route
d. appropriateness of drug use
e. frequency
f. possible medication interaction
g. patient allergies and sensitivities
h. variations in criteria for use
i. other contraindications
4. Pharmacist review/ return all med orders showing "First Dose Review- these medication(s) order(s) have been reviewed and deemed appropriate or inappropriate" with signature and date within 1 hour after receiving the order.
7. The nurse is responsible for indicting either in writing or via use of approved stamp that the medication in question has had a first dose review by pharmacist and has been approved prior to administration of that medication.

A review of the MAR for Patient #F4 revealed an order for Vistaril 25 mg po TID PRN for anxiety ordered on 10/05/2020. Further review failed to reveal any first dose review documented within the record.

On 10/13/2020 at 2:00 p.m. in an interview SF2DON stated they use Netsfere for first dose review of the medications. She reviewed Netsfere and verified she could not find a first dose review. She also confirmed there was not a faxed first dose review for said patient in the unit or within the medical record. Lastly, she confirmed the nurse failed to indicate either in writing or via use of approved stamp that the medication in question has had a first dose review by pharmacist per policy and the medication was available on the unit for patient use.






20310

Based on observation and interview, the hospital failed to ensure all drugs and biologicals were kept in a secure area. This deficient practice is evidenced by 1 (SF11US) of 1 unlicensed personnel having access to the medication room on the nursing unit.

Findings:

In an observation on 10/13/2020 at 4:30 p.m., when asked for entrance into the nursing station medication room, SF6RN charge nurse did not know the access code to allow entry. SF11US said she would let the surveyors and SF1CEO in and typed in the access code and unlocked the door to the medication room. Further observation revealed an unlocked medication cart with all of the current patients' medications except narcotics and unlocked cabinets with stock medications.

In an interview on 10/13/2020 at 4:32 p.m., SF1CEO verified the unit secretary should not have access to the medication room.

Based on record reviews and interviews, the hospital failed to ensure a full-time employee, delegated by the governing body and medical staff, served as director of the food and dietetic services, was responsible for the daily management of the dietary services, and was qualified by experience or training.
Findings

Review of the list of employees presented by SF1CEO revealed no documented evidence that a Dietary Manager was included in the list.

In an interview on 10/13/2020 at 11:20 a.m. S1F2DON indicated the hospital did not have a full-time employee who was responsible for the daily management of the dietary services. She further indicated the Registered Dietitian is contracted and does not work for the hospital full-time. She reported that the previous Dietary Manager transferred recently to their offsite campus in another city, but does not come to this campus anymore. She reported that the charge RN on each shift was responsible for overseeing dietary services provided on site, not a designated person.

In an interview 10/13/2020 at 11:30 a.m. SF1CEO confirmed the hospital did not currently have a dietary manager delegated by the governing body and medical staff for this campus and qualified by experience or training.