HospitalInspections.org

Based on record review and staff interview's the facility failed to provide care in a safe setting when a patient in heart failure did not recieve his Milrinone IV drip for over 8 hours.

Findings were:

In review of patient medical record it was revealed, " ...PLAN:
1. Heart failure. He has congestive heart failure with a reduced ejection fraction, with ejection fraction approximately 22% to 25% seen on both echocardiograrn as well as cardiac MRI. He is on guideline-directed medical therapy with beta blocker, ACE inhibitor, and spironolactone as well as diuretic therapy with torsemide with potassium supplementation. Will continue all these. He did come to us on a milrinone drip; that was not started yesterday as we did not have the dosage and the access to the drug until today. Will get him resumed on a continuous milrinone drip today and continue that on a continuous basis here. He will need to follow up with Cardiology as an outpatient as far as timing of what the next set of plans are for this. He is being evaluated for an LVAD. A decision has not been made at this point that I can tell as to what exactly the next step is in that plan ..."

In an interview with staff #1 on April 21, 2021 staff #1 stated, "I think there was some confusion about the Milrinone. He didn't come over on the Milrinone, so they didn't know, if he was still on the medication. I got a call from nursing asking if the medication should be restated [sic]. I told them I would review the chart in the morning. I reviewed the chart and realized he was to be on the IV Milrinone continuously. I understand the Heart Hospital was very upset about him not getting the medication. He didn't get the Milrinone for about 18 hours. We need to have a better way to do this. It is a problem that he didn't get the medication."

In an interview with staff #6 on April 26, 2021 at 2:45 pm staff #6 stated, "The patient arrived after hours with the Milrinone, but the medication was not running. I asked the EMS driver if he knew why the medication was not running, he said no. We called the hospital to see if they knew whether the medication was supposed to be stopped but didn't get answer because none of the staff knew the patient very well, so the medication was not restarted. We don't give any meds that have not been reviewed by pharmacy."