HospitalInspections.org

Based on record review and interview the hospital failed to meet the requirements of the Condition of Participation for Patient Rights as evidenced by:


Failure of the hospital to follow their policy and procedure for determining and ordering a "do not resuscitate order (DNR)" for 8 of 8 patients with a DNR Order or Advanced Directive out of a total sample of 30 medical records resulting in:

1) no documented evidence patients were assessed and determined to be at the end of life or have an irreversible condition by two physicians before being made a DNR as required by hospital policy (#2, #17, #22, #23, #27, #28);


2) initiation of ACLS (Advanced Cardiac Life Support) medication protocol on a 103 year old patient with an Advanced Directive indicating no CPR was to be implemented(#13). (See findings at Tag A0132).

Based on record review and interviews, the hospital failed to meet the Condition of Participation for Nursing services as evidenced by:

1) Failing to ensure the RN (registered nurse) supervised and evaluated the nursing care of each patient for 1 of 30 sampled patients (#15). The RN failed to ensure the blood pressure and pulse were assessed prior to the administration of Metoprolol for 1 of 3 patients with orders for Metoprolol from a total sample of 30 patients (#15). This resulted in Patient #15 being transferred to the intensive care unit (ICU) to have a Dopamine drip initiated and titrated to maintain the systolic blood pressure above 100 millimeters of mercury. The LPN (licensed practical nurse) failed to report a change in Patient #15's condition to the RN and the physician. The RN failed to ensure the nursing care of a patient with unstable blood pressure was not delegated to a LPN according to the Louisiana State Board of Registered Nurse's nurse practice act (#15) (see findings in tag A0395).

2) Failing to follow the hospital's policy for staff assignments in the ICU for 3 of 15 days of ICU assignment sheets reviewed from 04/29/12 through 05/13/12 (see findings in tag A0392).

3) Failing to have agency-contracted nursing staff oriented and assessed for competency by a hospital-employed RN prior to performing patient care for 4 of 4 agency-contracted nursing personnel files reviewed (S21, S22, S23, S25) (see findings in tag A0398).

4) Failing to ensure the RN assigned patient care according to patient need and the qualifications and competency of the nursing staff for 2 of 7 RN personnel files reviewed from a total of 22 RNs. The RN assigned RN S9 and RN S19, medical/surgical RNs, to the ICU with no documented evidence of competency to provide patient care to ICU patients (see findings in tag A0397).

5) Failing to ensure medications were administered according to physician orders, hospital policy, and accepted standards of practice for 4 of 30 sampled patients (#6, #14, #15, #30). The nurse failed to assess a patient's blood pressure and pulse prior to administering Metoprolol for 1 of 3 patients reviewed with physician orders for Metoprolol from a total sample of 30 patients (#15). This resulted in Patient #15 being transferred to the ICU to have a Dopamine drip initiated and titrated to maintain the systolic blood pressure above 100 millimeters of mercury. The nurse failed to document the amount of narcotics received from a PCA (patient controlled analgesia) pump, the amount of narcotic wasted, and maintain an accurate count of the use of PCA narcotics throughout the time the PCA pump was ordered for 3 of 3 patients with orders for a PCA pump from a total of 30 sampled patients (#6, #14, #30) (see findings in tag A0405).

Based on record review and interview the hospital failed to follow their policy and procedure for determining and ordering a "do not resuscitate order" for 8 of 8 patients with a DNR Order or Advanced Directive from a total of 30 sampled patients resulting in: 1) no documented evidence patients were assessed and determined to be at the end of life or have an irreversible condition by two physicians before being made a DNR for 6 patients with a DNR order (#2, #17, #22, #23, #27, #28); 2) initiation of ACLS (Advanced Cardiac Life Support) medication protocol on a 103 year old patient with an Advanced Directive indicating no CPR was to implemented for a patient with a completed advanced directive (#13). 3) failure to continue life saving measures on a patient (#25) experiencing respiratory arrest and who had an advanced directive for CPR at the request of the family and with no documented evidence the patient was at the end of life Findings:

1) no documented evidence patient were assessed and determined to be at the end of life or have an irreversible condition before being made a DNR

Patient #2
Review of the patient's clinical record revealed the patient was a 73 year old male who was transferred from a nursing home to the hospital's emergency department on 05/07/12. The patient was currently in the ICU (Intensive Care Unit).

Review of the History and Physical documented by S16 Primary Care Physician and dated 05/07/12, revealed in part the following:
"The patient is 73-year old African American male with history of hypertension, diabetes, atrial fibrillation, congestive heart failure, low ejection fraction, history of bacterial endocarditis, chronic peripheral neuropathy, depression, end-stage renal disease on dialysis on Monday, Wednesday and Friday, chronic heal ulcers...... Today, he was noted lethargic and weak at home, so he was brought to the emergency room. In the emergency room, workup showed high cell count and cultures were done and according to his wife, he toes turned blue color on the right side foot since a few days and progressively getting worse.
Assessment and Plan:
1. Gangrene of the right great toe, second toe and third toe. The patient is infectious, started with ....... Zyvox, Cipro and Flagyl (antibiotics) and the infectious disease consult, Dr. ____ and Dr. _____ consult was done for vascular surgery and possible amputation....The patient was admitted to River Parish Hospital multiple times. His condition was explained to his daughter and his wife. They understood the situation very well. I explained the prognosis. The prognosis is very poor. The wife does not want him on any ventilators or no resuscitation. So the patient will be do not resuscitate as per the patient wishes and family wishes. We will respect their wishes and will monitor closely and will followup the consult and expert recommendations."

Review of the physician's orders revealed on 05/08/12 at 12 noon, S16 Primary Physician documented the following orders:
Mucinex 600 mg. PO BID (By mouth, two times a day),
CBC, BMP, Mg (Blood tests) in AM,
DNR.

Review of the Consent for Services and Financial Responsibility form dated 05/07/12 revealed the patient did not have an Advance Directive.

Review of the physician's progress notes revealed there was no no documented evidence that two physician's had declared the patient to be in a terminal irreversible state. There was no documented evidence in the progress notes of the persons present during the discussion of the DNR, the information conveyed by the physician, and the date, time, printed name of the physician, and the physician's signature.

On 05/15/12 at 2:50 p.m., in a face to face interview with S24RN the patient's clinical record was reviewed. S24RN confirmed the documentation in the history and physical was the only documentation that referenced the DNR order on 05/08/12.

Patient #17
Review of the medical record for Patient #17 revealed a 90 year old female admitted to the hospital on 04/17/12 for decreased mobilization, decreased appetite, and weight loss after sustaining a fall two weeks ago. In addition, Patient #17 had a history of dementia and diabetes mellitus. Review of the "Consent for Treatment" dated/timed 04/16/12 2108 (9:08pm) revealed Patient #17 had not executed an Advanced Directive. The form was signed by the daughter of Patient #17.

Review of the History & Physical (H&P) for Patient #17 dated 04/17/12 revealed ... ... Assessment and Plan: 3. Dementia. Really not much to do but have discussed with the family members that it is probably an end-stage dementia, probably nothing more to do. If the patient does not rally in the next 24-48 hours consider hospice care. I have discussed places for hospice, appropriate hospice for her " .

Review of the Physicians Orders for Patient #17 dated/timed 04/17/12 at 0800 (8:00am) revealed an order for a DNR.

Review of the only Progress Note written for Patient #17 dated 04/18/12 revealed no documented evidence Patient #17 had been assessed as terminally ill or with an irreversible condition by two physicians; all siblings were informed of his/her mother's condition which included the consequences of the decision of the DNR; or his/her understanding of the decision.

Patient #22
Review of the medical record of Patient #22 revealed a 91 year old male admitted to the hospital on 04/05/12 via the Emergency Department for elevated temperature (103?), a change in mental status and possible pneumonia.

Review of the "Consent for Treatment" dated/timed 04/05/12 at 7:22am revealed no documented evidence Patient #22 had been asked if he had advanced directives.
Review of the Physicians Orders for Patient #22 dated/timed 04/13/12 at 1430 (2:30pm) revealed an order "Do not resuscitate".

Review of the Physician's Progress Notes for Patient #22 revealed 04/13/12 at 8:30am DNR documented by MD S14; 04/14/12 9:00am DNR documented by MD S18; and 04/15/12 at 9:35am revealed Patient #22 refused the blood transfusion due to the possibility of contracting AIDS. Further review revealed no documented evidence who the DNR status had been discussed with, the consequences of the decision of the DNR; or his/her understanding of the discussion.

Patient #23
Review of the patient's record revealed the patient was received in the emergency room by ambulance after sustaining a cardiac arrest at home. The patient was a 62 year old female and was admitted to the ICU (Intensive Care Unit) on 01/15/12 with diagnoses of Hypertension and Status Post Cardiac Arrest with evidence of significant brain damage.

Review of the Physician's Orders dated/timed 01/15/12 at 1020 (10:20 a.m.) revealed the following order: "Patient is DNR". The order was a verbal order and was signed by S17 Primary Care Physician.

Review of the patient's record revealed no documented evidence of any physician's progress notes.

Review of the History and Physical documented by S17 Physician revealed the following in part:
History of Present Illness: ......The patient was intubated in the field. The patient was shocked a total of approximately 10 times....The patient had fixed pupils, no gag reflex, agonal respirations and posturing of bilateral upper extremities at the end of approximately two hours of resuscitation....
Assessment and Plan: A 62 year old black female with history of hypertension, status post cardiac arrest with evidence of significant brain damage. The patient is now being maintained on normal saline......The patient does not wish any further cardioversions to be done.....
Prognosis: Grim. This has been explained to the family.

Review of the the Death Summary, dictated by S 17 Physician on 01/25/12 revealed the following in part:.....The patient's grim prognosis was explained to the family who made her a DNR. The patient became pulseless at approximately 5:00 in the afternoon and was pronounced dead at that time.

There was no documented evidence that 2 physicians had declared the patient to be in a terminal, irreversible state. There was no documented evidence that the physician had explained the basis and the consequences of the DNR to the family. There was no documented evidence of the persons that were present for the discussion of the DNR. There was no documented evidence that the physician documented the information that was conveyed to the family. There was no documented evidence that the family made a decision for the DNR status prior to the order for the DNR.

On 05/16/12 at 11:00 a.m., a face to face interview was conducted with S2 RN, Quality Resource Manager. After reviewing the patient's record, she confirmed there was no documented evidence of who in the family the DNR was discussed with. S2 confirmed there was no documented evidence of what was explained to the family. S2 confirmed there was no documented evidence that 2 physicians had declared the patient in a terminal irreversible stated as required by the hospital policy.

On 05/16/12 at 9:45 a.m., a face to face interview was conducted with S 9 RN. S9 verified she was assigned to the medical/surgical unit. S9 was asked to relate the process for DNR status. S9 stated the physician writes the order for a DNR after conferring with the patient or their family. S9 stated if a patient with a DNR order codes, she would make the patient comfortable, but would not start any resuscitation measures. S9 stated when a DNR order is received the chart is flagged with DNR stickers and DNR is added to the board next to the patient's information.

On 05/16/12 at 9:50 a.m., a face to face interview was conducted with S11LPN. S11 confirmed that she was assigned to the medical/surgical unit. When asked about the process for DNR, she stated the physician and the family make the decision and the physician writes and order. S11 stated stickers are placed on the outside of the patient's record to identify the DNR status and the charge nurse writes DNR on the board. S11 stated if the patient has a DNR order, this means you do nothing if the patient stops breathing.

Patient #27
Review of the medical record for Patient #27 revealed an 88 year old female admitted to the hospital on 05/13/12 via the Emergency Department for an altered level of consciousness. Further review revealed Patient #27 had a past history of Parkinson's disease, Hypertension, Rheumatoid Arthritis, Contractions, Urinary Tract Infections and Dementia and was being cared for at home.

Review of the "Consent for Treatment" dated/timed 05/13/12 at 1910 (7:10pm) revealed under #13, Advanced Directive Acknowledgement, the blank next to "I have not executed an Advanced Directive" was checked and the consent signed by the daughter of Patient #27.

According the History and Physical (H&P) dated 05/14/12, Patient #27 was assessed with a diminished level of consciousness and urinary tract infection. The plan for treatment included intravenous fluids, intravenous antibiotics, replace potassium, and observation of her neurological status.

Review of the Progress Notes for Patient #27 dated 05/15/12 at 0800 (8:00am) revealed the diagnosis was written as UTI (Urinary Tract Infection)? CVA (Cerebrovascular Accident)?. In addition MD14 had a discussion with the oldest daughter of Patient #27 who told the MD she and her family were in agreement they did not want any resuscitative measures done on their mother. Further review revealed no documented evidence Patient #27 had been assessed as terminally ill or with an irreversible condition by two physicians; all siblings were informed of his/her mother's condition, the consequences of the decision of the DNR; and his/her understanding.

Review of the Physicians Orders for Patient #27 dated 05/15/12 at 0800 (8:00am) revealed and order not to resuscitate.

In a face to face interview on 05/16/12 at 9:40am RN S10 verified she was assigned to Patient #27. S10 stated she knew the patient had at least 2 daughters. After reviewing the patient's record she confirmed only 1 daughter was identified in the record. S 10 RN stated the patient was a DNR and if the patient stopped breathing, she would notify the physician, but would not start any resuscitation measures. S10 verified the dry erase board in the nurse's station indicated the patient was a DNR and the patient's record was flagged with DNR stickers.

Patient #28
Review of the patient's clinical record revealed the patient was an 88 year old male admitted to the hospital on 05/06/12. The binder containing the patient's record was flagged with "DNR" (Do Not Resuscitate) stickers. The dry erase board in the nurse's station was observed to have "DNR" written in red next to the patient's room number.

Review of the patient's record revealed a Living Will Declaration signed by the patient's spouse and dated 09/02/10 was filed in the front of the patient's record. The Living Will Declaration revealed the form was checked to indicated the patient wanted cardiac resuscitation, intubation, and mechanical ventilation. Also included with the Living Will Declaration form was a Resident Consent for Cardiopulmonary Resuscitation form dated 09/02/10 that indicated the patient wanted CPR (Cardiopulmonary Resuscitation), full code performed.

Review of the Consent for Services and Financial Responsibility form dated/timed 05/06/12 at 1958 (7:58 p.m.) revealed, "I have not executed an Advance Directive" and the form was signed by the patient's spouse.

Review of the physician's orders dated/timed 05/15/12 at 0817 (8:17 a.m.) revealed the following order, "Do Not Resuscitate Pt.(Patient)." The order was signed by S14 Medical Director (Patient's Primary Care Physician).

Review of the Physician's Progress Notes revealed the following:
05/15/12 0815 (8:15 a.m.) Patient with _____ (unable to read) not able to do much more. Discuss this with his wife today. Dr. ___ (S18) had prior conference with family. Patient is dying and nothing we really can do to prevent. Will ____ (unable to read) and treat - no hospice but _____ (unable to read) the end is near. The progress note was signed by S14 Medical Director.

There was no documented evidence in the medical record that two physician's had documented the patient was in a terminal, irreversible state. There was no documentation of the information conveyed to the patient's spouse. There was no documented evidence that the DNR order was explained to the patient's spouse, nor was there documented evidence that the DNR was the decision of the patient's spouse.

On 05/15/12 at 2:30 p.m., a face to face interview was conducted with S2, RN Quality Resource Manager. After reviewing the patient's record, S2 confirmed there was a Living Will Declaration on the record that indicated the patient wanted to be resuscitated. S2 stated this form was from the patient's nursing home. S2 confirmed the Consent for Services and Financial Responsibility indicated the patient did not have an Advance Directive. S2 confirmed the physician had written a DNR order on 05/15/12 and there was no documented evidence that the patient's spouse wanted the DNR status. S2 confirmed there was no documented evidence that two physicians had documented the patient's terminal irreversible condition.

On 05/16/12 at 8:45 a.m., a face to face interview was conducted with S14 Medical Director. When asked what the process was for obtaining DNR status, S14 stated he talked to the patient's family members and then wrote the order for DNR. S14 verified that he had not documented who he had spoken to in the family and confirmed that 2 physician's had not documented the terminal condition. S14 confirmed he was not aware of the facility's policy for DNR required 2 physicians to declare the patient to be in a terminal and irreversible stated prior to ordering a DNR. After reviewing the hospital's policy titled, "Do Not Resuscitate", he confirmed the policy required 2 physicians to declare the patient terminal, and he confirmed the policy requirements for documenting the DNR in the progress notes.

Review of Policy # D-1 titled "Do Not Resuscitate" last revised 02/07 and submitted by the hospital as the one currently in use revealed ... ... " Procedure: When a patient has been deemed to be in a terminal and irreversible state, a physician may order to withhold resuscitation under the following conditions: 1. Two physicians, one of whom shall be the attending physician, have declared the patient to be in a terminal irreversible state. If the patient has executed a Living Will, it shall be placed in the current medical record. 2. Determining if a DNR order is medically appropriate prior to writing the order, the attending physician must assure that adequate dialogue has occurred between the physician and patient/family, regarding the basis for and consequences of a DNR order. The explanation, regarding a DNR order, may be provided by any licensed physician who has been integrally involved in the patient's care. If the patient is incompetent, this discussion must be held with the patient's family and/or guardian. The physician providing the explanation is to make the required notation in the progress notes, which must include at least the following: persons present during discussion, information conveyed by the physician, and the decision of patient/family and/or guardian. The note must be dated, timed and include the printed name of the physician, as well as his/her signature ".

2.) initiation of ACLS (Advanced Cardiac Life Support) medication protocol on a 103 year old patient with an Advanced Directive indicating no CPR was to be implemented

Patient #13
Review of the medical record for Patient #13 revealed a 103 year old female admitted to the hospital on 04/28/12 at 0703 (7:03am) unresponsive and hypotensive from the nursing home.

Review of the Consent for Cardiopulmonary Resuscitation dated 07/01/09 and signed by someone other than the patient. Further review revealed a check was placed next to the statement indicating the following: " I understand that CPR constitutes an extraordinary measure and should not be done on this resident. However, I wish that essential life support interventions such as oxygen, nutrition, hydration, and certain medications for relief of pain should be administered to maintain resident comfort "

Review of the Emergency Department Record for Patient #13 revealed she was not in respiratory distress; however breath sounds were assessed as decreased as shallow. Cardiac status revealed sinus Bradycardia and a blood pressure of 70/52. Further review revealed IV fluids and Dopamine administered to keep systolic blood pressure above 90mmHg (millimeters mercury). At 0715 (7:15am) Patient #13 was administered ACLS protocol medications of Atropine and Epinephrine without a positive response. The patient was pronounced at 0722 (7:22am) by the Emergency Room physician.

In a face to face interview on 05/16/12 at 9:30am MD S14 Medical Director indicated these situations are very difficult because the nursing homes frequently send residents who have DNR orders to the emergency room when they begin to code. Further he indicated sometimes the family comes and wants the patient to be resuscitated. S14 indicated because he was not in attendance when Patient #25 came to the ED (Emergency Department) it is not possible to be sure.

The Emergency Department Physician who cared for Patient #13 on 04/28/12 was a contract MD and could not be reached by the hospital for interview.

3) failure to continue life saving measures on a patient (#25) experiencing respiratory arrest and who had an advanced directive for CPR at the request of the family and with no documented evidence the patient was at the end of life

Patient #25
Review of the medical record for Patient #25 revealed a 71 year old female admitted to the hospital on 04/15/12 via the Emergency Department in Respiratory Arrest. In addition Patient #25 had a history of COPD (Chronic Obstructive Pulmonary Disease) and was living in a nursing home.

Review of the "Consent for Treatment" form Patient #25 was unable to sign due to her medical condition and her son indicated his mother had not executed an advanced directive as evidenced by an X placed in the box indicating this statement. Also contained in the medical record was an "Advanced Directive Acknowledgment" which was signed by Patient #25's husband on 04/10/12 along with the LaPOST (Louisiana Physicians Orders for Scope of Treatment) also signed by Patient #25's husband on 04/10/12 indicating CPR was to be initiated.

Review of the Emergency Department Record dated/timed 04/15/12 1925 (7:25pm) revealed Patient #25 was living at a nursing home and was talking with her family when she started complaining of chest pain and then became unresponsive. Initially the oxygen saturation was 68% with oxygen at 5 liters (no route documented) became apneic so an oral airway was inserted and Patient #25 was bagged with 100% oxygen. Patient #25 maintained a faint pulse at 82. 1728 (7:28pm) the family requested to discuss the code status of Patient #25 with the MD. 1731(7:31pm) Family member (not named) was very upset at the bedside talking to the MD because he wanted no resuscitation measures performed. 1945 (7:45pm) A discussion took place with the husband of Patient #25 who indicated his wife's wishes were not to have measures taken to prolong her life. The MD explained that without further interventions Patient #25 would die in the near future, her husband still insisted nothing be done but comfort measures and only oxygen and occasional suctioning was done. 2145 (9:45pm) Patient #25 pronounced. Further review of the medical record revealed no documented evidence Patient #25 had been assessed to be at the end of life or had an irreversible condition.





17091

Based on record review and interviews, the hospital failed to follow the hospital's policy for staff assignments in the ICU for 3 of 15 days of ICU (intensive care unit) assignment sheets reviewed from 04/29/12 through 05/13/12 . Findings:

Review of "ICU Daily Charge Nurse Worksheet" dated 05/11/12 revealed the night shift (7:00pm to 7:00am) had an ICU RN with 1 patient and RN S19 (medical/surgical) with 1 patient. Further review revealed RN S25, contracted through Company B, was responsible for monitoring the telemetry patients from the medical/surgical (med/surg) unit. Further review revealed no documented evidence that RN S25 had been assessed for competency in monitoring the rhythm strips of telemetry patients by a hospital-employed RN.

Review of "ICU Daily Charge Nurse Worksheet" dated 05/12/12 revealed the day shift (7:00am to 7:00pm) had an ICU RN caring for 2 patients and overseeing the care of a third patient whose care was provided by med/surg RN S10. Further review revealed the night shift had an ICU RN caring for 3 patients, one of whom had med/surg RN S26 administering medications, monitoring intake and output, weighing, and bathing the patient. Further review revealed the rhythm strips of the telemetry patients was monitored by RN S25 contracted through Company B who had not been assessed for competency in monitoring the rhythm strips of telemetry patients by a hospital-employed RN.

Review of "ICU Daily Charge Nurse Worksheet" dated 05/13/12 revealed the day shift had an ICU RN caring for 2 patients and overseeing the care of a third patient being cared for by med/surg RN S9. Further review revealed the night shift had an ICU RN caring for 2 patients and overseeing the care of a third patient whose care was provided by med/surg RN S19.

In a face-to-face interview on 05/17/12 at 11:05am, RN Quality Resource Manager S2 confirmed that the hospital did not have an acuity system to determine ICU staffing by patient acuity.

In a face-to-face interview on 05/17/12 at 2:10pm, med/surg RN S9 confirmed that she worked ICU on 05/13/12. She indicated that she was assigned the care of 1 patient and performed patient assessments, administered medications, took vital signs, and provided for the needs of the patient. S9 indicated her patient had a new diagnosis of atrial fibrillation and had been in the ICU for a couple days. S9 indicated the charge nurse, who was assigned the care of 2 other patients, assisted her (S9) as needed.

In a face-to-face interview on 05/17/12 at 2:15pm, Chief Nursing Officer S1 confirmed there was a problem with staffing in ICU. She indicated the med/surg nurses who were pulled to assist in covering ICU had some ICU training, but they were not ICU-experienced nurses.

Review of the hospital's policy titled "ICU/CCU (cardiac care unit) Staffing Plan Summary", presented by RN Quality Resource Manager S2 as a current policy, revealed, in part, "...C. Staffing requirements ... will be determined by patient and telemetry intensity levels (acuity) ...
Census RN Staff Monitor Tech
6 3 1
5 3 1
4 2 1
3 2 1
2 1 1
1 1 1".

According to the hospital policy 1 RN could provide care to only 2 patients.

Based on record review and interviews, the hospital failed to ensure the RN (registered nurse) supervised and evaluated the nursing care of each patient for 2 of 30 sampled patients (#15, #19). 1) The RN failed to ensure the blood pressure and pulse were assessed prior to the administration of Metoprolol for 1 of 3 patients with orders for Metoprolol from a total sample of 30 patients (#15). This resulted in Patient #15 being transferred to the intensive care unit (ICU) to have a Dopamine drip initiated and titrated to maintain the systolic blood pressure above 100 millimeters of mercury. 2) The nurse failed to report a change in the patient's condition to the RN (when assessed by a licensed practical nurse) and the physician for 1 of 1 patient reviewed with a change in condition from a total sample of 30 patients (#15). 3) The RN failed to ensure the nursing care of a patient with unstable blood pressure was not delegated to a LPN according to the Louisiana State Board of Registered Nurse's nurse practice act for 1 of 1 patient reviewed with unstable blood pressure from a total sample of 30 patients (#15). 4) The RN failed to assess a patient's intake and output (I&O) and weight for 1 of 1 patients with orders for I&O and daily weights from a total of 30 sampled patients (#19).
5) The RN failed to ensure Sliding Scale insulin was administered as ordered and Accucheck blood sugar was monitored for 1 of 3 sampled patients with sliding scale insulin ordered from a total sample of 30 (#11). Findings:

1) The RN failed to ensure the blood pressure and pulse were assessed prior to the administration of Metoprolol:
Review of Patient #15's medical record revealed he was a 51 year old male admitted on 03/08/12 with diagnoses of generalized weakness and dehydration. Review of the H&P (history and physical) performed on 03/09/12 revealed Patient #15 had a significant history of hypertension, history of alcoholism, and a history of an abnormal CT (computerized tomography) scan in the past with possible cirrhosis.

Review of Patient #15's "Physician's Orders" revealed an order dated 03/08/12 with no documented evidence of the time the order was written for Toprol XL (Metoprolol Succinate) 100 mg (milligrams) by mouth every day.

Review of the "2012 Lippincott's Nursing Drug Guide", the resource available to the nursing staff presented by Quality Resource Manager S2, revealed nursing considerations for the administration of Metoprolol was that the nurse should assess the patient's blood pressure and pulse when administering Metoprolol.

Review of Patient #15's "Medication Name Administration Record" revealed LPN (licensed practical nurse) S15 administered Metoprolol on 03/10/12 at 8:37am and on 03/11/12 at 9:15am. There was no documented evidence of Patient #15's blood pressure or pulse when S15 administered the Metoprolol on 03/10/12 and 03/11/12.

Review of Patient #15's "Patient Vital Signs" revealed his blood pressure on 03/10/12 at 7:52am was 84/50 (Metoprolol was administered at 8:37am). There was no documented evidence of another blood pressure assessed and documented until 12:40pm, and the blood pressure at that time was 81/49. Further review revealed Patient #15's blood pressure was as follows on 03/10/12: 4:33pm - 89/55; 8:12pm - 159/69; 12:19am on 03/11/12 - 78/47; and 4:19am on 03/11/12 - 80/40. There was no documented evidence LPN S15 notified the RN or physician of Patient #15's hypotension from 7:52am through 4:33pm. Further review revealed no documented evidence RN S29 notified the physician of Patient #15's hypotension from 12:19am through 4:19am on 03/11/12.

Review of Patient #15's "Patient Vital Signs" revealed his blood pressure on 03/11/12 at 7:41am was 64/42 (Metoprolol was administered at 9:15am), 88/50 at 11:52am, and 81/50 at 4:12pm. There was no documented evidence LPN S15 notified the RN or physician of Patient #15's hypotension from 7:41am through 4:12pm. Further review revealed Patient #15's blood pressure on 03/11/12 at 8:11pm was 84/52, 90/51 on 03/12/12 at 12:19am, and 89/54 at 4:19am. Review of the "Patient Care Notes" and the "Med-Surg Flowsheet-Standard" revealed no documented evidence RN S29 notified the physician of Patient #15's hypotension from 8:11pm on 03/11/12 through 4:19pm on 03/12/12.

Review of Patient #15's "Patient Care Notes" for 03/12/12 revealed the following documentation by RN S30:
8:00am - blood pressure 92/64; Toprol held; will notify physician during rounds;
10:00am - IV (intravenous) fluids changed to Dextrose 5% (per cent) with 1 ampoule multivitamins and 1 ampoule Sodium Bicarbonate (order received by telephone at 9:10am);
11:55am - blood pressure 72/44; placed in trendelenburg;
12:00pm - spoke with physician regarding change in status; orders given to transfer to ICU (intensive care unit);
12:25pm - blood pressure 78/44;
12:30pm - transferred to ICU.
Further review revealed Patient #15, once in ICU, had Dopamine 400 mg in 250 milliliters begun at 2.5 meq (milliequivalents) per kilogram to keep his systolic blood pressure above 100 millimeters mercury.

In a face-to-face interview on 05/17/12 at 8:55am, LPN S15 indicated the nurse was supposed to check a patient's apical pulse (not below 60 beats per minute) and blood pressure (systolic not below 100) prior to administering Metoprolol. She further indicated she would have documented the apical pulse on the medication administration record if she took it. S15 confirmed there was no documented evidence of a blood pressure or pulse documented on Patient #15's MAR on 03/10/12 and 03/11/12 when she administered the Metoprolol. S15 indicated the nursing assistants took vital signs at 8:00am, 12:00pm, 4:00pm, and 8:00pm. She further indicated she went by what the nursing assistant had documented for the patient's blood pressure. S15 indicated she administered Metoprolol without checking a patient's blood pressure or pulse and would not check the vital signs recorded by the nursing assistant. She further indicated she would rely on the nursing assistant to report an abnormal blood pressure or pulse to her. S15 confirmed that she did not check Patient #15's pulse or blood pressure prior to administering his Metoprolol. S15 indicated she was not aware of Patient #15's low blood pressure on 03/10/12 and 03/11/12 until it was brought to her attention at the time of this interview. She further indicated that she did not report the change in condition to the RN, because she was not aware of Patient #15's change in condition.

2) The nurse failed to report a change in the patient's condition to the RN (when assessed by a LPN) and the physician:
Review of Patient #15's medical record revealed he was a 51 year old male admitted on 03/08/12 with diagnoses of generalized weakness and dehydration. Review of the H&P (history and physical) performed on 03/09/12 revealed Patient #15 had a significant history of hypertension, history of alcoholism, and a history of an abnormal CT scan in the past with possible cirrhosis.

Review of Patient #15's "Patient Vital Signs" revealed his blood pressure on 03/10/12 at 7:52am was 84/50 with no documented evidence of another blood pressure assessed and documented until 12:40pm. Patient #15's blood pressure at 12:40pm was 81/49 and 89/55 at 4:33pm. There was no documented evidence LPN S15 (the nurse assigned the care of Patient #15) notified the RN or physician of Patient #15's hypotension from 7:52am through 4:33pm. Further review revealed Patient #15's blood pressure from 7:00pm on 03/10/12 through 7:00am on 03/11/12 was 159/69 at 8:12pm, 78/47 at 12:19am, and 80/40 at 4:19am. Further review revealed no documented evidence RN S29 notified the physician of Patient #15's hypotension from 12:19am through 4:19am on 03/11/12.

Review of Patient #15's "Patient Vital Signs" revealed his blood pressure on 03/11/12 at 7:41am was 64/42, 88/50 at 11:52am, and 81/50 at 4:12pm. There was no documented evidence LPN S15 notified the RN or physician of Patient #15's hypotension from 7:41am through 4:12pm. Further review revealed Patient #15's blood pressure on 03/11/12 at 8:11pm was 84/52, 90/51 on 03/12/12 at 12:19am, and 89/54 at 4:19am. Review of the "Patient Care Notes" and the "Med-Surg Flowsheet-Standard" revealed no documented evidence RN S29 notified the physician of Patient #15's hypotension from 8:11pm on 03/11/12 through 4:19pm on 03/12/12.

In a face-to-face interview on 05/17/12 at 8:55am, LPN S15 indicated she was not aware of Patient #15's low blood pressure on 03/10/12 and 03/11/12 until it was brought to her attention at the time of this interview. She further indicated that she did not report the change in condition to the RN, because she was not aware of Patient #15's change in condition.

RN S29 was not available to be interviewed during the survey. Quality Resource Manager S2 confirmed there was no documented evidence that RN S29 had notified the physician of Patient #15's hypotension on the night shifts of 03/10/12 and 03/11/12.

Review of the hospital policy titled "Assessment and Reassessment of Patients", policy number A-3, revised 04/12, and presented by the S 1 Chief Nursing Officer as current, revealed, in part, "Assessment and reassessments of the patient's physical and psychosocial status are multidisciplinary responsibilities, depending upon the discipline(s) involved at the point of care, the status of the patient's condition, the patient's desire for care, and the patient's response to any previous treatment.
The goal of patient assessment/reassessment is to determine what kind of care is required to meet the patient's initial needs as well as his or her needs as the change in response to care. This process is designed to provide each patient the best care and treatment possible, taking into consideration the patient's physiological, psychological, social and environmental situation and needs.
Reassessment is the systematic review of patient-specific data to prioritize needs and care or treatment based on changes, additional patient requests, and/or additional information. This process follows the evaluation step in the interdisciplinary process as the cycle of care continues.

3) The RN failed to ensure the nursing care of a patient with unstable blood pressure was not delegated to a LPN according to the Louisiana State Board of Registered Nurse's nurse practice act:
Review of Patient #15's medical record revealed he was a 51 year old male admitted on 03/08/12 with diagnoses of generalized weakness and dehydration. Review of the H&P (history and physical) performed on 03/09/12 revealed Patient #15 had a significant history of hypertension, history of alcoholism, and a history of an abnormal CT (computerized tomography) scan in the past with possible cirrhosis.

Review of Patient #15's "Patient Vital Signs" revealed his blood pressure on 03/10/12 at 7:52am was 84/50 with no documented evidence of another blood pressure assessed and documented until 12:40pm. Patient #15's blood pressure at 12:40pm was 81/49 and 89/55 at 4:33pm. There was no documented evidence LPN S15 (the nurse assigned the care of Patient #15) notified the RN or physician of Patient #15's hypotension from 7:52am through 4:33pm. Further review revealed no documented evidence that Patient #15's care was transferred to a RN when his blood pressure became unstable.

Review of Patient #15's "Patient Vital Signs" revealed his blood pressure on 03/11/12 at 7:41am was 64/42, 88/50 at 11:52am, and 81/50 at 4:12pm. There was no documented evidence LPN S15 notified the RN or physician of Patient #15's hypotension from 7:41am through 4:12pm. Further review revealed no documented evidence that Patient #15's care was transferred to a RN when his blood pressure became unstable.

In a face-to-face interview on 05/17/12 at 8:55am, LPN S15 indicated that she did not report the change in condition to the RN, because she was not aware of Patient #15's change in condition.

In a face-to-face interview on 05/17/12 at 10:05am, RN S7 indicated that she worked as charge nurse on 03/10/12 and 03/11/12 with LPN S15. S7 further indicated if a LPN had a patient with unstable vital signs or blood sugar, she would take over the care of the patient until the patient's condition stabilized. S7 indicated that once the patient stabilized, she (S7) would return the care of the patient to the LPN. S7 further indicated she would only act if the LPN reported a patient's condition to her. S7 indicated did not review each patient's vital signs documented by the nursing assistants when she was the charge nurse.

Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part, "3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. a. Any situation where tasks are delegated should meet the following criteria: ...iv. the patient's status is safe for the person to carry out the task ... b. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: i. nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and ii. change in the patient's clinical conditions is predictable; and iii. medical and nursing orders are not subject to continuous change or complex modification...".
4) The RN failed to assess a patient's I&O and weight as ordered by the physician:
Review of the medical record for Patient #19 revealed she was a 46 year old female with a prior history of hypertension and diabetes mellitus. She came to the emergency room on 05/05/12 and was hypotensive and was admitted to the ICU (Intensive Care Unit) for acute hypotension from acute renal failure.

Review of the Physician Orders revealed her diagnoses to the ICU were sepsis, renal failure, and urinary tract infection. A Foley catheter was place in the patient on admit to the ICU, Levophed drip was started to titrate for a systolic blood pressure of 100 mmHg (millimeter of Mercury), and a renal ultrasound was ordered. On 05/07/12 the patient was transferred to the med surg unit with physician orders for daily weights and input and output ( I's and O's) monitoring.

Review of the electronic nurses notes from 05/05/12 to her discharge on 05/08/12 revealed her weight was monitored on 05/05/12 and 05/07/12 not on 05/06/12 and 05/08/12.

An interview was conducted with S3 RN. She reported the patient's weight was only documented in the electronic nurses notes on 05/05/12 and 05/07/12. She further reported with the diagnosis of Acute Renal Failure that the weight should have been monitored daily.

Review of the hospital's policy on Weight Measurement revealed in part "...Because body weight provides the best overall picture of fluid status, monitoring it daily also proves important for patients receiving sodium-retaining or diuretic medications. Rapid weight gain may signal fluid retention; rapid weight loss may indicate diuresis...".

Review of the electronic nurses notes revealed after the patient was transferred to the med surg unit with the order for I and O's (intake and output), the patient's urine output was not measured, but counted as the number of times she voided.

Review of the electronic nurses notes for Intake and Output on 05/07/12 at 18:01 (6:01 p.m.) revealed one void was documented without being measured and on 05/08/12 at 7:40 a.m. 2 voids were documented with unmeasured noted in the comments section. No other output was documented on the patient.

An interview was conducted with S3 RN on 05/15/12 at 10:45 a.m. She reported the nurses were counting voids and not measuring the urine as ordered by the physician.

Review of the hospital policy for Intake and Output revealed in part, "...Intake and output should be measured in milliliters and recorded on a 24-hour intake and output sheet...".

5) The RN failed to ensure Sliding Scale insulin was administered as ordered and Accucheck blood sugar was monitored:
Review of the Patient #11's record revealed the patient was a 69 year old male admitted to the hospital on 05/13/12 with diagnoses of COPD (Chronic Obstructive Pulmonary Disease). The record also revealed the patient was an insulin dependant diabetic.

Review of the physician's orders dated/timed 05/13/12 1745 (5:45 p.m.) revealed the following orders:
Novolin 70/30 sub Q (subcutaneous injection) 43 units in the morning and 33 units in the evening.
Accucheck AC & HS (Before Meals and Bedtime)
Regular Insulin Sliding Scale
Less than 150 = no coverage needed
150-200 = 2 units
201-250 = 4 units
251-300 = 6 units
301-350 = 8 units
351-400 = 12 units
Greater than 400 = 14 units and recheck in 2 hours.
If accucheck results less than 50 or greater than 500, order lab draw for verification and notify MD of results.

Review of the Patient Flowsheet Report and the Vital Sign sheet revealed an accucheck blood sugar was done on 05/13/12 at 1930 (7:30 p.m.) and the results were 348.

Review of the patient's Medication Administration Record revealed the only insulin administered to the patient was Novolin 70/30 33 units sub Q at 8:40 p.m. There was no documented evidence of any Regular Insulin given on 05/13/12, nor was there any documented evidence that the patient's blood sugar (Accucheck) was checked again until the next day (05/14/12).

Review of the Patient Care Notes documented by S12LPN revealed the following:
05/13/12 2040 (8:40 p.m.) HS (Bedtime) CBG (finger stick blood sugar) check preformed at this time patient is 348. Gave Novolin 70/30 33 units SUB-Q to LLQ (left lower quadrant) of abdomen as ordered by MD (Medical Doctor). Patient tolerated well......Patient also stated had not received dinner tray, provided cardiac dinner tray to patient and patient able to assist self to eat. Call bell in reach, side rails up X 2 and bed in low position for safety. Will continue to monitor.
There was no documented evidence of any other nursing entries until 5:00 a.m. the next morning (05/14/12).

On 05/14/12 at 2:45 p.m. a face to face interview with conducted with S 2 RN Quality Resource Manager. After reviewing the patient's electronic and paper records, S2 confirmed the physician's order for sliding scale regular insulin before meals and at bedtime as indicated above. After reviewing the nursing documentation, she confirmed the regular insulin was not administered as ordered in the sliding scale. S2 confirmed the patient should have received 8 units of regular insulin for a blood sugar of 348. S2 stated the nurse should have administered the insulin as ordered and should have re-checked the patient's blood sugar.

On 05/15/12 at 10:05 a.m., in a face to face interview with S12LPN, she verified she was assigned to Patient #11 on 05/13/12 for the 7 p.m. to 7 a.m. shift. When asked why the regular insulin was not given as ordered, she stated she was afraid to give the regular insulin because his blood sugar may drop. S12 stated she administered the patient's routine evening dose of Novolin 70/30 insulin with his evening meal. S12 verified she did not check the patient's blood sugar again that evening. When asked if she consulted the RN or the physician on whether the regular sliding scale insulin should have been administered, she stated no. S12 stated she does not notify the physician or the RN unless the blood sugar is less than 50 or greater than 500. S12 stated the patient was stable and she did not need to discuss a blood sugar of 358, or how to handle the sliding scale.



26351







17091

Based on record review and interview the hospital failed to ensure the registered nurse assigned patient care based on the patient needs and the competencies of the nursing staff for 3 of 7 nurses' personnel files reviewed from a total of 125 nurses employed. 1) The hospital failed to ensure medical/surgical nurses pulled to provide care to intensive care unit (ICU) patients were oriented, trained, and assessed for competency for providing care to an ICU patient (S9, S19). 2) The hospital failed to remediate a nurse who scored less than 80% (per cent) on the medication portion of the 2011 National Patient Safety Goals Quiz (S12). Findings:

1) The hospital failed to ensure medical/surgical nurses pulled to provide care to intensive care unit (ICU) patients were oriented, trained, and assessed for competency for providing care to an ICU patient:
RN S9
Review of the ICU (Intensive Care Unit) Charge Nurse Worksheet dated 05/13/12 revealed S9 RN med/surg (medicine/surgery) nurse was pulled from the med/surg unit to work in the ICU on 05/13/12 on the 7 a.m. to 7 p.m. shift.

Review of S9 RN's personnel file revealed she was orientated to the unit and was evaluated for being competent in her knowledge of the ICU policies, performance improvement, infection control, patient safety, and the environmental care. There was no documented evidence of competency related to providing care to the patient with medications administered by titration, ventilators, arterial lines, and swan-ganz lines.

RN S19
Review of the ICU Charge Nurse Worksheet dated 05/13/12 revealed S19 med/surg RN was pulled from the med/surg unit to work in the ICU on 05/13/12 on the 7 p.m. to 7 a.m. shift.

Review of the S19 RN's personnel file revealed she was orientated to the unit and was evaluated for being competent in her knowledge of the ICU policies, performance improvement, infection control, patient safety, and the environmental care. There was no documented evidence of competency related to providing care to the patient with medications administered by titration, ventilators, arterial lines, and swan-ganz lines except for a self assessment performed by S19 RN. The self assessment included the following items she checked as being competent in performing: admit patient, vital signs, discharge patient, blood glucose, I & O (intake and output), Foley catheter care, bath, collect urine/stool specimens, administer cardiac drips, administer critical IV (intravenous) medications, central line dressing change, wound/surgical dressing care, prepare patient for surgery/procedure, infusion pump, PCA (patient controlled analgesic) pumps, blood administration, IV/IVPB (intravenous/intravenous piggyback) administration, start IV's, administer TPN (total parenteral nutrition) and IV Heparin, Maintain central lines and peripheral IV lines, insert Foley catheter, care of surgical drains and chest tube maintenance. Further review revealed documented at the bottom of the self assessment sheet was a note dated 05/11/12 of "Oriented to cardizem and amiodarone gtt (drip)- ICU RN to monitor, chart and titrate gtts (drops)". There was no documentation that a nurse with ICU experience evaluated S19's competency with care of an ICU patient.

In a face-to-face interview on 05/17/12 at 2:10pm, med/surg RN S9 confirmed that she worked ICU on 05/13/12. She indicated that she was assigned the care of 1 patient and performed patient assessments, administered medications, took vital signs, and provided for the needs of the patient. S9 indicated her patient had a new diagnosis of atrial fibrillation and had been in the ICU for a couple days. S9 indicated the charge nurse, who was assigned the care of 2 other patients, assisted her (S9) as needed.

In a face-to-face interview on 05/17/12 at 2:15pm, Chief Nursing Officer S1 confirmed there was a problem with staffing in ICU. She indicated the med/surg nurses who were pulled to assist in covering ICU had some ICU training, but they were not ICU-experienced nurses.

Review of the hospital policy titled "Scheduling/Staffing", policy number S-6, revised 04/11, and submitted by RN Quality Resource Manager S2 as a current policy, revealed, in part, "...H. Persons assigned to a unit outside of their routine areas of function will be required to perform only basic duties/tasks common to all nursing areas (i.e, vital signs). They will not be expected to take on responsibilities beyond their scope of practice (i.e., take charge, read cardiac monitors)...".

2) The hospital failed to remediate a nurse who scored less than 80% (per cent) on the medication portion of the 2011 National Patient Safety Goals Quiz:
Review of the results of the 2011 National Patient Safety Goals Quiz given by the hospital to all RN and LPN staff revealed LPN S12 missed 5 of 19 questions. Further review of S12's personnel file revealed no remediation was performed.

In a face to face interview on 05/17/12 at 2:30pm RN S2 Quality Resource Manager indicated the passing score is 80% but because the quiz is not scored by individual topic, S12 was not remediated.












26351

Based on record review and interview, the hospital failed to ensure the non-employee nurses had adequate supervision and evaluation of clinical activities by failing to have agency-contracted nursing staff oriented and assessed for competency by a hospital-employed RN prior to performing patient care for 4 of 4 agency-contracted nursing personnel files reviewed (S21, S22, S23, S25). Findings:

RN S21
Review of RN S21's personnel file revealed she was an agency RN contracted through Company A, and her first shift worked was 07/02/11. Further review revealed no documented evidence of an assessment of competency by a hospital-employed RN prior to her performing patient care.

LPN (licensed practical nurse) S22
Review of RN S22's personnel file revealed she was an agency LPN contracted through Company B. Further review revealed S22 completed a self-assessment of skills competency on 04/11/12. Further review revealed no documented evidence of an assessment of competency by a hospital-employed RN prior to her performing patient care.

RN S23
Review of RN S23's personnel file revealed she was an agency RN contracted through Company C. Further review revealed a self-assessment of skills competency by RN S23. Further review revealed no documented evidence of an assessment of competency by a hospital-employed RN prior to her performing patient care.

RN S25
Review of the the nursing staff assignment sheets for ICU (Intensive Care Unit) revealed S 25 RN was assigned to monitor the telemetry monitors in ICU on 05/11/12 from 7 p.m. to 7 a.m. Under the assignment for S 25 RN was noted, "Contract".

On 05/17/12, personnel record for S 25 RN was requested for review and was provided by S1 Chief Nursing Office (CNO). Review of the records provided revealed S 25 RN was a contract nurse with S____ (Company B). Review of the form titled, Agency Orientation, revealed S25 had a 2 week contract from 05/10/12 to 05/24/12 and the first shift scheduled was 05/11/12 for 7 p.m. to 7 a.m. The Agency Orientation form revealed S25 was functioning as a telemetry monitor. Review of the orientation covered revealed no documented evidence that S 25 RN was oriented to the telemetry equipment. Review of the records for competency evaluation revealed the only competency document was a self check list completed and signed only by S 25 RN. There was no documented evidence that a hospital RN had assessed the competency of S 25 RN before assigning her to patient care.

On 05/17/12 at 10:35 a.m., an interview was conducted with S 2 RN Quality Resource Manager in person, and with S 31 RN on speaker phone. S 31 RN stated S 25 RN came in early for her shift on the first day she worked, and she oriented her to the telemetry monitors and the duties of the telemetry technician. She confirmed she did not document any of the orientation she did with S 25 RN. S 31 RN confirmed she did not do any competency assessment of S 25 RN and stated her competency was in her profile. S 2 RN reviewed the documents provided for S 25 RN and confirmed the self-assessment completed by S 25 RN was the only competency assessment they had on S 25 RN. S 2 RN confirmed this self-assessment was provided by the contracted nurse staffing agency.

In a face-to-face interview on 05/17/12 at 12:15pm, Human Resource Director S32 indicated there was online training available that the contract agency had to have their employee perform before the agency could submit the nurse's name to the hospital for use. She further indicated the records submitted were all that the hospital had on each agency staff member.




25065

Based on record review and interview, the hospital failed to ensure drugs were administered according to the physician orders and acceptable standards of practice. 1) The hospital failed to ensure the blood pressure and pulse were assessed prior to the administration of Metoprolol for 1 of 3 patients with orders for Metoprolol from a total sample of 30 patients (#15). This resulted in Patient #15 being transferred to the intensive care unit (ICU) to have a Dopamine drip initiated and titrated to maintain the systolic blood pressure above 100 millimeters of mercury. 2) The hospital failed to maintain an accurate disposition of narcotics administered by a PCA pump to 3 of 3 patients reviewed for PCA pump usage from a total of 30 sampled patients (#6, #14, #30). 3) The hospital failed to administer sliding scale insulin as ordered for 1 of 3 sampled patients with sliding scale insulin ordered from a total sample of 30 sampled patients (#11). 4) The hospital failed to administer medications within 1 hour when ordered, to clarify physician orders for medications, and to administer the medications at the time interval ordered by the physician for 1 of 30 sampled patients (#15). Findings:

1) The hospital failed to ensure the blood pressure and pulse were assessed prior to the administration of Metoprolol:
Review of Patient #15's medical record revealed he was a 51 year old male admitted on 03/08/12 with diagnoses of generalized weakness and dehydration. Review of the H&P (history and physical) performed on 03/09/12 revealed Patient #15 had a significant history of hypertension, history of alcoholism, and a history of an abnormal CT (computerized tomography) scan in the past with possible cirrhosis.

Review of Patient #15's "Physician's Orders" revealed an order dated 03/08/12 with no documented evidence of the time the order was written for Toprol XL (Metoprolol Succinate) 100 mg (milligrams) by mouth every day.

Review of the "2012 Lippincott's Nursing Drug Guide", the resource available to the nursing staff presented by Quality Resource Manager S2, revealed nursing considerations for the administration of Metoprolol was that the nurse should assess the patient's blood pressure and pulse when administering Metoprolol.

Review of Patient #15's "Medication Name Administration Record" revealed LPN (licensed practical nurse) S15 administered Metoprolol on 03/10/12 at 8:37am and on 03/11/12 at 9:15am. There was no documented evidence of Patient #15's blood pressure or pulse when S15 administered the Metoprolol on 03/10/12 and 03/11/12.

Review of Patient #15's "Patient Vital Signs" revealed his blood pressure on 03/10/12 at 7:52am was 84/50 (Metoprolol was administered at 8:37am). There was no documented evidence of another blood pressure assessed and documented until 12:40pm, and the blood pressure at that time was 81/49.

Review of Patient #15's "Patient Vital Signs" revealed his blood pressure on 03/11/12 at 7:41am was 64/42 (Metoprolol was administered at 9:15am), 88/50 at 11:52am, and 81/50 at 4:12pm.

Review of Patient #15's "Patient Care Notes" for 03/12/12 revealed he was transferred to ICU at 12:30pm to have a Dopamine drip initiated to maintain his systolic blood pressure above 100 milliliters mercury.

Review of Patient #15's "Medication Name Administration Record" (MAR) for his entire stay from 03/08/12 through 04/03/12 revealed no documented evidence of his blood pressure or pulse at the time the Metoprolol was administered.

In a face-to-face interview on 05/17/12 at 8:55am, LPN S15 indicated the nurse was supposed to check a patient's apical pulse (not below 60 beats per minute) and blood pressure (systolic not below 100) prior to administering Metoprolol. She further indicated she would have documented the apical pulse on the medication administration record if she took it. S15 confirmed there was no documented evidence of a blood pressure or pulse documented on Patient #15's MAR on 03/10/12 and 03/11/12 when she administered the Metoprolol.

2) The hospital failed to maintain an accurate disposition of narcotics administered by a PCA pump:
Patient #6 Review of the medical record for Patient #6 revealed she was a 75 year old female admitted on 05/14/12 to the hospital for a left knee arthroplasty. Review of the physician orders for 05/14/12 revealed she was placed on a PCA pump with Morphine Sulfate 30 mg (milligrams)/30 ml (milliliters) to be administered per pump at a dose of 1.5 mgs every 15 minutes.
Review of the PCA Flowsheet revealed the PCA pump was set up on 05/14/12 at 1030 (10:30 a.m.) with a total volume of 30 mls at a dose of 1.5 mgs every 15 minutes and no continuous infusion. The patient was transferred to the med surg unit at 1040 (10:40 a.m.) with a total volume of 30 ml.
Review of the Patient Flowsheet Report revealed on 05/14/12 at 12:00 (12 noon) there were no attempts by the patient to receive a dose of morphine. Review of the Patient Flowsheet report revealed on 05/14/12 at 1600 (4 p.m.) there were 3 attempts by the patient to receive a dose of morphine, but no documentation how many doses the patient received. On 05/14/12 at 19:30 (7:30 p.m.) no attempts were documented that the patient attempted to receive a dose of Morphine and the only documentation was that 19 remained in the syringe. The documentation did not specify mls or mgs. The Patient Flowsheet Report for 05/14/12 at 23:10 (11:10 p.m.) revealed no documentation of the patient attempts to administer the morphine or the amount of Morphine currently in the syringe. Review of the Patient Flowsheet Report for 05/15/12 at 3:10 (3:10 a.m.) revealed no documentation of the number of attempted doses by the patient or the amount of morphine in the syringe. The Patient Flowsheet Report for 05/15/12 at 05:10 (5:10 a.m.) only documented there were 9 ml of Morphine remaining in the syringe.
Review of the Acudose-RX station event report revealed there was a 3 ml profile waste for the Morphine Sulfate 30 mg/30ml in a 30 ml syringe at 05/15/12 at 18:04 (6:04 p.m.).
Due to the lack documentation the surveyor was unable to determine the disposition of the morphine for Patient #6.
Patient #14 Review of the medical record for Patient #14 revealed she had been admitted to the facility on 03/23/12 with admission diagnosis that included perforated carcinoma of the sigmoid colon with local regional metastasis. Patient #14's plan was listed by the physician as the reversal of a colostomy and removal of the left ovary.
Review of the medical record for Patient #14 revealed a document titled "PCA Pump Physician Orders" dated 03/23/12 at 12:45 p.m. Review of the orders revealed Morphine Sulfate 1 milligram per milliliter (mg/ml) was ordered per PCA pump as follows: 1 mg every 10 minutes (lockout interval), a maximum dosage of 20mg/20ml every four hours, an initial loading dose of 3 mg IV push, and a continuous dose of 0.5 mg/hour. Further review revealed an order dated 03/26/12 at 8:00 a.m. to D/C (discontinue) continuous Morphine from PCA.

Review of the PCA Flowsheet for Patient #14 revealed the PCA pump was loaded with 30 milliliters (ml) of Morphine on 03/23/12 at 1305 (1:05 p.m.). Pharmacy Director S4 stated the second vial of 30 ml of Morphine was placed into the PCA pump at 6:39 a.m. on 03/24/12. No documentation could be provided by the facility about the dispensation of the first 30 ml vial of Morphine that had been placed in the pump on 03/23/12. No documentation was presented for the amount of doses administered, doses attempted, or wastage.

A document titled "Acudose-RX Station Events Report By Medication" was provided by Pharmacy Director S4. Review of the document revealed 30mg/30ml of Morphine was removed from the Acudose medication dispensing machine on 03/23/12 at 12:48 p.m. (1st vial), 03/24/12 at 06:39 a.m. (2nd vial), 03/25/12 at 15:21 (3:21 p.m.) (vial charted as having been dropped), and 03/25/12 at 15:26 (3:26 p.m.) (3rd vial). Wastage was recorded on 03/25/12 of 30ml (dropped on floor) and 14 ml on 03/26/12 at 19:28 (7:28 p.m.). No wastage was recorded for the first or second vial withdrawn for the PCA pump for Patient #14. This was verified by Pharmacy Director S4 and Chief Nursing Officer (CNO) S1.

Review of the PCA Patient Flowsheet Reports provided by CNO S1 revealed in part the following:
30 ml Morphine loaded into PCA pump in the Post Anesthesia Care Unit on 03/23/12 at 1305(1:05 p.m.).No further PCA flowsheet documentation for 03/23/12.
No PCA flowsheet documentation for 03/24/12 until 6:29 p.m.
03/24/12 at 18:29 (6:29 p.m.) - 11.8 ml used, volume cleared. 0 mg wasted. No documentation about the number of attempts by Patient #14 or how many doses were given to the patient. The verification by two nurses of the narcotic count was charted by one nurse using an electronic signature.
03/25/12 at 15:30 (3:30 p.m.) -0 wasted. No documentation of doses administered or attempted.
03/25/12 at 19:00 (7:00 p.m.) - 3.8 ml used, volume cleared. No documentation about the number of attempts by Patient #14 or how many doses were given to the patient. The verification by two nurses of the narcotic count was charted by one nurse using an electronic signature.
No further PCA documentation until 03/28/12 when a new pump was started.
S1 said all documentation about the dispensation of the Morphine in Patient #14's PCA pump since 03/23/12 had been provided.

In an interview on 05/15/12 at 11:45 a.m. with Pharmacy Director S4, he stated no accurate system was being used to account for the Morphine administration via the PCA pump from 03/23/12 through 03/26/12 for Patient #14. He said the PCA pump had the capability of noting how many attempts were made by the patient to receive Morphine and how many attempts were successful, but this information was not being recorded anywhere consistently by the nursing staff. S4 also said accurate Morphine counts of the amount of medication administered and the amount of medication remaining in the pump were not being charted by the nursing staff.
In an interview on 05/15/12 at 11:50 a.m. with Chief Nursing Officer S1, she stated she realized there was a problem accounting for the amount of Morphine administered to Patient #14 from 03/23/12 at 1305 (1:05 p.m.) until 03/24/12 at 1829 (6:29 p.m.). S1 verified 30 ml was inserted into the PCA pump on 03/23/12 at 1:05 p.m. and no further documentation about the disposition of the Morphine was recorded until 03/24/12 at 6:29 p.m. She said 30 ml of Morphine was removed from the Acudose system (medication dispensing unit) at 6:39 a.m. on 03/24/12 to replace the first vial. She said she could not produce any documentation by the nursing staff as to the disposition of the first 30 milliliters of Morphine. S1 said the nursing staff had not recorded the amount of Morphine that had been administered to Patient #14 via the PCA pump accurately from 03/23/12 until 03/26/12 or the amount of Morphine wasted. She further said the nursing staff should have recorded the amount of Morphine administration on the PCA flowsheet.
In an interview on 05/16/11 at 11:00 a.m. with Pharmacy Director S4, he stated when a narcotic was placed in a PCA pump, the amount of medication wasted to prime the tubing was not recorded anywhere. He also said if the morphine vial in the PCA pump was empty when it was removed, 0 balance remaining was not recorded anywhere. He said when the second Morphine vial was placed in the PCA pump for Patient #14 on 03/24/12 at 6:39 a.m., no waste had been recorded for the first 30 ml vial. He said he assumed the first was empty, but the count had not been recorded. He said two nurses were supposed to reconcile the narcotic count every shift change. After reviewing Patient #14's PCA record, he stated the reconciliation by two nurses was not being done correctly. He also said the reconciliation was not being done on other patients. He stated he could see narcotic medication administration on the PCA pump was a problem in the facility.
In an interview on 05/16/12 at 3:10 p.m. with Registered Nurse S5, she stated at the change of shift, two nurses should have verified the amount of narcotic used from a PCA pump and the amount remaining in the PCA pump. She stated when she entered her name on the PCA flow sheet to verify the narcotic reconciliation, she would also sign the nurse's name that she checked the medication with. When asked if the second nurse did not verify the narcotic count with their own electronic signature, she replied she typed in the other nurse's name.
In an interview on 05/16/12 at 4:00 p.m. with Clinical Infomatics RN S27, she stated that after reviewing the chart for Patient #14, she realized the nurses were validating narcotic counts with two nurses incorrectly on the PCA flow sheet. She stated after one nurse validated the count on the PCA flow sheet, that nurse should have signed off of the computer and the second nurse should have signed on to validate with their signature. She also said nobody was monitoring the system for accurate charting of narcotic counts.
In an interview on 05/16/12 at 4:25 p.m. with Quality Resource Manager S2, she stated PCA narcotic waste was not being monitored correctly. When asked how the staff monitored charts for medication administration errors, she stated it was not being done correctly at this time.
Patient #30 Review of the medical record for Patient #30 revealed she was a 75 year old female admitted on 05/15/12 for a revision of a failed left total hip arthroplasty.
Review of the Acute Pain Management Physician Orders -Adult for 05/15/12 revealed a PCA pump with Morphine Sulfate was ordered for the patient with a dose of 1 mg of Morphine every 10 minutes with no continuous infusion of Morphine.
Review of the PCA Flowsheet for 05/15/12 revealed the pump was started at 1210 (12:10 p.m.). Patient #30 was transferred to the med surg unit at 1255 (12:55 p.m.) with 2 mls administered and 28 mls of Morphine left in the syringe.
Review of the Patient Flowsheet Report for the PCA dated 05/15/12 at 18:30 (6:30 p.m.) revealed the patient made 3 attempts for doses of Morphine and the pump had 27 mls left in the syringe.
Review of the Patient Flowsheet Report for the PCA dated 05/16/12 at 00:00 (12 a.m.) revealed the number attempts were 1 by the patient with no documentation of how much medication the patient received and how much Morphine was left in the syringe.
Review of the Patient Flowsheet Report for the PCA for 05/16/12 at 04:00 (4 a.m.) revealed the number of attempts by the patient was 2 with no documentation of how much medication the patient received and how much Morphine was left in the syringe.
Due to the lack of documentation the surveyor was unable to determine the disposition of the Morphine from 6:30 p.m. on 05/15/12 to 05/16/12 at 3 p.m. when the Patient Flowsheets Reports were given to the surveyor by S3 RN.
The policy titled "Controlled Drug Administration", policy # 15-10, reviewed on 01/12 was provided by the facility. The policy stated in part, "...Controlled drugs shall be administered in accordance with medical staff rules and regulations relating to administration of medications and the facility's policies and procedures relating to the administration of medications ...
...Administration of designated controlled drugs shall be recorded on a Medication Administration Record ...Entries- Date and time of administration, ...Administered amount, wastage amount if any, signature of person giving the medication, signature of person witnessing the waste if any ...The disposition of a portion of a controlled drug remaining in an ampoule, vial, syringe, or tablets must be documented ...a licensed person must witness and cosign for all wastage and destruction ...".

The policy titled "PCA Flow sheet", policy # P-2, submitted 6/02 was provided by the facility. The policy stated in part, "...A PCA flow sheet or similar version in EMR (PCA Standard) will be initiated on all patients who have a PCA pump ...Entries are made upon: 1. Initiation of a PCA cartridge 2. Amount administered and amount to be absorbed are documented at time of shift or nurse change and at change of a cartridge 3. Change of cartridge 4 ...6. Discontinuation of the PCA pump and waste of narcotic ...I. For electronic flow sheet: all wastage is documented at the "amount of medication wasted" section of the flow sheet...".

3) The hospital failed to administer sliding scale insulin as ordered: Review of Patient #11's medical record revealed the patient was a 69 year old male admitted to the hospital on 05/13/12 with diagnoses of COPD (Chronic Obstructive Pulmonary Disease). The record also revealed the patient was an insulin dependant diabetic.

Review of the physician's orders dated/timed 05/13/12 1745 (5:45 p.m.) revealed the following orders:
Novolin 70/30 sub Q (subcutaneous injection) 43 units in the morning and 33 units in the evening.
Accucheck AC & HS (Before Meals and Bedtime)
Regular Insulin Sliding Scale
Less than 150 = no coverage needed
150-200 = 2 units
201-250 = 4 units
251-300 = 6 units
301-350 = 8 units
351-400 = 12 units
Greater than 400 = 14 units and recheck in 2 hours.
If accucheck results less than 50 or greater than 500, order lab draw for verification and notify MD of results.

Review of the Patient Flowsheet Report and the Vital Sign sheet revealed an accucheck blood sugar was done on 05/13/12 at 1930 (7:30 p.m.) and the results were 348.

Review of the patient's Medication Administration Record revealed the only insulin administered to the patient was Novolin 70/30 33 units sub Q at 8:40 p.m. There was no documented evidence of any Regular Insulin given on 05/13/12, nor was there any documented evidence that the patient's blood sugar (Accucheck) was checked again until the next day (05/14/12).

Review of the Patient Care Notes documented by S2LPN revealed the following:
05/13/12 2040 (8:40 p.m.) HS (Bedtime) CBG (finger stick blood sugar) check preformed at this time patient is 348. Gave Novolin 70/30 33 units SUB-Q to LLQ (left lower quadrant) of abdomen as ordered by MD (Medical Doctor). Patient tolerated well......Patient also stated had not received dinner tray, provided cardiac dinner tray to patient and patient able to assist self to eat. Call bell in reach, side rails up X 2 and bed in low position for safety. Will continue to monitor.
There was no documented evidence of any other nursing entries until 5:00 a.m. the next morning (05/14/12).

On 05/14/12 at 2:45 p.m. a face to face interview with conducted with S 2 RN Quality Resource Manager. After reviewing the patient's electronic and paper records, S2 confirmed the physician's order for sliding scale regular insulin before meals and at bedtime as indicated above. After reviewing the nursing documentation, she confirmed the regular insulin was not administered as ordered in the sliding scale. S2 confirmed the patient should have received 8 units of regular insulin for a blood sugar of 348. S2 stated the nurse should have administered the insulin as ordered and should have re-checked the patient's blood sugar.

On 05/15/12 at 10:05 a.m., in a face to face interview with S2LPN, she verified she was assigned to Patient #11 on 05/13/12 for the 7 p.m. to 7 a.m. shift. When asked why the regular insulin was not given as ordered, she stated she was afraid to give the regular insulin because his blood sugar may drop. S12 stated she administered the patient's routine evening dose of Novolin 70/30 insulin with his evening meal. S12 verified she did not check the patient's blood sugar again that evening. When asked if she consulted the RN or the physician on whether the regular sliding scale insulin should have been administered, she stated no. S12 stated she does not notify the physician or the RN unless the blood sugar is less than 50 or greater than 500. S12 stated the patient was stable and she did not need to discuss a blood sugar of 358, or how to handle the sliding scale.

4) The hospital failed to administer medications within 1 hour when ordered, to clarify physician orders for medications, and to administer the medications at the time interval ordered by the physician:
Review of Patient #15's medical record revealed he was a 51 year old male admitted on 03/08/12 with diagnoses of generalized weakness and dehydration. Review of the H&P (history and physical) performed on 03/09/12 revealed Patient #15 had a significant history of hypertension, history of alcoholism, and a history of an abnormal CT (computerized tomography) scan in the past with possible cirrhosis.

Review of Patient #15's "Critical Value Communication/Documentation" revealed his potassium level was 6.8. Further review revealed a telephone order was received to administer Kayexalate 60 grams by mouth one dose now on 03/08/12 at 1420 (2:20pm). Review of the "Physician's Order" dated 03/08/12 at 1415 (2:15pm) revealed a telephone order was received to administer Kayexalate 30 grams by mouth now. Further review revealed a clarification order was written on 03/08/12 at 1530 (3:30pm), 1 hour and 10 minutes and 1 hour and 15 minutes respectively, to give Kayexalate 60 grams by mouth now.

Review of Patient #15's MAR revealed he received Kayexalate 60 grams on 03/08/12 at 1530 (3:30pm), 1 hour and 15 minutes after the initial order was received.

Review of Patient #15's "Physician's Order" dated 03/09/12 at 2:00pm revealed an order for Cipro 200 mg IVPB (intravenous piggyback) every 12 hours. Review of his MAR revealed he received the first dose of Cipro on 03/09/12 at 2030 (8:30pm), 6 and a half hours after it was initially ordered rather than within 1 hour as required by hospital policy.

Review of Patient #15's "Physician's Order" dated 03/13/12 at 1420 (2:20pm) revealed an order for Protonix 40 mg IVPB every 12 hours. Review of the MAR revealed Patient #15 received Protonix 40 mg IVPB on 03/13/12 at 1554 (3:54pm) and 2038 (8:38pm), 4 hours and 40 minutes between doses rather than 12 hours as ordered.

Review of Patient #15's "Physician's Order" dated 03/13/12 at 8:50am revealed a hemodialysis order that included Heparin bolus 2000 units IV was to be administered. Review of the "Hemodialysis Treatment Sheet" dated 03/13/12 revealed Heparin 3000 units was administered at 8:50am rather than 2000 units as ordered.

In a face-to-face interview on 05/16/12 at 2:25pm, RN Quality Resource Manager S2 confirmed the wrong dose of Heparin was administered by the agency-contracted RN for Patient #15. She indicated the ordered Kayexalate was not administered within 1 hour of the order as required by hospital policy. S2 indicated the hospital's computer system defaults the medication administration time for every 12 hours to the next scheduled time if the medication was initially administered between 5:00am and 4:00pm. She explained that the Protonix that was given at 3:54pm defaulted by the computer for the next dose to be given at 9:00pm even though the order was for every 12 hours. She further indicated the nurse does not contact the physician to clarify that he/she wants the medication in this instance to be given sooner than 12 hours.

Review of the hospital policy titled "Orders, Routine, Now and Stat", policy number O-6, revised 04/12, and presented by the S 1 Chief Nursing Officer as current, revealed, in part, "...Orders for testing procedures, laboratory work, medications and treatments will be transcribed and performed in a timely fashion according to the priority assigned by the physician... B. Now orders are carried out within an hour upon receipt of order...".

Review of the "Standard Medication Administration Times Policy & (and) Procedure", submitted by RN Quality Resource Manager S2, revealed when a medication schedule is every 12 hours, the scheduled time is 9:00am and 9:00pm. Further review revealed when the medication is first administered between the hours of 5:00am and 4:00pm, the next dose would be administered at 9:00pm, regardless of the time the initial dose was administered. This meant that a medication ordered every 12 hours could be first administered at 4:00pm and then the second dose would be given 5 hours later at 9:00pm.

Review of the hospital policy titled "Medications", policy number M-6, revised 04/12, and submitted by RN Quality Resource Manager S2, revealed, in part, "...3. Prepare and give medications within the one hour window...".








17091










25065

Based on interviews and record review, the hospital failed to meet the Condition of Participation for Pharmaceutical Services as evidenced by:
1) Failing to ensure the Director of Pharmacy supervised and coordinated all the activities of the pharmacy services. The Director of Pharmacy failed to ensure all first doses of medications were not administered to patients before being reviewed by a pharmacist for known allergies, therapy contraindications, dose and route of administration, directions for use, duplication of therapy, interactions, and optimum therapeutic outcomes. The Director of Pharmacy failed to ensure accurate records were kept for the disposition of the scheduled drug Morphine for 3 of 3 patients reviewed with orders for Patient Controlled Analgesia (PCA) pump usage (#6, #30, #14). The Director of Pharmacy failed to ensure drug administration errors were immediately reported to the attending physician and the hospital-wide quality assurance program. There were 48 medication errors noted during chart reviews that were not identified by the hospital for for 5 of 30 sampled patients (#6, #11, #14, #15, #30). (see findings in tags A0492, A0494, A0500, A0508).
2) Failing to ensure all drugs were kept locked and in a secure area as evidenced by Lidocaine being stored in an unlocked drawer in a patient corridor of the hospital (see findings in A0502).

Based on interviews and record reviews, the hospital failed to ensure the Director of Pharmacy supervised and coordinated all the activities of the pharmacy services. 1) The Director of Pharmacy failed to ensure all first doses of medications were not administered to patients before being reviewed by a pharmacist for known allergies, therapy contraindications, dose and route of administration, directions for use, duplication of therapy, interactions, and optimum therapeutic outcomes. 2) The Director of Pharmacy failed to ensure accurate records were kept for the disposition of the scheduled drug Morphine for 3 of 3 patients reviewed with orders for Patient Controlled Analgesia (PCA) pump usage (#6, #30, #14). 3) The Director of Pharmacy failed to ensure all drugs and biologicals were secured in a locked area as evidenced by four Lidocaine vials being stored in an unlocked drawer on a pediatric code cart located in a patient corridor in the hospital. 4) The Director of Pharmacy failed to ensure drug administration errors were immediately reported to the attending physician and the hospital-wide quality assurance program. There were 48 medication errors noted during chart reviews that were not identified by the hospital for for 5 of 30 sampled patients (#6, #11, #14, #15, #30). Findings:
1) The Director of Pharmacy failed to ensure all first doses of medications were not administered to patients before being reviewed by a pharmacist for known allergies, therapy contraindications, dose and route of administration, directions for use, duplication of therapy, interactions, and optimum therapeutic outcomes.
See findings in tag A0500.

2) The Director of Pharmacy failed to ensure accurate records were kept for the disposition of the scheduled drug Morphine for 3 of 3 patients reviewed for Patient Controlled Analgesia (PCA) pump usage.
See findings in tag A0494.

3) The Director of Pharmacy failed to ensure all drugs and biological were secured in a locked area as evidenced by four Lidocaine vials being stored in an unlocked drawer on a patient corridor in the hospital.
See findings in tag A0502.

4) The Director of Pharmacy failed to ensure drug administration errors were immediately reported to the attending physician and the hospital-wide quality assurance program. There were 48 medication errors noted during chart reviews that were not identified by the hospital for for 5 of 30 sampled patients (#6, #11, #14, #15, #30).
See findings in tag A0405 and A0508.

Review of the "Director of Pharmacy Position Description" signed by Director of Pharmacy S4 in December 2011 revealed in part, "... The Director of Pharmacy is responsible for overseeing all medication processing, preparation, dispensing, and storage in the institution; ...The Director ensures that the pharmacy provides optimal services; meets all legal, accreditation, and certification requirements; and complies with applicable policies, procedures, codes ...".

30364


Based on interview and record review, the hospital failed to maintain accurate records for the disposition of the scheduled drug Morphine which was being administered per a Patient Controlled Analgesia (PCA) pump for 3 of 3 patients (#6, #14, #30) reviewed for PCA pump usage from a total of 30 sampled patients. Findings:
Patient #6 Review of the medical record for Patient #6 revealed she was a 75 year old female admitted on 05/14/12 to the hospital for a left knee arthroplasty. Review of the physician orders for 05/14/12 revealed she was placed on a PCA pump with Morphine Sulfate 30 mg (milligrams)/30 ml (milliliters) to be administered per pump at a dose of 1.5 mgs every 15 minutes.
Review of the PCA Flowsheet revealed the PCA pump was set up on 05/14/12 at 1030 (10:30 a.m.) with a total volume of 30 mls at a dose of 1.5 mgs every 15 minutes and no continuous infusion. The patient was transferred to the med surg unit at 1040 (10:40 a.m.) with a total volume of 30 ml.
Review of the Patient Flowsheet Report revealed on 05/14/12 at 12:00 (12 noon) there were no attempts by the patient to receive a dose of morphine. Review of the Patient Flowsheet report revealed on 05/14/12 at 1600 (4 p.m.) there were 3 attempts by the patient to receive a dose of morphine, but no documentation of how many doses the patient received. On 05/14/12 at 19:30 (7:30 p.m.) there was no documented evidence that Patient #6 had attempted to receive a dose of Morphine, and the only documentation was that 19 remained in the syringe. The documentation did not specify mls or mgs. The Patient Flowsheet Report for 05/14/12 at 23:10 (11:10 p.m.) revealed no documentation of the patient attempts to administer the morphine or the amount of Morphine currently in the syringe. Review of the Patient Flowsheet Report for 05/15/12 at 3:10 (3:10 a.m.) revealed no documentation of the number of attempted doses by the patient or the amount of morphine in the syringe. The Patient Flowsheet Report for 05/15/12 at 05:10 (5:10 a.m.) revealed the only documentation was that there were 9 ml of Morphine remaining in the syringe.
Review of the Acudose-RX station event report revealed there was a 3 ml profile waste for the Morphine Sulfate 30 mg/30ml in a 30 ml syringe at 05/15/12 at 18:04 (6:04 p.m.).
Due to the lack documentation the surveyor was unable to determine the disposition of the morphine for Patient #6.
Patient #14 Review of the medical record for Patient #14 revealed she had been admitted to the facility on 03/23/12 with the admission diagnosis of perforated carcinoma of the sigmoid colon with local regional metastasis. Patient #14's plan was listed by the physician as the reversal of a colostomy and removal of the left ovary.
Review of the medical record for Patient #14 revealed a document titled "PCA Pump Physician Orders" dated 03/23/12 at 12:45 p.m. Review of the orders revealed Morphine Sulfate 1 milligram per milliliter (mg/ml) was ordered per PCA pump as follows: 1 mg every 10 minutes (lockout interval), a maximum dosage of 20mg/20ml every four hours, an initial loading dose of 3 mg IV (intravenous) push, and a continuous dose of 0.5 mg/hour. Further review revealed an order dated 03/26/12 at 8:00 a.m. to D/C (discontinue) continuous Morphine from PCA.

Review of the PCA Flowsheet for Patient #14 revealed the PCA pump was loaded with 30 milliliters (ml) of Morphine on 03/23/12 at 1305 (1:05 p.m.). Pharmacy Director S4 indicated the second vial of 30 ml of Morphine was placed into the PCA pump at 6:39 a.m. on 03/24/12. No documentation could be provided by the facility about the dispensation of the first 30 ml vial of Morphine that had been placed in the pump on 03/23/12. No documentation was presented for the amount of doses administered, doses attempted, or wastage.

A document titled "Acudose-RX Station Events Report By Medication" was provided by Pharmacy Director S4. Review of the document revealed 30mg/30ml of Morphine was removed from the Acudose medication dispensing machine on 03/23/12 at 12:48 p.m. (1st vial), 03/24/12 at 06:39 a.m. (2nd vial), 03/25/12 at 15:21 (3:21 p.m.) (vial charted as having been dropped), and 03/25/12 at 15:26 (3:26 p.m.) (3rd vial). Wastage was recorded on 03/25/12 of 30ml (dropped on floor) and 14 ml on 03/26/12 at 19:28 (7:28 p.m.). No wastage was recorded for the first or second vial withdrawn for the PCA pump for Patient #14. This was verified by Pharmacy Director S4 and Chief Nursing Officer (CNO) S1.

Review of the PCA Patient Flowsheet Reports provided by CNO S1 revealed in part the following:
30 ml Morphine loaded into PCA pump in the Post Anesthesia Care Unit on 03/23/12 at 1305(1:05 p.m.).No further PCA flowsheet documentation for 03/23/12;
No PCA flowsheet documentation for 03/24/12 until 6:29 p.m.;
03/24/12 at 18:29 (6:29 p.m.) - 11.8 ml used, volume cleared. 0 mg wasted. No documentation about the number of attempts by Patient #14 or how many doses were given to the patient. The verification by two nurses of the narcotic count was charted by one nurse using an electronic signature.
03/25/12 at 15:30 (3:30 p.m.) -0 wasted. No documentation of doses administered or attempted.
03/25/12 at 19:00 (7:00 p.m.) - 3.8 ml used, volume cleared. No documentation about the number of attempts by Patient #14 or how many doses were given to the patient. The verification by two nurses of the narcotic count was charted by one nurse using an electronic signature.
No further PCA documentation until 03/28/12 when a new pump was started.
CNO S1 indicated all documentation about the dispensation of the Morphine in Patient #14's PCA pump since 03/23/12 had been provided.

In an interview on 05/15/12 at 11:45 a.m. with Pharmacy Director S4, he indicated no accurate system was being used to account for the Morphine administration via the PCA pump from 03/23/12 through 03/26/12 for Patient #14. He said the PCA pump had the capability of noting how many attempts were made by the patient to receive Morphine and how many attempts were successful, but this information was not being recorded anywhere consistently by the nursing staff. S4 further indicated accurate Morphine counts of the amount of medication administered and the amount of medication remaining in the pump were not being charted by the nursing staff.
In an interview on 05/15/12 at 11:50 a.m. with Chief Nursing Officer S1, she indicated she realized there was a problem accounting for the amount of Morphine administered to Patient #14 from 03/23/12 at 1305 (1:05 p.m.) until 03/24/12 at 1829 (6:29 p.m.). S1 verified 30 ml was inserted into the PCA pump on 03/23/12 at 1:05 p.m. and no further documentation about the disposition of the Morphine was recorded until 03/24/12 at 6:29 p.m. She indicated 30 ml of Morphine was removed from the Acudose system (medication dispensing unit) at 6:39 a.m. on 03/24/12 to replace the first vial. She indicated she could not produce any documentation by the nursing staff as to the disposition of the first 30 milliliters of Morphine. S1 indicated the nursing staff had not recorded the amount of Morphine that had been administered to Patient #14 via the PCA pump accurately from 03/23/12 until 03/26/12 or the amount of Morphine wasted. She further indicated the nursing staff should have recorded the amount of Morphine administration on the PCA flowsheet.
In an interview on 05/16/11 at 11:00 a.m. with Pharmacy Director S4, he indicated when a narcotic was placed in a PCA pump, the amount of medication wasted to prime the tubing was not recorded anywhere. He further indicated if the morphine vial in the PCA pump was empty when it was removed, 0 balance remaining was not recorded anywhere. He indicated when the second Morphine vial was placed in the PCA pump for Patient #14 on 03/24/12 at 6:39 a.m., no waste had been recorded for the first 30 ml vial. He indicated he assumed the first was empty, but the count had not been recorded. He indicated two nurses were supposed to reconcile the narcotic count every shift change. After reviewing Patient #14's PCA record, S4 indicated the reconciliation by two nurses was not being done correctly. He further indicated the reconciliation was not being done on other patients. He indicated he could see narcotic medication administration on the PCA pump was a problem in the facility.
In an interview on 05/16/12 at 3:10 p.m. with Registered Nurse S5, she indicated at the change of shift, two nurses should have verified the amount of narcotic used from a PCA pump and the amount remaining in the PCA pump. She indicated when she entered her name on the PCA flow sheet to verify the narcotic reconciliation, she would also sign the nurse's name that she checked the medication with. When asked if the second nurse did not verify the narcotic count with their own electronic signature, she replied she typed in the other nurse's name.
In an interview on 05/16/12 at 4:00 p.m. with Clinical Infomatics RN S27, she indicated that after reviewing the chart for Patient #14, she realized the nurses were validating narcotic counts with two nurses incorrectly on the PCA flow sheet. She indicated after one nurse validated the count on the PCA flow sheet, that nurse should have signed off the computer, and the second nurse should have signed on to validate with their signature. She further indicated nobody was monitoring the system for accurate charting of narcotic counts.
In an interview on 05/16/12 at 4:25 p.m. with Quality Resource Manager S2, she indicated PCA narcotic waste was not being monitored correctly. When asked how the staff monitored charts for medication administration errors, she indicated it was not being done correctly at this time.
Patient #30 Review of the medical record for Patient #30 revealed she was a 75 year old female admitted on 05/15/12 for a revision of a failed left total hip arthroplasty.
Review of the Acute Pain Management Physician Orders -Adult for 05/15/12 revealed a PCA pump with Morphine Sulfate was ordered for the patient with a dose of 1 mg of Morphine every 10 minutes with no continuous infusion of Morphine.
Review of the PCA Flowsheet for 05/15/12 revealed the pump was started at 1210 (12:10 p.m.). Patient #30 was transferred to the med surg unit at 1255 (12:55 p.m.) with 2 mls administered and 28 mls of Morphine left in the syringe.
Review of the Patient Flowsheet Report for the PCA dated 05/15/12 at 18:30 (6:30 p.m.) revealed the patient made 3 attempts for doses of Morphine, and the pump had 27 mls left in the syringe.
Review of the Patient Flowsheet Report for the PCA dated 05/16/12 at 00:00 (12 a.m.) revealed the number of attempts was 1 by the patient with no documentation of how much medication the patient received and how much Morphine was left in the syringe.
Review of the Patient Flowsheet Report for the PCA for 05/16/12 at 04:00 (4 a.m.) revealed the number of attempts by the patient was 2 with no documentation of how much medication the patient received and how much Morphine was left in the syringe.
Due to the lack of documentation the surveyor was unable to determine the disposition of the Morphine from 6:30 p.m. on 05/15/12 to 05/16/12 at 3 p.m. when the Patient Flowsheets Reports were given to the surveyor by S3 RN.
The policy titled "Controlled Drug Administration", policy # 15-10, reviewed on 01/12 was provided by the facility. The policy stated in part, "...Controlled drugs shall be administered in accordance with medical staff rules and regulations relating to administration of medications and the facility's policies and procedures relating to the administration of medications ...
Administration of designated controlled drugs shall be recorded on a Medication Administration Record ... Entries- Date and time of administration, ...Administered amount, wastage amount if any, signature of person giving the medication, signature of person witnessing the waste if any ... The disposition of a portion of a controlled drug remaining in an ampoule, vial, syringe, or tablets must be documented ...a licensed person must witness and cosign for all wastage and destruction ...".

The policy titled "PCA Flow sheet", policy # P-2, submitted 06/02 was provided by the facility. The policy stated in part, "...A PCA flow sheet or similar version in EMR (PCA Standard) will be initiated on all patients who have a PCA pump ...Entries are made upon: 1. Initiation of a PCA cartridge 2. Amount administered and amount to be absorbed are documented at time of shift or nurse change and at change of a cartridge 3. Change of cartridge 4 ...6. Discontinuation of the PCA pump and waste of narcotic ...I. For electronic flow sheet: all wastage is documented at the "amount of medication wasted" section of the flow sheet...".

Based on interviews and record reviews, the hospital failed to ensure the pharmacy distributed medications in accordance with applicable standards of practice and consistent with Federal and State laws. The pharmacy failed to ensure all first doses of medications were not administered to patients before being reviewed by a pharmacist for known allergies, therapy contraindications, dose and route of administration, directions for use, duplication of therapy, interactions, and optimum therapeutic outcomes for all patients admitted after pharmacy working hours. Findings:
In an interview on 05/16/12 at 2:30 p.m. with Pharmacy Director S4, he indicated a pharmacist was on call at night if needed for emergencies or questions, but a pharmacist did not review first dose medications before administration when the pharmacy was closed from 7:00 p.m. to 7:00 a.m. Monday through Friday and 4:00 p.m. through 8:00 a.m. on Saturdays and Sundays. He further indicated the nurses could override the system and pull the first dose of medications from the Acudose (medication administration system) machine even though they had not been reviewed by a pharmacist. S4 indicated the night nursing supervisors reviewed the first dose medications before they were given, because he thought the nursing supervisors had special training to review the medications. When asked if any of the nursing supervisors were pharmacists, he replied no. He indicated since the pharmacy was closed at night, he was not aware a pharmacist had to review the first dose medications before they were given at night.
In an interview on 05/16/12 4:18 p.m. with Chief Nursing Officer S1, she indicated after the pharmacy staff left in the evening, no pharmacist reviewed the first doses of medications before they were administered to the patients. S1 indicated the medications were reviewed by the pharmacists when they returned in the morning.
In an interview on 05/16/12 at 4:20 p.m. with Registered Nurse S20, she indicated if a first dose medication was given after the pharmacy department was gone for the night, it was not reviewed by a pharmacist before administration. She further indicated first dose medications were being given at night if ordered.
The policy and procedure titled "Dispensing first dose Policy", policy # 11-06, revised 03/10 was provided by the facility. The policy stated in part, "...Medication orders are to be implemented only after review by a pharmacist for drug-drug/ drug-food/ drug-allergy/ and drug-disease contraindications as well as dose. In the event a medication is ordered after pharmacy hours of operation, the medication will not begin until the following day after a pharmacist has processed and approved the medication order ...A healthcare professional determined to be qualified by the organization will review the medication order in the pharmacist's absence...".

Review of the "Louisiana Administrative Code Title 46 - Professional and Occupational Standards Part III: Pharmacists Chapter 15. Hospital Pharmacy", revealed, in part, "...1511. Prescription Drug Orders A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency...". Further review of definitions listed revealed, in part, "...(13) "Drug regimen review" means and includes, but is not limited to, the following activities: (a) Review of the prescription drug order and patient record for [i] known allergies, [ii] therapy contraindications, [iii] dose and route of administration, and [iv] directions for use, (b) Review of the prescription drug order and patient record for duplication of therapy, (C) Review of the prescription drug order and patient record for interactions, and (d) Review of the prescription drug order and patient record for proper utilization including over- or under-utilization, and optimum therapeutic outcomes...".

Based on observation and interview the hospital failed to ensure all drugs were kept locked and in a secure area as evidenced by Lidocaine being stored in an unlocked drawer in a patient corridor of the hospital. Findings:

An observation was made on 05/16/12 at 2:45 p.m. on the med/surg (medicine/surgery) unit of the pediatric code cart. Further observation revealed the drawers on top of the pediatric code cart were unlocked. Further observation revealed one of the unlocked drawers contained 4 vials of 1% (per cent) Lidocaine 10 mg/ml (milligrams/milliliters). The pediatric code cart was kept in a hallway where patient rooms were located. The observation was confirmed by S3 RN.

An interview was conducted with S4 Pharmacist on 05/16/12 at 2:45 p.m. He indicated that the Lidocaine should have been in the code cart drawers that were locked, not in the unlocked drawers on top of the pediatric code cart.

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Based on record review and interview, the hospital failed to ensure drug administration errors were immediately reported to the attending physician and the hospital-wide quality assurance program. There were 48 medication errors noted during chart reviews that were not identified by the hospital for for 5 of 30 sampled patients (#6, #11, #14, #15, #30). Findings:

Review of the medical records of Patients #6, #11, #14, #15, and #30 revealed a total of 48 medication errors that had not been identified by the hospital, not reported to the physician, and not included in the quality assurance program.

See findings in tag A0405.

In a face-to-face interview on 05/17/12 at 11:40am, RN Quality Resource Manager S2 indicated the night nurses performed chart audits. When asked if the management relied on the staff nurses to audit charts for medication variances, the nurses who were actually the ones who made the errors, S2 indicated that she did spot checks of some charts.

Review of the hospital policy titled "Medication Variance", policy number 14-03, revised 12/01 and reviewed 05/12, and presented by the S1Chief Nursing Officer as current, revealed, in part, "...The purpose of this policy is to delineate those actions, which violate healthcare standards of practice relating to the use of medications. Every effort shall be made to avoid such variances in practice, and tracking/trending of variances is to permit the continuous improvement of the medication use process. .. Reporting variances is not intended to be rewarded with punitive measures, but to enable improvement of the system and minimize future recurrence.
Medication use shall follow current standards of practice according to hospital policy. All employees have an affirmative duty to complete a report on medication variances and "near miss" situations. Willful failure to do so can subject the employee to disciplinary action. Variance from standard shall be reported utilizing standard format and reporting guidelines.
All medication variances and/or adverse drug reactions are reported to the physician and nursing supervisor and facility's designated person responsible for collection and review of such reports within twenty-four (24) hours, unless there is a change requiring medical intervention and added treatment, in which case immediate notification of the physician is required...".

Based on observation and interview the hospital failed to ensure the dietary manager responsible for food and dietary services maintained a clean and safe environment for the storage of food used in the preparation of diets served to patients in the hospital. Findings:

Observation on 05/16/12 at 10:00am with RN S2 Quality Resource Manager and Dietary Manager S28 revealed two large free-standing freezers, two small serving refrigerators, two large free-standing refrigerators all with evidenced of liquid spills and food particles. All the refrigerators were used to store food for patient consumption.
Further observations revealed three large plastic bins containing dry foods of rice, flour and sugar and stored under a food preparation area were found to be sticky and covered with the dried foods contained in the bins. Upon opening the bin containing the flour, pieces of lettuce were visible mixed with the flour and a plastic disposable bowl was in the rice bin.

In a face to face interview on 05/16/12 at 10:15am Dietary Manager S28 indicated the lettuce probably fell in the container because the bins were not closed properly. In addition, S28 indicated the kitchen had a regular cleaning schedule; however S28 agreed the bins needed to be cleaned.

In a face to face interview on 05/16/12 at 10:30am RN S2 Quality Resource Manager agreed the refrigerators and bins had not been appropriately cleaned and maintained.

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Based on record review and interview the hospital failed to set priorities for high-risk, high volume and problem-prone areas as evidenced by failing to monitor the hospital process for implementing Advanced Directives and Do Not Resuscitate Orders resulting in: 1) failing to follow policy and procedure for 8 of 8 patients with orders for a DNR and failure to honor the written Advanced Directives of a patient (#13) by administering Advanced Cardiac Life Support medications to a patient who had requested no CPR and only comfort measures. 2) The hospital also failed to focus on patient safety and quality of care by not including the pharmacy in the performance improvement process. Findings:

1) failing to follow policy and procedure for 8 of 8 patients with orders for a DNR and failure to honor the written Advanced Directives of a patient (#13) by administering Advanced Cardiac Life Support medications to a patient who had requested no CPR and only comfort measures:

Review of the Mortality Review form used by the hospital to monitor deaths occurring in the hospital revealed no documented evidence the process for implementing advanced directives and following the hospital's policy and procedure for determining the patient a do not resuscitate was included. (See findings at Tag A0132).

Review of the Performance Improvement Plan, last reviewed 02/12 and submitted as the one currently in use, revealed.... "VI. Organization-Wide Performance Improvement A. Establishing Priorities for Performance Improvement: Problem prone procedures/processes.

Review of the Performance Improvement Summary for 2011 revealed no documented evidence problems with Advanced Directives and DNR implementation had been identified as a problem. Further review of the recommendations for 2012 revealed no documented evidence Advanced Directives and DNR implementation was identified for monitoring in 2012.

In a face to face interview on 05/16/12 at 9:30am MD S14 Medical Director indicated Advanced Directives and DNR orders cause many problems due to the Nursing Homes sending patients with a Code Status of DNR to the Emergency Department because they do not want the patient to die at the nursing home or they have problems with the family making decisions of wanting the patient to be revived. Further S14 indicated he knows that he follows the policy and procedure, but cannot be certain all physicians are doing the same.

2) failing to focus on patient safety and quality of care by not including the pharmacy in the performance improvement process:

On 05/17/12 S4, Pharmacist provided the Pharmacy & Therapeutics (P & T) Committee Minutes for review. Review of the minutes revealed the following:
01/27/11 - The pharmacy PI (Performance Improvement) report was presented for the 4th quarter. Our PI deals with override reports and anticoagulation management. We continue to monitor these areas. Next year we will focus on the placement of emergency pediatric medication sheets in the charts of these patients.
Medication Errors/Adverse Drug Reactions (ADRs) - We had two ADRs reported for the quarter....

06/30/11 - We had one ADR reported for the quarter. An endoscopy patient who was allergic to Demerol was given a dose. The patient developed a rash and was treated with Benadryl. This led to discussion about the nursing policy dealing with medication errors. Although the CRNA (Certified Nurse Anesthetist) was not a hospital employee, her medical director was notified.

03/15/12 - We had one ADR reported for the quarter....

Review of the Performance Improvement Committee meetings revealed no documented evidence that Pharmacy & Therapeutics was incorporated into the Quality Improvement process. The only documentation that Pharmacy was involved in the QAPI process was in the end of the year summary report which contained only data for 3 indicators being monitored (Pediatric emergency drugs and anticoagulants). There was no documented evidence that the Pharmacist attended any of the monthly Quality Improvement meetings.

In an interview on 05/17/12 at 11:00 a.m. with Director of Pharmacy S4, he said he reviewed patient's medical records randomly for variances. S4 stated he did not have any documentation of having reviewed patient ' s medical records for medication variances. He stated if he found any medication errors during his review, he would have filled out an incident report.
Review of the incident report log dated December 2011 to April 2012 revealed no incident reports for medication variances had been filled out by Pharmacist S4. This was verified by Registered Nurse S6 on 05/17/12 at 12:00 p.m.







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