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The Facility failed to ensure that departments within the hospital (medicine, nursing and pharmacy) were accountable for safe and effective ordering, distribution and administration of medications.
Cross reference A347, 395, 404, and 501.

Based on a review of clinical records, review of facility policies, review of facility documentation, and interviews, the facility failed to ensure the accountability of medical staff for the quality of care provided to 2 of 2 patients (#56 and 79) requiring intravenous medication.

a. Review of Patient #56's clinical record indicated that the patient was admitted on 10/18/11 with Alcohol withdrawal. Review of a preprinted order form titled "Alcohol Withdrawal Syndrome" directed administration of Valium 5 mg intravenously (IV) now and every five (5) minutes until drowsy but arousable. The order failed to include a maximum dose and/or level of sedation desired by the physician.
Additionally, the same preprinted order directed Valium 5 mg IV every four hours for 24 hours, hold for oversedation, Valium 5 mg IV every hour as needed for agitation, and Haldol 5-10 mg IV every four hours as needed for agitation. The order failed to include the maximum dose of Valium and Haldol, sedation parameters, and specific guidelines for Haldol dosing 5 mg versus the 10 mg dose.

Review of the record dated 8/18/11 during the period of 3:45 PM through 7:40 PM identified that the patient received 70 mg of Valium IV.


b. Patient #79 was admitted on 1/14/11 with Alcohol withdrawal. Review of the physician's order sheet dated 1/15/11 identified a protocol for "Alcohol Withdrawal Syndrome" that directed Valium 5 mg intravenously (IV) now and every five (5) minutes until drowsy but arousable. Additionally, the same preprinted order directed Valium 5 mg IV every four hours for 24 hours, hold for oversedation, Valium 5 mg IV every hour as needed for agitation, and Haldol 5-10 mg IV every four hours as needed for agitation. The order failed to include the maximum dose of Valium and Haldol, sedation parameters, and specific guidelines for Haldol dosing 5 mg versus the 10 mg dose.

Review of the medication administration record during the period of 1/15/11 through 1/17/11 reflected that the patient received Haldol 5 mg IV on five (5) occasions and Haldol 10 mg IV on (5) five occasions.


Interview on 10/26/11 at 11:00 AM with the VP of Medical Affairs indicated that the facility does not utilize a sedation scale to monitor the patient.

Based on a review of clinical records, review of facility policies, and staff interviews, the facility failed to ensure that nursing staff questioned incomplete medication orders prior to administration for two patients (79 and 56) who required support for alcohol withdrawal and/or failed to ensure that CIWA and/or skin assessments were completed and/or accurate for three patients (#56, 57 and 59) and/or for one patient (Patient #60), who received Propofol, the facility failed to ensure that Propofol was titrated in accordance with hospital policy and/or for one of two sampled patients (Patient #59), the facility failed to ensure that physician's orders were complete for Insulin administration and/or blood sugars were monitored in accordance with physician's orders. The findings include:



a. Patient #79 was admitted on 1/14/11 with Alcohol withdrawal. Review of the physician's order sheet dated 1/15/11 identified a protocol for "Alcohol Withdrawal Syndrome" that directed Valium 5 mg intravenously (IV) now and every five (5) minutes until drowsy but arousable. Additionally, the same preprinted order directed Valium 5 mg IV every four hours for 24 hours, hold for oversedation, Valium 5 mg IV every hour as needed for agitation, and Haldol 5-10 mg IV every four hours as needed for agitation. The order failed to include the maximum dose of Valium and Haldol, sedation parameters, and specific guidelines for Haldol dosing 5 mg versus the 10 mg dose.

Although the physician order for Valium failed to specify parameters for maximum dose and/or level of sedation desired, nursing staff administered Valium on 1/16/11. The nursing staff transcribed and administered the medications without asking the prescriber for specific parameters for administration. (i.e. maximum dose, length of order, use of the range dose, administering concurrent valium doses). Review of the medication administration record during the period of 1/15/11 through 1/17/11 reflected that the patient received Haldol 5 mg on five (5) occasions and 10 mg on (5) five occasions.


b. Review of Patient #56's emergency room record dated 10/18/11 reflected that the patient received Ativan 1 mg IV on four (4) occasions and Valium 5 mg IV on five (5) occasions for agitation. The medical record failed to reflect the patients response to the medications.

c. Review of Patient #56's clinical record indicated that the patient was admitted on 10/18/11 with Alcohol withdrawal. Review of a preprinted order form titled "Alcohol Withdrawal Syndrome" directed administration of Valium 5 mg intravenously (IV) now and every five (5) minutes until drowsy but arousable.
Additionally, the same preprinted order directed Valium 5 mg IV every four (4) hours for 24 hours, hold for oversedation, Valium 5 mg IV every (1) hour as needed for agitation, and Haldol 5-10 mg IV every four hours as needed for agitation. The order failed to include the maximum dose of Valium and Haldol, sedation parameters, and specific guidelines for Haldol dosing 5 mg versus the 10 mg dose.

Although the physician order for Valium failed to specify parameters for maximum dose and/or level of sedation desired, nursing staff initiated administration of Valium on 10/18/11. The nursing staff transcribed and administered the medications without asking the prescriber for specific parameters for administration. (i.e. maximum dose, length of order, use of the range dose, administering concurrent valium doses).

Review of the the medication administration record (MAR) identified an order for Valium 5 mg IV every (1) hour for agitation, however, the transcribed order was "written over" and documentation reflected that during the period of 10/18/11 at 6:10 AM through 7:40 PM, the patient received Valium every 10 minutes for a total of 35 mg instead of hourly as identified on the MAR. The hospital failed to ensure that the order was transcribed correctly and/or in accordance with standards of practice.


d. Review of Patient #56's clinical record dated 10/18/11 during the period of 3:45 PM through 7:40 PM, identfied that the patient received 70 mg of Valium IV. The record failed to reflect that the patient's sedation level was monitored during this time.



e. Review of Patient #56's Alcohol Withdrawal Syndrome orders dated 10/18/11 directed that CIWA assessments should be completed every one (1) hour for the initial 24 hours and then every four (4) hours. The clinical record failed to identify the the hourly CIWA assessments were completed in the first 24 hours and sporadic gaps in the CIWA monitoring of up to fours hours.


Review of the clinical records of patient #56 and #79 and interview with the Nurse Manager on 10/25/11 failed to identify that nursing staff clarified incomplete physician orders and/or had a policy for monitoring the patients sedation level.


f. Patient #57 was admitted on 10/14/11 with urinary tract infection and polynephritis. Review of the nursing assessment dated 10/14/11 identified that the patient had a stage one (1) pressure area of the gluteal cleft that was reddened and blanchable. The nursing assessment dated 10/17/11 and 10/24/11 identified that the stage-one pressure area gluteal cleft was described as "an open slit" and was 0.3 cm in size. The record failed to contain documentation as to when the pressure ulcer had progressed from reddened and blanchable to an open slit and/or that the pressure ulcer was accurately staged. Interview with staff identified that skin assessments should be performed every Wednesday. Review of the policy indicated wound assessments should be completed on admission, weekly and on discharge.


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g. Patient #59 was admitted to the hospital on 10/22/11 with hyponatremia, and metabolic encephalopathy. Patient #59 has a history of quadriplegia and was admitted with a stage-four pressure ulcer to his/her coccyx. Physician orders dated 10/23/11 direct to pack the sacral ulcer with seasorb and apply biatain dressing once daily and as needed. Interview and review of the clinical record with the Director of the Intensive Care Unit on 10/24/11 at 11:50 AM failed to identify that a complete wound assessment was conducted on admission. Further interview identified that the wound should have been measured for length, width, depth, the presence or absence of drainage and/or odor, general appearance of the ulcer, and the stage of the pressure sore. On 10/22/11 the clinical record identified Patient #59 as having one coccyx pressure ulcer. A photograph was taken of the coccyx ulcer with a tape measure indicating the diameter of the ulcer. The hospital policy for skin wound assessments directs in part that on admission each existing wound site is identified and wound assessments are completed including the location, stage, measurement, wound bed appearance and drainage. Subsequent to surveyor inquiry the wound nurse assessed the wound, changed the dressing and documented the wound assessment according to the hospital policy.


h. Patient #60 was admitted to the hospital on 10/14/11 with chronic obstructive pulmonary disease exacerbation, aspiration pneumonia and elevated troponin levels. On 10/17/11, Patient #60 required intubation and mechanical ventilation for respiratory distress and was sedated with Propofol. Physician's orders dated 10/17/11 directed Propofol 1000 milligrams/100 milliliters to be administered at 5 micrograms (mcg)/kilogram (kg)/minute (min). The physician's order further directed the rate to be adjusted to 5-10 mcg/kg/min every 5 minutes until the goal was achieved (titrate to riker score of 3). On 10/17/11 at 1:00 PM Propofol was administered at 20 mcg/kg/min. with a riker sedation score of 3. Propofol was maintained at this rate until 3:30 PM when Propofol was titrated to 35 mcg/kg/min for further sedation. Interview and review of the clinical record with the Director of the Intensive Care Unit on 10/24/11 at 11:00 AM failed to identify that Propofol was increased by 5-10 mcg/kg/min every 5 minutes in accordance with the hospital policy. The hospital policy for Propofol Infusion directed that Propofol will be adjusted 5-10 mcg/kg/min every 5 minutes until the titration goal is achieved.


i. Patient #59 was admitted to the hospital on 10/22/11 with hyponatremia, and metabolic encephalopathy. Patient #59 has a history of quadriplegia and type 2 diabetes mellitus. Physician admission orders written on 10/22/11 at 6:00 PM directed insulin to be administered via a sliding scale. The nurses flow sheet dated 10/22/11 at 6:30 PM identified that Patient #59's blood sugar was 220 and insulin was not administered. On 10/23/11 Patient # 59's blood sugar was 211 at 5:58 AM and 224 at 12:00 PM and 4 units of Insulin was administered subcutaneous (SC). On 10/23/11 Patient #59's blood sugar was 160 at 5:00 PM and 200 at 10:30 PM and 2 units of Insulin was administered SC. On 10/24/11 Patient #59's blood sugar was 158 at 5:45 AM and 2 units of Insulin was administered SC. Interview and review of the clinical record with the Director of the Intensive Care Unit on 10/24/11 at 11:30 AM failed to identify the type of Insulin that was ordered, the route the insulin was ordered, the time to administer insulin and/or when to obtain blood sugar levels. The hospital policy for medication administration directed in part the individual administering medication will verify that the medication selected for administration is the correct medication based on the medication order. The policy further directed the individual administering the medication will be aware of the route and frequency of administration, and that the medication is given at the proper time.

Based on review of the clinical record, hospital policy, and interviews for one of two sampled patients (Patient #59), who received Insulin, the facility failed to ensure that physician's orders were complete. The findings include:

a. Patient #59 was admitted to the hospital on 10/22/11 with hyponatremia, and metabolic encephalopathy. Patient #59 has a history of quadriplegia and type 2 diabetis mellitus. Physician admission orders written on 10/22/11 at 6:00 PM directed insulin to be administered via a sliding scale. The nurses flow sheet dated 10/22/11 at 6:30 PM identified that Patient #59's blood sugar was 220 and insulin was not administered. On 10/23/11 Patient #59's blood sugar was 211 at 5:58 AM and 224 at 12:00 PM with 4 units of Insulin administered subcutaneously (SC). On 10/23/11, Patient #59's blood sugar was 160 at 5:00 PM and 200 at 10:30 PM with 2 units of Insulin administered SC. On 10/24/11 Patient #59's blood sugar was 158 at 5:45 AM with 2 units of Insulin administered SC. Interview and review of the clinical record with the Director of the Intensive Care Unit on 10/24/11 at 11:30 AM failed to identify the type of Insulin that was ordered, the route the insulin was ordered, the time to administer insulin and/or when to obtain blood sugar levels.

Based on clinical record reviews, review of hospital documentation and interviews with facility personnel, the pharmacy department failed to ensure that medication orders for two patients (#56 and 79) included all elements of a physician's order prior to dispensing for administration by nursing. The findings include the following:

a. Review of Patient #56's clinical record indicated that the patient was admitted on 10/18/11 with Alcohol withdrawal. Review of the clinical record identified a preprinted order form titled "Alcohol Withdrawal Syndrome" directed that Valium 5 mg intravenously (IV) now and every five (5) minutes until drowsy but arousable. In addition the same order directed Valium 5 mg IV every four hours for 24 hours, hold for oversedation, Valium 5 mg IV every hour as needed for agitation, and Haldol 5-10 mg IV every four hours as needed for agitation in addition to the Valium. The physician's order failed to direct a maximum dose, level of sedation desired by the physician, parameters for the use of the concurrent Valium orders and/or specific guidelines for range doses for Haldol. The hospital failed to have a policy that identified a mechanism for patient monitoring (e.g. SAS scores).

Review of Patient #56's clinical record indicated that on 8/18/11 during the period of 3:45 PM through 7:40 PM the patient received 70 mg of Valium IV.


b. Review of Patient #79's clinical record identified the "Alcohol Withdrawal Syndrome" order sheet dated 1/15/11. The order sheet directed that Valium 5 mg intravenously (IV) now and every five (5) minutes until drowsy but arousable. In addition the same order directed Valium 5 mg IV every four hours for 24 hours, hold for oversedation, Valium 5 mg IV every hour as needed for agitation, and Haldol 5-10 mg IV every four hours as needed for agitation in addition to the Valium. Review of the MAR indicated that on 1/15/11-1/17/11 the patient received Haldol 5 mg IV on 5 occasions and Haldol 10 mg IV on five occasions.


Interview with the VP of Medical Affairs indicated that the order set had been reviewed in the appropriate committees and approved for use.

Based on observation, interview with hospital personnel and review of hospital policy, the hospital failed to have in place a system for identifying neuromuscular blocking medications that had a limited life outside of refrigeration. The finding includes:


a. During tour of the Operating Suite on 10/24/11 with the VP of Patient Care Services and the OR Coordinator, OR #4's anesthesia cart was observed to contain vials of succinylcholine that failed to identify when the medication had been removed from refrigeration. Tour of the OR medication room identified vials of succinylcholine stored within the refrigerator. During interview on 10/25/11, the Director of Pharmacy stated that although the hospital was moving toward suppliers that provided neuromuscular blocking agents that could be stored at room temperature, the hospital continued to provide vials of neuromuscular blocking agents that required refrigeration during storage, however, the hospital did not have a policy in place for identifying the expiration date of such medications when removed from refrigeration.

1. A tour of the Surgical Center on 10/25/11 at approximately 10:15 AM, the surveyor accompanied by the Director of Safety observed that floors and cove bases within Operating Rooms #1 through #4 and work rooms between the Operating Rooms were gouged, torn and separating at the welded seams.

2. The facility failed to ensure that the buildings, equipment and surroundings were kept clean and in good repair at all times. 10/24/11 at 1:15 PM the surveyors accompanied by the Safety Director/FNS Director during a tour of the Dietary Department the following was observed:
a. The paint finish at the ceiling and walls of the dish machine room, above the clean dishware and utensils, was observed to be peeling and flaking.
b. There was a build-up of grease, grime and dust on exposed overhead mechanical piping and ductwork above the preparation areas, cooking equipment, pot wash sinks; walk-in coolers and freezers.
c. There was a build-up of grime and food debris under and behind the cooking equipment.

Based on tour, interview with hospital personnel, and review of hospital policy, the hospital failed to ensure that infection control practices were implemented throughout the Operating Suite and/or Central Sterile processing. The findings include:

a. During tour of the Operating Suite on 10/24/11 with the the VP of Patient Care Services and the OR Coordinator, OR #4 (cleaned and not in use at the time) was observed to contain miscellaneous pieces of equipment (i.e. positioning devices, foam supports) lying atop carts, towels on top of the anesthesia medication cart and a stack of blank documentation forms on top of the anesthesia machine that failed to be either removed from the room for storage and/or stored within cabinets and drawers within the OR. Review of the hospital policies for cleaning of the operating rooms identified that all furniture within the room is cleaned and all surfaces damp dusted prior to the first case of the day.


b. Tour of the scrub/substerile rooms between Operating rooms identified that carts with shelves lined with unprotected foam were utilized to transport soiled specialized equipment such as cameras to the decontamination room and were reused from case to case. During interview on 10/24/11, the OR Coordinator stated that the foam was used to transport the contaminated equipment and reused without the benefit of being disinfected.


c. Review of the Central Processing biological testing documentation log for the Sterrad machines on 10/24/11, identified that on 10/18/11 (Tuesday), Sterrad #2 failed to have a biological test run and implanted in the incubator. Further review of the Sterrad biological testing log failed to identify the time the test was implanted in the incubator or the time it was removed from the incubator (at the completion of the test). According to manufacturer's directions for biological testing of the Sterrad sterilizers, a 24 hour incubation time was required to ensure an accurate reading.

Based on a review of the clinical record, review of hospital policy, and interview the facility failed to complete a timeout prior to completing a nerve block. The findings include the following:

Review of the clinical record for Patient #64 identified that the patient had a total right knee replacement completed on 10/21/11. Although review of the anesthesia record stated that a time out had been completed, the clinical record failed to identify that a comprehensive time out had been completed and who was in attendance. The clinical record indicated that the patient's surgery was completed at 9:30 AM and the patient was moved to PACU at that time. The post anesthesia note on 10/21/11 identified that the patient was pain free in PACU and suggested a femoral nerve block. The nurse's notes indicated that at 10:40 AM the patient was pain free and at 11:45 the patient had a femoral nerve block performed. The dictated note dated 10/21/11 at 2:12 PM indicated that a femoral nerve block was completed. The note failed to identify the side the nerve block was completed on, that consent had been obtained and/or that a timeout was completed prior to the procedure. The record indicated that the patient signed a consent on 9/29/11 for the TKR that included the statement that the patient was consenting to the administration of anesthesia connection with the procedure if necessary.

Review of the Time Out Policy indicated that a timeout should be performed immediately prior to starting a surgical procedure.

Based on a review of clinical records and review of the medical staff bylaw Rules and Regulations, the hospital failed to ensure that the quality of the patient history and physical (H&P) included evidence of physical evaluation for three patients (#67, 70, and 73). The findings include:


a. Review of Patient #67's clinical record identified that on 10/24/11, the patient underwent a left breast lumpectomy. A review of the patient's H&P dated 10/13/11, identified a failure to address the condition, at a minimum, of the patient's heart and lungs prior to surgery. The H&P identified that the patient "was healthy appearing 64 year old in no acute distress" and failed to reflect that the patient's heart and/or lungs were evaluated. Review of the medical staff bylaw Rules and Regulations reflected that the physician's responsibilities include a physical examination (inspection, auscultation, palpation, percussion) of the patient's condition prior to anesthesia, surgery and/or invasive procedure.


b. Review of the clinical record for Patient #70 identified that the patient underwent a right total knee arthroplasty on 10/24/11. Review of the H&P identified a document that outlined the patient's orthopedic symptomology and failed to address the current condition, at a minimum, of the the patient's heart and lungs prior to undergoing surgery and anesthesia.


c. Review of Patient #73's clinical record identified that the patient underwent placement of an IVC filter in interventional radiology on 10/24/11. Review of the H&P, dated 10/19/11 failed to reflect the condition of the patient's heart and lungs prior to undergoing the invasive procedure. The physician's procedure form for a radiology H&P failed to indicate that the patient had been assessed prior to the procedure with any changes noted. The form referred the reader to the "H&P".

Based on review of the clinical record, review of the policy and interview the facility failed to ensure that an informed consent was obtained for a nerve block. The finding includes the following:

Review of the clinical record for Patient #64 identified that the patient had a total right knee replacement completed on 10/21/11. The clinical record indicated that the patient's surgery was completed at 9:30 AM and the patient was moved to PACU at that time. The post anesthesia note on 10/21/11 identified that the patient was pain free in PACU and suggested a femoral nerve block. The dictated note dated 10/21/11 at 2:12 PM indicated that a femoral nerve block was completed. The note failed to identify the side the nerve block was completed on, that consent was been obtained and/or that a timeout was completed. The record indicated that the patient signed a consent on 9/29/11 for the TKR that included the statement that the patient was consenting to the administration of anesthesia connection with the procedure if necessary. Interview with the VP of Medical Affairs on 10/26/11 indicated that a separate consent is not obtained for a nerve block that the consent for the surgery includes the nerve block.

Review of the consent policy indicated that informed consent should be completed for all procedures requiring the the use of anesthesia or procedural sedation and invasive procedures.