Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 531311	(X3) Date Survey Completed 11/17/2011
Name of Provider or Supplier Crook County Hospital	Street Address, City, State 713 Oak Street, Sundance, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag

Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)

C0297

NURSING SERVICES
CFR(s): 485.635(d)(3)

All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws.

This STANDARD is not met as evidenced by:
Based on medical record review, staff interview, review of policies and procedures, and review of the QAPI program, the hospital failed to ensure staff administered medications appropriately for 7 of 22 sample patients (#2, #4, #9, #12, #14, #15, #18). In addition, staff failed to verify questionable medication orders prior to administration for patient #10. The effect of these failures resulted in an immediate jeopardy situation due to the increased risk to patient health and safety. The findings were: 1. Review of the medical record showed patient #9 was admitted to acute care on 11/2/11. According to the admission orders, staff were to administer Clindamycin (antibiotic) 900 mg IV every 8 hours (three times a day), Ancef (antibiotic) 1.5 grams IV every 8 hours, and Valium (antianxiety) 5 mg IV or orally every 6 hours (four times a day), routinely. The physician also ordered wound care, a Nicotine patch 21 mEq daily, and D5 1/2 NS (5% Dextrose and 1/2 strength normal saline) with 20 mEq of potassium IV at 120 ml per hour (8.3 hours infusion time). The orders were written at 4:53 PM on 11/2/11. At 11 PM that night, the physician changed the order for the IV fluids to 1/2 NS with 20 mEq of potassium to run at 120 ml per hour. However, he ordered this to start after the D5 1/2 NS was completed. The physician ordered Megace 20 ml daily on 11/3/11 at 12:04 PM. On 11/5/11 at 2:33 PM the physician ordered Valium to be decreased to 2.5 mg twice daily for 2 days and then discontinued. On 11/6/11 the physician ordered D5 1/2 NS with 4 grams of Magnesium IV at 90 ml per hour with telemetry in place during the infusion. Review of the November 2011 MARs identified the following deficient practices: a. There was no evidence the patient received Clindamycin and Ancef as ordered. According to the MARs, the patient received two doses of both medications on 11/3 instead of three doses as ordered. b. Valium was not administered on 11/2/11 and was given twice on 11/3/11 instead of every 6 hours as ordered. In addition, on 11/3/11 initials and times were circled or scratched out at 8 AM and 2 PM so it was not possible to determine if the medication was administered at those times. c. Documentation indicated the IV of D5 1/2 NS with 20 mEq of potassium was started at 6 PM on 11/2/11. The completion time for an IV to run at 120 ml per hour would have been at 2:20 AM. Instead, the next bag of IV solution was started at 5 AM on 11/3/11, indicating the first bag took eleven hours to complete. Documentation as to why this discrepancy occurred was not present in the record. d. The Megace ordered daily on 11/3/11 at 12:04 PM was not initiated until 11/4/11. There was no documentation that the physician authorized starting the medication the next day. e. The 11/5/11 order to decrease Valium to 2.5 mg for 2 days was transcribed onto the MAR to be administered for 3 days. However, there was no evidence staff administered the medication correctly for the 2 days it was given as the 8 AM dose on 11/5/11 was circled as not administered; no explanation for this discrepancy was documented. f. The Nicotine patch was not initialed as administered on 11/6/11. g. Detailed review of the MARs and nursing documentation showed no evidence 4 grams of Magnesium in D5 1/2 NS was ever infused as ordered on 11/6/11. Nor was there evidence the order was cancelled. h. Wound care was implemented with "barrier cream" to the buttocks, but the "barrier cream" was never identified so there was no way to determine if it was appropriate. On 11/15/11 at 2:00 PM the CNO reviewed the MARs and confirmed these medication errors. 2. Medical record review showed 3 year old patient #14 was admitted on 1/6/11 after being seen in the emergency department. Orders in the emergency department at 8:40 AM on 1/6/11 included an IV of NS with potassium chloride (KCl) 20mEq and 1/2 ampule of bicarbonate per liter to run at 200 ml per hour for 2 hours. The second IV order on 1/6/11 at 3:45 PM was for 1/2 NS with 20 mEq KCl and 1/2 ampule adult bicarbonate per liter to run at 200 ml per hour for 2 hours and then finish the bag at 60 ml per hour. Orders after admission at 6:20 PM on 1/6/11 included Tylenol 15 mg per kilogram every 6 hours, scheduled, and an IV of 1/2 NS with 20 mEq KCL per liter to run at 60 ml per hour. An order dated 1/7/11 at 10:14 AM was for 1000 ml of 1/2 NS with 20 mEq KCL and one ampule adult bicarbonate. The following deficient practices were identified: a. Even though the first order for IV fluids was written by the physician at 8:40 AM, documentation indicated the bag was hung at 8:00 AM. Although the order did not specify whether adult or infant bicarbonate was to be infused, the nurse documented she added the infant type. There was no verbal order written by the nurse for the medications she administered, and there was no evidence she questioned the physician regarding the type of bicarbonate to be used before adding it. b. The second IV order written at 3:45 PM specified that adult bicarbonate be infused. However, the nurse documented she noted the order at 1:10 PM, but started the IV at 12:30 PM. Again, there was no evidence a verbal order was obtained prior to 3:45 PM. c. The second IV at 200 ml per hour for 2 hours should have been completed at 2:30 PM if started at 12:30 PM as documented. However, the IV was not slowed to continue at 60 ml per hour until 3:30 PM. d. There was no evidence the IV ordered on 1/7/11 was ever infused; no order to cancel it was found. e. Tylenol was not administered every 6 hours as ordered; the noon and midnight doses were circled as not given. Review of the documentation showed no rationale for not administering the medication. 3. Review of the July 2011 MAR and 7/6/11 nurse's notes for patient #15 showed RN #6 administered Haldol 5 mg intravenously on 7/6/11 at 3 PM. Review of the medial record for this patient showed no physician's order for the administration of the medication. Interview with the DON on 11/16/11 at 11 AM confirmed the lack of a physician's order. Although the medication box was clearly labeled "For intramuscular use only," review of the manufacturer's packaged insert information for Haldol showed the product recommendations included the following warning: "Haldol injection is not approved for intravenous administration. If Haldol injection is administered intravenously, electrocardiogram monitor..." for changes in heart pattern and arrhthymias. Review of the medical record revealed no evidence of monitoring or nursing assessments for changes in heart patterns or arrhthymias. During an interview on 11/16/11 at 11:20 AM, RN #6 confirmed she administered the medication, but she did not remember the circumstances regarding administering the medication without a physician's order. She stated she was not aware of the need for post injection monitoring; therefore, she had not done this after administering the intravenous Haldol. 4. Review of the medical record revealed patient #18 was admitted to swing bed status in the hospital on 7/27/11; the admitting diagnoses included dementia and severe agitation. Review of the physician's admission orders showed medications included intravenous or intramuscular injections of Haldol 10 mg with Benadryl 25 mg every six hours as needed. Review of the MAR showed the patient received IV Haldol eleven times before the route was changed to intramuscular on 8/1/11. Interview with the pharmacy manager on 11/17 /11 at 10:02 AM revealed the only type of Haldol the facility stocked was that with the box labeled for intramuscular use only. 5. Review of the medical record for patient #4 showed his/her diagnosis included diabetes mellitus and the physician ordered daily insulin doses and blood glucose testing four times daily. Further review of this medical record revealed the following documentation: a. On 11/9/11 the physician ordered three scheduled Humalog insulin injections in addition to the sliding scale insulin doses. b. On 11/11/11 the three times a day dose of Humalog insulin was increased from two units to three units at mealtimes. c. On 11/10/11 the blood glucose levels were 144, 228, 149 and 199. On 11/11/11 the blood glucose levels were 141, 167, 162 and 247. On 11/12 to 11/13/11 the blood glucose levels ranged from 142 to 212. d. Review of the documentation in the MAR showed insulin was administered as ordered every day except 11/11/11. The documentation on the MAR for the 5 PM scheduled insulin on 11/11/11 was circled and left blank. At that time the glucose level was 162. The next time the glucose level was checked, it was 247 (the highest level recorded from 11/10/11 to 11/13/11). During an interview on 11/16/11 at 11:35 AM, RN #6 stated she provided care for the patient on 11/11/11, but she could not remember whether or not she administered the 5 PM scheduled dose of insulin. She also confirmed the 5 PM dose was circled, and she stated that usually meant she did not administer the medication. 6. According to the medical record, patient #2 was admitted to swing bed status on 11/8/11. Review of the admission orders showed the physician ordered Calcium 600 mg with Vit D to be administered twice daily. Review of the MAR showed the patient received all 8 AM medications on 11/9/11 except Calcium with Vitamin D. Review of the nursing notes showed no documentation as to why the medication was not given. 7. Review of the medical record for patient #12 showed s/he was an inpatient from 8/19 to 8/23/11. Further review showed an 8/20/11 physician's order for coumadin (a blood thinning medication) 3 mg to be administered daily. Review of the nurse's notes and MAR showed no evidence the medication was administered on 8/22/11. 8. Review of the physician's orders dated 10/24/11 at 11:44 showed he ordered Digoxin 0.75 mg orally twice daily for patient #10. According to the facility's reference, "Nursing 2011 Drug Handbook," by Wolters and Kluwer, the maximum initial dose of Digoxin for rapid digitalization is 0.4 to 0.6 mg orally or IV, followed by 0.1 to 0.3 mg every 6 to 8 hours. Although the ordered dose exceeded the maximum recommended amount, review of the MAR showed the medication was given at 8 PM that evening and at 8 AM on 10/25/11. Review of the nursing documentation showed no evidence the physician was questioned about the order. Review of the laboratory results completed on 10/26/11 showed the patient's digoxin level was critically high. 9. Review of the QAPI program with the CNO on 11/16/11 at 10 AM showed medication errors were one of the indicators being monitored. On 11/16/11 at 11:40 AM review with the CNO of the reported medication errors from January 2011 to 11/16/11 showed only two errors were identified and reported during the eleven month period. According to the facility's policy and procedure entitled "Medication Errors," last revised 9/9/08, errors were defined to include omissions; they were to be reported immediately to the physician and to the director of nursing and pharmacy manager within 24 hours, and staff were to complete an incident report. The failure of the facility to ensure staff verified medication orders and administered medications appropriately resulted in a determination of immediate jeopardy on 11/16/11 at 2:27 PM. The hospital's action plan included immediate education of all professional staff currently working or scheduled to work during the next four shifts (two days) to include: a. All orders to be transcribed with verification by two nurses; both to initial the MARs; b. Each patient's MAR to be started with the same date and all recopied MARs to flow forward for the next seven days; c. Questionable orders to be verified with the physician before being carried out. If the nurse is still uncomfortable giving the medication, s/he is to notify the CNO or nursing supervisor, notify the provider s/he cannot or does not wish to give the medication, and ask the provider if s/he would like to give it. d. Completion of a medication error report if any error is made or discovered. The action plan was accepted on 11/17/11 at 2:10 PM, and immediate jeopardy was abated at that time. 27095