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STATE OF WASHINGTON

DEPARTMENT OF HEALTH

August 2, 2010

Sheila Hagar

Walla Walla Union Bulletin Email: sheilahagar@wwub.com

Dear Sheila Hagar:

Your public disclosure request regarding the Federal, State and Complaint reports associated with Complaint #26898 has been processed.

Information withheld: None

If you have any questions, please contact me at (360) 236-4836.

_ Sincerely,

~~

Christina Nosich, Forms and Records Analyst Public Disclosure Records Center

Health Systems Quality Assurance

PO Box 47865

Olympia WA 98504

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 07/30/2010 FORM APPROVED OMB NO 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

500002

(X2) MULTIPLE CONSTRUCTION A. BUILDING

(X3) DATE SURVEY COMPLETED

(X1) PROVIDERISUPPLIERlCLIA IDENTIFICATION NUMBER:

NAME OF PROVIDER OR SUPPLIER

PROVIDENCE ST MARY MEDICAL CENTER

(X4)ID PREFIX TAG

Findings:

B. WlNG _

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

C 05/19/2010

(XS) COMPLETION DATE

7/16110

(X6) DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMAT!ON)

A 000 INITIAL COMMENTS

Surveyor: 00220

This hospital Medicare certification complaint investigation survey was conducted in response to complaint #26898 by Marcia Cook MN, MS, RN on May 18-19, 2010.

SHELL #OSUN11

A 285 482.21 (c)(1) OAPI PATIENT SAFETY

The hospital must set priorities for its performance improvement activities that --

Focus on high-risk, high-volume, or problem-prone areas;

Consider the incidence, prevalence, and severity of problems in those areas; and

Affect health outcomes, patient safety, and quality of care.

This STANDARD is not met as evidenced by:

Surveyor: 00220

Based on review of patient records, review of hospital policy, and staff interview, the hospital failed to ensure that all staff followed approved policies and procedures related to the administration of medications to patients for 2 of 8 patient records reviewed (Patients #1 and #2).

Failure to implement performance improvement actions on known drug administration system issues risked patient health and safety,

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

STREET ADDRESS, CITY, STATE, ZIP CODE 401 W POPLAR 5T

WALLA WALLA, WA 99362

ID PREFIX TAG

AOOO

A285

TITLE _

Any deficiency statement ending with an asterisk n denotes a deficiency which the institution may be excused from correcting providing it is detennined that other- safeguards provide sufficient protection to the patients. (See instructlons.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursinq homes, the above findings and plans of correction are disclosable 14 . days fallowing the date these documents are made available to the facility. If deficiencies are cited, an approved plan of ccrrection is requisite to continued program participation.

FORM CMS-2567(D2-99) Previous versions Obsolete

EventlD: OSUN 11

Facility ID: 000079

If continuation sheet Page 1 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEnlCARE & MEDICAID SERVICES

PRINTED: 07/3012010 FORM APPROVED OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

500002

(X2) MULTIPLE CONSTRUCTION A. BUilDING

(X3) DATE SURVEY COMPLETED

(X5) COMPLETION DATE

(X1) PROVIDER/SUPPLlER/CLlA IDENTIFICATION NUMBER:

C 05/19/2010

NAME OF PROVIDER OR SUPPLlER

PROVIDENCE ST MARY MEDICAL CENTER

(X4) 10 PREFIX TAG

Review of the nurses notes evidenced that the morphine drip was initiated at 2 mglhr and was

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR lSC IDENTIFYING INFORMATION)

A 285 Continued From page 1

The following policies related to medication administration were reviewed:

1. The patient care policy, "Administration of Medication (#8720.5480 dated 2/2009) under item 12 read, "A valid range order will include a minimum and maximum dose and a maximum frequency."

2. The Pharmacy Department policy, "Medication Orders (#7170.5422 dated 11/08) under item 12 regarding "Titrate Orders-Corders to increase or decrease a drug dose based upon patient response such as morphine drips ... ") read, " ... A valid order includes an initial starting dose, criteria for and amount of incremental increases or decreases, and a maximum dose OR specify 'no limit or no maximum dose' when appropriate."

Patient #1-Record review evidenced this patient was admitted on 3/1/2010 in respiratory failure. After determining that palliative comfort care was desired by the patient and family, a physician wrote the following order: "Morphine 1 mg (milligram) IV continuously (after) 2 mg IV bolus. Titrate for comfort and respiratory distress."

There was no specific range, no incremental increases identified, and no maximum dose or 'no limit' specified in the written order as required by hospital mandated pharmacy and patient care procedures.

Pharmacy filled the order without contacting the physician for clarification, and nursing administered the medication without contacting the physician for required parameters of drug management.

FORM CMS-2567{02-99) Previous Versions Obsolete

EvenlID:OSUN11

STREET ADDRESS, CITY. STATE. ZIP CODE 401 W POPLAR ST

WALLA WALLA, WA 99362

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCy)

10 PREFIX TAG

A285

Facility ID: 000079

If continuation sheet Page 2 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 0713012010 FORM APPROVED OMS NO. 0938·0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION A. BUILDING

(X3) DATE SURVEY COMPLETED

C 05119/2010

500002

B.~NG __

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

NAME OF PROVIDER OR SUPPLIER

PROVIDENCE ST MARY MEDICAL CENTER

(X4) 10 PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

STREET ADDRESS, CITY, STATE, ZIP CODE 401 W POPLAR ST

WALLA WALLA, WA 99362

ID PREFIX TAG

(X5) COMPLETION DATE

A 285 Continued From page 2 .

increased to 60 mg/hr in less than 3 hours. Documentation of the patient's symptoms did not include pain assessments, and only brief descriptions of respiratory effort and heart rate. For example, at 1300 on 311/2010 a nursing progress note read, "Face cyanotic. Continues to be (rapid breathing). Morphine drip increased to 20 mg/hr." One and one-half hours later the rate was increased to 50 mg/hr.

Staff interviews on 5/18 and 19/2010 confirmed that in palliative or comfort care the amounts,

rate and increases of the medication

administered to Patient #1 were within normal limits to meet patient comfort needs. Staff agreed that the written order lacked required information for an acceptable range, and maximum dose (or 'no limit') to be in compliance with approved policy and procedure.

I n staff interviews on 5118 and 19/2010 with nursing, pharmacy and administrative staff, it was acknowledged that not all physicians wrote palliative orders in accordance with approved policies, and that pharmacy and nursing staff did not consistently ask for clarification prior to medication administration to the patient.

A similar example was observed for Patient #2.

The hospital failed to ensure that all departments followed approved policies and procedures related to medication administration to all patients.

A 405 482.23(c)(1) ADMINISTRATION OF DRUGS

All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State

A285

A 405

7/16/10

FORM CMS-25S7(02-99) Previous Versions Obsolete

Event ID: OSUN11

Facility ID: 000079

If continuation sheet Page 3 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 07/30/2010 FORM APPROVED OMB NO 0938-0391

STATEMENT OF DEFICI ENCIES AND PLAN OF CORRECTION

500002

(X2) MULTIPLE CONSTRUCTION A. BUILDING

(X3) DATE SURVEY COMPLETED

(XS) COMPLETION DATE

(X 1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

C 05/19/2010

NAME OF PROVIDER OR SUPPLIER

PROVIDENCE ST MARY MEDICAL CENTER

(X4)ID PREFIX TAG

Patient #1-Record review evidenced this patient

B. WlNG _

STREET ADDRESS, CITY, STATE, ZIP CODE 401 W POPLAR ST

WALLA WALLA, WA 99362

PROVIDER'S PLAN DF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORYOR LSC IDENTIFYING INFORMATION)

A 405 Continued From page 3

laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures.

This STANDARD is not met as evidenced by:

Surveyor: 00220

Based on review of patient records, review of hospital policy, and staff interview, the hospital failed to ensure that all staff followed approved policies and procedures related to the administration of medications to patients for 2 of 8 patient records reviewed (Patients #1 and #2).

Failure to implement hospital approved policy and procedure for the safe administration of medication to all patients risked patient health and safety.

Findings:

The following policies related to medication administration were reviewed:

1. The patient care policy, "Administration of Medication (#8720.5480 dated 2/2009) under item 12 read, "A valid range order will include a minimum and maximum dose and a maximum frequency."

2. The Pharmacy Department policy, "Medication Orders (#7170.5422 dated 11/08) under item 12 regarding "Titrate Orders-(orders to increase or decrease a drug dose based upon patient response such as morphine drips ... ") read, " ... A valid order includes an initial starting dose, criteria for and amount of incremental increases or decreases, and a maximum dose OR specify 'no limit or no maximum dose' when appropriate."

ID PREFIX TAG

A405

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: OSUN 11

Facility 10: 000079

If continuation sheet Page 4 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 07/30/2010 FORM APPROVED OMS NO 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X 1) PROVI DERISUPPLIERlCLIA IDENTIFICATION NUMBER:

500002

(X2) MULTIPLE CONSTRUCTION A. BUILDING

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OR SUPPLIER

PROVIDENCE 8T MARY MEDICAL CENTER

(X4)ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

A 405 Continued From page 4

was admitted on 3/1/2010 in respiratory failure. After determining that palliative comfort care was desired by the patient and family, a physician wrote the following order: "Morphine 1 mg (milligram) IV continuously (after) 2 mg IV bolus. Titrate for comfort and respiratory distress."

There was no specific range, no incremental increases identified, and no maximum dose or 'no limit' specified in the written order as required by hospital mandated pharmacy and patient care procedures.

Pharmacy filled the order without contacting the physician for clarification, and nursing administered the medication without contacting the physician for required parameters of drug management.

Review of the nurses notes evidenced that the morphine drip was initiated at 2 mglhr and was increased to 60 mglhr in less than 3 hours. Documentation of the patient's symptoms did not include pain assessments, and only brief descriptions of respiratory effort and heart rate. For example, at 1300 on 3/1/2010 a nursing progress note read, "Face cyanotic. Continues to be (rapid breathing). Morphine drip increased to 20 mg/hr." One and one-half hours later the rate was increased to 50 mg/hr.

Staff interviews on 5118 and 19/201 0 confi rrned that in palliative or comfort care the amounts,

rate and increases of the medication

administered to Patient #1 were within normal limits to meet patient comfort needs. Staff agreed that the written order lacked required information for an acceptable range, and maximum dose (or 'no limit') to be in compliance with approved policy

FORM CMS~2567(a2-99) Previous Versions Obsolete

Event ID:OSUN11

C 05/19/2010

B. WING _

STREET ADDRESS. CITY. STATE. ZIP CODE 401 W POPLAR ST

WALLA WALLA, WA 99362

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

10 PREFIX TAG

A 405

Facility ID: 000079

If continuation sheet Page 5 of 6

(X5) COMPLETION DATE

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 07/30/2010 FORM APPROVED OMB NO 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

500002

(X2) MULTIPLE CONSTRUCTION A. BUILDING

(X3) DATE SURVEY COMPLETED

(X5) COMPLETION DATE

(X1) PROVlDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

C 05/19/2010

NAME OF PROVIDER OR SUPPLIER

PROVIDENCE ST MARY MEDICAL CENTER

(X4)ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR lSC IDENTIFYING INFORMATION)

A 405 Continued From page 5 and procedure.

In staff interviews on 5/18 and 19/2010 with nursing, pharmacy and administrative staff, it was acknowledged that not all physicians wrote palliative orders in accordance with approved policies, and that pharmacy and nursing staff did not consistently ask for clarification prior to medication administration to the patient.

A similar example was observed for Patient #2.

The hospital failed to ensure that all departments followed approved policies and procedures related to medication administration to all patients.

FORM CMS·2567(02-99) Previous Versions Obsolete

EventID:OSUN11

B. WlNG _

STREET ADDRESS, CITY, STATE, ZIP CODE 401 W POPLAR ST

WALLA WALLA, WA 99362

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS·REFERENCED TO THE APPROPRIATE DEFICIENCY)

10 PREFIX TAG

A405

..

-,

Facility ID: 000079

If continuation sheet Page 6 of 6

PRINTED: 07/30/2010 FORM APPROVED

State of Washinqton

STATEMENT OF DEFICIENCIES AND PlAN OF CORRECTION

(X3) OATE SURVEY COMPLETED

(X 1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION A. BUILDING

B.~NG __

C 05/19/2010

000079

STREET ADDRESS, CITY, STATE, ZIP CODE 401 W POPLAR ST

WALLA WALLA, WA 99362

NAME OF PROVIDER OR SUPPLIER

PROVIDENCE ST MARY MEDICAL CENTER

(X4) 10 SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PlAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR lSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
BODO Initial Comments B 000
This hospital state licensure complaint
investigation survey was conducted in response
to complaint # 26898 by Marcia Cook MN, MS,
RN on May 18-19, 2010.
SHELL #OSUN11
B 265 WAC 246-320-136 Leadership-Nursing Practice: 8265 7/16/10
Policy & Procedu
-
The hospital leaders must
(6) Adopt and implement policies and procedures
addressing patient care and nursing practices;
This Washington Administrative Code is not met .....
as evidenced by:
Based on review of patient records,. review of
hospital policy, and staff interview, the hospital
failed to ensure that all staff followed approved
policies and procedures related to the
administration of medications to patients for 2 of
8 patient records reviewed (Patients #1 and #2).
Failure to implement hospital approved policy and
procedure for the safe administration of
medication to all patients risked patient health
and safety.
Findings:
The following policies related to medication
administration were reviewed:
1. The patient care policy, "Administration of
Medication (#8720.5480 dated 2/2009) under
item 12 read, "A valid range order will include a
minimum and maximum dose and a maximum
frequency."
2. The Pharmacy Department policy, "Medication
ADSA - Residential Care Services or Department of Health
TITLE (X6) DATE
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
STATE FORM 6899 OSUN11 If continuation sheel 1 of 6 State of Washinqton

PRINTED: 07/30/2010 FORM APPROVED

STREET ADDRESS, CITY, STATE, ZIP CODE 401 W POPLAR ST

WALLA WALLA, WA 99362

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION A, BUILDING

B. WlNG _

(X3) DATE SURVEY COMPLETED

C 05/19/2010

000079

NAME OF PROVIDER OR SUPPLIER

PROVIDENCE ST MARY MEDICAL CENTER

(X4)ID PREFIX TAG

Review of the nurses notes evidenced that the morphine drip was initiated at 2 mg/hr and was increased to 60 mglhr in less than 3 hours. Documentation of the patient's symptoms did not include pain assessments, and only brief descriptions of respiratory effort and heart rate, For example, at 1300 on 3/1/2010 a nursing progress note read, "Face cyanotic, Continues to be (rapid breathing), Morphine drip increased to 20 mg/hr." One and one-half hours later the rate was increased to 50 mg/hr.

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

B 265 Continued From page 1

Orders (#7170,5422 dated 11/08) under item 12 regarding "Titrate Orders-(orders to increase or decrease a drug dose based upon patient response such as morphine drips ... ") read, " ... A valid order includes an initial starting dose, criteria for and amount of incremental increases or decreases, and a maximum dose OR specify 'no limit or no maximum dose' when appropriate."

Patient #1-Record review evidenced this patient was admitted on 3/1/2010 in respiratory failure, After determining that palliative comfort care was desired by the patient and family, a physician wrote the following order: "Morphine 1 mg (milligram) IV continuously (after) 2 mg IV bolus. Titrate for comfort and respiratory distress."

There was no specific range, no incremental increases identified, and no maximum dose or 'no limit' specified in the written order as required by hospital mandated pharmacy and patient care procedures.

Pharmacy, filled the order without contacting the physician for clarification, and nursing administered the medication without contacting the physician for required parameters of drug management.

ADSA -- Residential Care Services or Department of Health STATE FORM

10

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCy)

PREFIX

TAG

B 265

6899

OSUN11

(X5) COMPLETE DATE

If continuation sheet 2 of 6

State of Washinqton

PRINTED: 07/30/2010 FORM APPROVED

STATEMENT OF DEFICIENCIES AND PlAN OF CORRECTION

(X1) PROVIDER/SUPPLIERlCLIA IDENTIFICATION NUMBER:

NAME OF PROVIDER OR SUPPLIER

000079

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING ~

(X3) DATE SURVEY COMPLETED

C 05/19/2010

(X4)JO PREFIX TAG

STREET ADDRESS, CITY, STATE, ZIP CODE 401 W POPLAR 5T

WALLA WALLA, WA 99362

PROVIDENCE 5T MARY MEDICAL CENTER

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

ID PREFIX TAG

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVIE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5) COMPLETE DATE

8265 Continued From page 2

Staff interviews on 5/18 and 19/2010 confirmed that in palliative or comfort care the amounts, rate and increases of the medication administered to Patient #1 were within normal limits to meet patient comfort needs. Staff agreed that the written order lacked required information for an acceptable range, and maximum dose (or 'no limit') to be in compliance with approved policy and procedure.

In staff interviews on 5118 and 19/2010 with nursinq, pharmacy and administrative staff, it was acknowledged that not all physicians wrote palliative orders in accordance with approved policies, and that pharmacy and nursing staff did not consistently ask for clarification prior to medication administration to the patient.

A similar example was observed for Patient #2_

The hospital failed to ensure that all departments followed approved policies and procedures related to medication administration to all patients,

8815 WAC 246-320-171 Hospital Performance-Implement & Monitor

Hospitals must:

(1) Have a hospital-wide approach to process design and performance measurement, assessment, and improving patient care services according to RCW 70.41'.200_

(d) Implement and monitor actions taken to improve performance;

ThisWashington Administrative Code is not met as evidenced by:

8265

B 815

7/16/10

ADSA -_ ReSidential Care Services or Department of Health STATE FORM

68""

OSUN11

If continuation sheet 3 of 6

PRINTED; 07/30/2010 FORM APPROVED

State of WashinalOn

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X3) DATE SURVEY COMPLETED

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION ABUILDING

B. WlNG _

C 05/19/2010

000079

STREET ADDRESS, CITY, STATE, ZIP CODE 401 W POPLAR ST

WALLA WALLA, WA 99362

NAME OF PROVIDER OR SUPPLIER

PROVIDENCE ST MARY MEDICAL CENTER

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS·REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5) COMPLETE DATE

(X4) ID PREFIX TAG

10 PREFIX TAG

B 815

B 815 Continued From page 3

Based on review of patient records, review of hospital policy, and staff interview, the hospital failed to ensure that all staff followed approved policies and procedures related to the administration of medications to .patients for 2 of 8 patient records reviewed (Patients #1 and #2).

Failure to implement performance improvement actions on known drug admini'Stration system issues risked patient health and safety.

Findings:

The following policies related to medication administration were reviewed:

1. The patient care policy, "Administration of Medication (#8720.5480 dated 2/2009) under item 12 read, "A valid range order will include a minimum and maximum dose and a maximum frequency."

2. The Pharmacy Department policy, "Medication Orders (#7170.5422 dated 11/08) under item 12 regarding "Titrate Orders-(orders to increase or decrease a drug dose based upon patient response such as morphine drips ... ") read, " ... A valid order includes an initial starting dose, criteria for and amount of incremental increases or decreases, and a maximum dose OR specify 'no limit or no maximum dose' when appropriate,"

Patient #1-Record review evidenced this patient was admitfed on 3/1/2010 in respiratory failure. After determining that palliative comfort care was desired by the patient and family, a physician wrote the following order: "Morphine 1 mg (milligram) IV continuously (after) 2 mg IV bolus. Titrate for comfort and respiratory distress."

There was no specific range, no incremental increases identified, and no maximum dose or 'no

ADSA _.- ReSIdential Care Services or Department of Health STATE FORM

6899

If continuation sheet 4 of 6

OSUN11

PRINTED: 07/30/2010 FORM APPROVED

State of Washinaton

(X3) DATE SURVEY COMPLETED

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NuMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUilDING

B. WlNG~~~~~~~~~_

C 05/19/2010

000079

STREET ADDRESS, CITY, STATE, ZIP CODE 401 W POPLAR ST

WALLA WALLA, WA 99362

NAME OF PROVIDER OR SUPPLIER

PROVIDENCE 5T MARY MEDICAL CENTER

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5) COMPLETE DATE

10 PREFIX TAG

(X4) 10 PREFIX TAG

B 815

B 815 Continued From page 4

limit' specified in the written order as required by hospital mandated pharmacy and patient care procedures.

Pharmacy filled the order without contacting the physician for clarification, and nursing administered the medication without contacting the physician for required parameters of drug management.

Review of the nurses notes evidenced that the morphine drip was initiated at 2 mg/hr and was increased to 60 mg/hr in less than 3 hours. Documentation of the patient's symptoms did not include pain assessments, and only brief descriptions of respiratory effort and heart rate. For example, at 1300 on 3/1/2010 a nursing progress note read, "Face cyanotic, Continues to be (rapid breathing). Morphine drip increased to 20 mg/hr." One and one-half hours later the rate was increased to 50 mg/hr.

Staff interviews on 5118 and 19/2010 confirmed that in palliative or comfort care the amounts, rate and increases of the medication administered to Patient #1 were within normal limits to meet patient comfort needs, Staff agreed that the written order lacked required information for an acceptable range, and maximum dose (or 'no limit') to be in compliance with approved policy and procedure.

In staff interviews on 5/18 and 19/2010 with nursing, pharmacy and administrative staff, it was acknowledged that not all physicians wrote palliative orders in accordance with approved policies, and that pharmacy and nursing staff did not consistently ask for clarification prior to medication administration to the patient:

ADSA -- ReSidential Care Services or Department of Health STATE FORM

If continuation sheet 5 of 6

OSUN11

State of Washinqton

PRINTED: 07/30/2010 FORM APPROVED

STREET ADDRESS, CITY, STATE, ZIP CODE 401 W POPLAR ST

WALLA WALLA, WA 99362

STATEMENT OF DEFICIENCIES AND PlAN OF CORRECTION

(Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. W1NG _

(X3) DATE SURVEY COMPLETED

C 05/19/2010

000079

NAME OF PROVIDER OR SUPPLIER

PROVIDENCE ST MARY MEDICAL CENTER

(X4) 10 PREFIX TAG

The hospital failed to ensure that all departments followed approved policies and procedures related to medication administration to all patients.

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

B 815 Continued From page 5

A similar example was observed for Patient #2.

ADSA - ReSidential Care Services or Department of Health STATE FORM

10 PREFIX TAG

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

B 815

""9S

OSUN11

[XS) COMPLETE DATE

If continuation sheet 6 of 6

COMPLAINT INVESTIGATION FINDINGS

COMPLAINT NUMBER SHELL #

FACILITY:

DATE OF INVESTIGATION:

DATE REPORT WRITTEN:

INVESTIGATOR NAME AND TITLE:

26898 OSUN11

Providence St. Mary Medical Center May 18-19, 2010

May 20, 2010

Marcia Cook MN, MS, RN Complaint Investigator Institutional Nursing Consultant

STATEMENT OF DEFICIENCY: Yes

Based on a contact to the Complaint Hotline on 4/23/2010, a complaint investigation survey was conducted. The complainant was contacted prior to the investigation to clarify and update the information and issues.

ISSUES: The complainant alleged a patient died as a result of an accidental acute morphine overdose (as determined by a forensic pathologist's autopsy).

The allegation of an accidental overdose did not apply to the palliative comfort care patient identified in the complaint, and was not substantiated. However, deficiencies were written at Nursing Services and Quality Assurance related to medication administration.

PROCESS: The investigation process included the following:

1. An entrance conference was held with administrative and nursing staff.

2. The chief nursing officer, who was also the chair of the Ethics Committee was interviewed regarding issues pertinent to the complaint.

3. Interviewed the quality assurance director regarding recall of the case and hospital review. Reviewed Quality Assurance Plan, program and department quality indicators,

4. Reviewed other hospital documentation.

5. Reviewed information (including interviews) and hospital approved policies and procedures covering issues pertinent to the complaint including:

a. Quality Assessment and Performance Improvement -medical director and responsibility for monitoring and evaluation of quality services; timeliness of response to concerns; staff organization to investigate incidents when primary staff person was absent; communication with physicians; timely follow-up, investigations and analysis of incidents; correction and staff training, supervision and monitoring. Reviewed current projects, quality indicators, and priorities.

b. Nursing Services - organization and staffing; care planning; orientation, training and supervision of staff; licensure and competency, supervision of

care; preparation and administration of medications; adherence to Standards of Practice and approved hospital policies and procedures.

6. Interviewed the palliative comfort care ARNP and bedside RN involved in the care of the patient identified in the complaint. Information obtained included criteria and practices ofthe palliative and comfort care program) usual range of medications administered, clarification of orders, physician contacts; employee qualifications; and supervision and monitoring of patient care.

7. Reviewed 10 hospital records (including 8 patients and 2 employee files and the patient identified in the complaint) for evidence of staff adherence to hospital approved policies and procedures) and adherence to Professional Standards of Practice; reviewed patient plans of care, and documentation of medications and treatments provided.

8. Reviewed 2 employee files including the RN and ARNP involved in the care of the patient identified in the complaint for evidence of hiring process and completion of orientation to hospital policies and procedures, validation of skills , and competencies; current licensure, on-going education and training, and Performance Evaluations.

9. Toured medical patient care area.

10. Observed staff interactions with patients and visitors, methodologies to promote and protect patient privacy and safety; infection control and contact isolation procedures; timeliness of answering call lights and patient requests for assistance.

11. Interviewed 3 current patients and 2 family members regarding quality and timeliness.of.nursing.care and interventions.

12. Interviewed the Director of Pharmacy regarding format of physician orders and current hospital policy and procedure for medication orders, parameters, and maximum doses.

13. Reviewed staffing levels.

14. Reviewed Quality Assurance Meeting Minutes and data for 6 months.

CONCLUSION: There were observations of deficient practices identified related to hospital Medicare Certification Code of Federal Regulations 42 CFR 482 and hospital state licensure Chapter 246 - 320 WAC pertinent to this complaint. The allegation (in regard to the alleged intent and result of the treatment rendered) was not substantiated.

ACTION TAKEN: Deficiencies were written at Nursing Services and Quality Assurance related to medication administration.