Beth Israel Deaconess Hospital Plymouth

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 40928 The Hospital was out of compliance for the Condition of Participation for Nursing Services. Findings included: Based on record review and interviews, the Hospital failed to ensure physician orders (medication administration) were followed for one Patient (#1) out of a total sample of ten patients. Cross Reference: 482.23(c) - Standard: Preparation and Administration of Drugs (405)”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State 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: 40928 Based on records reviewed and interviews, the Hospital failed to ensure intravenous (IV) Levophed (a vasoconstrictive medication used to manage low blood pressure) was administered as ordered for 1 Patient (#1) out of a total sample of 10 patients. Findings included: Review of the Hospital policy titled “Medication Use (Ordering, Transcription, and Administration of Medications), revised 1/2024, indicated: -Verify the five rights of medication (right patient, medication, dose, route, and frequency) administration against the electronic medication administration record (e-MAR). -Scan medications and administer, assisting the patient as necessary. -If the medication was omitted, held for parameters or refused, document the reason it was not given on the e-MAR prior to saving. Notify the provider if the patient is refusing the medication. Patient #1 was admitted to the Hospital on 3/11/25 for weakness, difficulty ambulating and abnormal labs. Review of Patient #1 ’ s medical record indicated that on 3/31/25, Patient #1 had a Magnetic resonance cholangiopancreatography (MRCP- an imaging test used to diagnose problems with the liver, pancreas, gallbladder, pancreatic ducts and bile ducts) which identified large volume ascites (a condition in which fluid collects in abdominal spaces), and a mass at the pancreatic tail concerning for primary malignancy with additional hepatic lesions suspected to be metastatic disease burden. On 4/7/25, Patient #1 was observed to have bradycardia (low heart rate) and a rapid response was called. During the rapid response, Patient #1 became pulseless, was not responsive and compressions were started. Patient #1 was intubated and after four rounds of cardiopulmonary resuscitation (CPR), return of spontaneous circulation (ROSC) was achieved. Patient #1 was transferred to the Intensive Care Unit (ICU) and on 4/8/25, Patient #1 ’ s code status was changed to Do Not Attempt Resuscitation (DNAR) with no further escalation of care. On 4/8/25, Patient #1 was ordered to receive continuous intravenous (IV) Norepinephrine (Levophed- a vasoconstrictive medication used to treat life threatening low blood pressure) 8 milligrams (mg)/ 250 milliliters (ml) at a rate of 50.1 ml/hour. Review of Patient #1 ’ s Medication Administration Report (MAR) indicated that on 4/12/25 at 7:37 P.M., Registered Nurse (RN)#1 hung a new 250ml bag of Levophed at a rate of 50.1ml/hour. Further review of Patient #1 ’ s medical record indicated no additional bags of Levophed were administered after the bag at 7:37 P.M. was hung. On 4/13/25 at 1:00 A.M., Patient #1 ’ s blood pressure was 42/16 and his/her pulse was 42. On 4/13/25, at 1:26 A.M., Patient #1 was pronounced dead. During an interview on 5/2/25 at 11:30 A.M., Registered Nurse (RN) #1 said that she cared for Patient #1 during the overnight shift on 4/12/25-4/13/25. RN#1 said that Patient #1 began to decompensate around midnight on 4/13/25 and would have runs of ventricular tachycardia (an abnormal heart rhythm) and then revert to normal sinus rhythm. She said she notified the Nurse Practitioner of this and said another nurse came into Patient #1 ’ s room to assist her during this time. RN #1 said she was in the room with Patient #1 continuously after he/she started to decompensate until Patient #1 expired. She said that she couldn ’ t remember hanging the bag of Levophed or how often the bag was changed during her shift. RN#1 said a 250ml bag would last for about 5 hours at a rate of 50.1 ml/hour. RN#1 said the medical record documentation shows Patient #1 ’ s Levophed bag ran dry, but said she didn ’ t recall the bag running dry while she was in the room. RN#1 said that when an IV bag is hung, the nurse will scan the patient ’ s identification band and then the bag and it will automatically populate in the patient ’ s record with the date and time the medication was hung. RN #1 said medications should be administered as ordered and if a medication isn ’ t administered, it should be documented in the medical record with the reason why it wasn ’ t administered. During an interview on 5/2/25 at 1:28 P.M., the Chief Nursing Officer said that the Hospital investigation into this event was ongoing but indicated that Patient #1 ’ s Levophed would have run dry at 12:36 A.M. on 4/13/25 and that Registered Nurse (RN) #1 did not hang another bag in accordance with physician orders. The Hospital failed to ensure IV Levophed was administered to Patient #1 as ordered.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 43882 The Condition of Participation: Nursing Services Findings included: Based on record review and interviews the Hospital failed to ensure Morphine Sulfate (an opioid pain medication) was administered correctly and per Hospital policy, resulting in an adverse drug event requiring naloxone (a medication used for the emergent treatment of known or suspected over dose) administration for one patient, Patient #10, out of a sample of 10 patients. Cross reference TAG: A-0405.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State 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: 43882 Based on record review and interviews the Hospital failed to ensure Morphine Sulfate (an opioid pain medication) was administered correctly and per Hospital policy, resulting in an adverse drug event requiring naloxone (a medication used for the emergent treatment of known or suspected over dose) administration for one patient, Patient #10, out of a sample of 10 patients. Findings include: The Hospital Policy titled, “Medication Use (Ordering, Transcription and Administration of Medications)”, revision date January 2024 included the following: -All inpatients will have a completed computer-generated Medication Reconciliation Record. -Medication reconciliation must occur when a patient is transferred from one level of care to another. -Verify the five rights of medication, (right patient, medication, dose, route and frequency) administration against the e-MAR. Patient #10 was admitted to the Hospital on 1/30/24 with diagnoses including, dementia, diabetes, hypertension, and a history of falls. Review of Patient #10 ’ s medical record indicated Patient #10 presented to the Hospital ’ s Emergency Department (ED) from an Assisted Living Memory Unity with a concern for increased falls. Medical record further indicated Patient #10 had multiple falls with a head strike and daughter brought Patient #10 into the ED for care. Medical records also indicated Patient #10 was disenrolled from hospice services on 1/30/24 by Patient #10 ’ s daughter, who was requesting workup for traumatic injuries and an evaluation for a Urinary Tract Infection (UTI). A medication reconciliation was completed on admission on 1/30/24 at 4:35 P.M. and included Morphine 20 milligrams (mgs) by mouth (PO) every 4 hours and Lorazepam 0.5 mgs tab PO every 4 hours and indicated medications were obtained from a list from outside facility. A Physician ordered Patient #10 ’ s medication per the medication reconciliation per Hospital protocol. A medication list from the outside facility indicated morphine 20mg/ml concentrate 0.25-0.5 milliliters (mls) orally every 4 hours as needed (PRN) for pain/air hunger. The list also indicated Lorazepam 0.5 mgs tablet PO every 4 hours PRN for anxiety/agitation. Review of Patient #10 ’ s Medication Administration Report indicated on 1/30/24 at 11:47 P.M., Patient # 10 received 20 mgs of Morphine PO and Lorazepam 0.5 mgs. Further review indicated on 1/31/24 at 3:09 A.M., Patient #10 received 20 mgs of Morphine PO. On 1/31/24 at 8:10 A.M., indicated Patient #10 received Naloxone 2 mgs via nostril. Review of the medication/fluid event incident report dated 2/1/24 indicated on 12/30/24 Patient #10 ’ s home medications were updated by a Registered Nurse (RN) #2 and Morphine was entered as 20 mgs PO every 4 hours. The medications were reconciled, ordered, and verified. Two doses of morphine were administered, and the patient required Narcan (an emergency medication used to reverse opioid) on 1/31/24 at 8:47 A.M. The incident report failed to indicate corrective actions were fully investigated or implemented. During an interview on 7/11/24 at 12:01 P.M., Emergency Department (ED) Nurse Manager said the medication error event occurred due to a home medication list that was incorrectly put into the medical record. The ED Nurse Manager recalled Patient #10 ’ s medication error incident but does not have any documentation to support that staff education was implemented following the adverse event. During an interview on 7/11/24 at 2:48 P.M., RN #2 said she input Patient #10 ’ s medications into the electronic medical record incorrectly and said she was new to the process of medication reconciliation. RN #2 said she remembers some discussion about the incident but received no written education/follow up.”