Regulatory ?196146842418 02/04/2019 16:34:53 #22274 none/on MOUNT CARMEL 6150 East Broad Street - Columbus. Ohio 432r3. 574 mounuarmelhnithmam February 4. 2019 Ms. Pamela J. Para Center for Medicare 0 Medicaid Services Non-Long Term Care Certi?cation r. Enforcement Branch 233 North Michigan Avenue Suite 600 Chicago. Illinois 60801 Re: Mount Carmel WM CON: 38-0035 res Wilt Strut Ohio 43222 Dear Ms. Para: Enclosed is the Plan of Correction addressing the deficiencies cited under Hospitd Conditions of Participation 42 CFR 402.25 Phannaceullml Services based on the survey conducted by the Ohio Depertrnenl of Health on Janua'y 10. 2019. Thank you reviewiig the attached information. if you have any questions or need additional please contact me via phone or email. max @25? Cheryl Wolfe. Regions Director Regulatory Services a Patient Safety Risk Management Mount Carmel Health System 6150 East Broad Street Columbus. Ohio 43213 Phone: 614?546-4034 Fax: 614-546-3281 Email: madam Enclosure: Signed 2567 Form Plan of Correction Policy: Automated Dispensing System-Medication Overrides - Attachment A Policy: Pharmacist Documentation and Escalation Process - Attachment 3 Policy: Palliative Venillaior? Attachment Policy: Medication Ordera- Attachment High Reliablity Organ'nalion Education Attachment CC: Ohio Department of Health Regulatory T0961 46642418 02/04/2010 10:35:08 #22274 FaxServer 1/30/2019 1:54:34 PM PAGE 2/022 Fax Server PENTED: mm DEMTMENT I-IEALTHAND HUMAN SERVIGEB FORM mg CENTERS FOR MEDICARE I HEDIEAJD SERVICES 0? 0:101 swimmer ?new? my ?mum on} mm: mm mu mumv mama! 0mm 0!"!me mil Alumna com I 3500? ommw 0F my: on mm manual-acmmam aim: MINT WEST NI communism 43:22 am ID am sum"! as airman mamas mm m. mm mu must-Internalnmuwmwnun m3 mammw-tmm 0E nun?) A000 INITIAL COMMENTS A000 an" Substantial Allocation ?102135 On 01109 II 3:45 RM. Immune. mime was um. Du'Inglhe Mammal-gallon Iuww Ilwu WIN In: facilIIy falud to 9mm! Manama ul' "Oamm "mus Swlam (CNS) such all Med. ?u?ld. and WHO-1119 m: mum hopudy on01117m It 2:56 M. Dn01i10'10at apptuxlmalely 3 10 PM .Inull numeral!? was II mu: IIme the Mm milled Ina Immodlamoopardym nrgolng. Thu de?ciencies are hand on ma manual-NW ?100102135 com on raqulmnaml found at 42 How. A409 Quinlan at 80 A420 aFR(a) 402.25 540225 Condllionu?l Parllahll?on The mum ml hm plummiw services mouth. mdto?hep?lmts. The mama-mum I wished pram: er I my Home area unlar umpaIanI "magma! TITLE mm uln- "mun-mm Muhammwu ill-mm Ema-punt nmmuM-m-Mumm?u ?any. Mnmqumrm arm-mammalian nun? own 'r-nyu cm I "mm .3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE IF. MEDICAID SERVICES PRINTED: 02l11l2019 FORM APPROVED OMB NO. 0933-0391 STATEIENT OF DEFICIHHCIES (X1) PROVIDERJSUPPLIERICLIA All) PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DIATE SURVEY COMPLE 01 I1 $2019 0(2) WLTIPLE CONSTRUCTION A. BUILDING B. WING OF PROVIDER OR SUPPLIER MOUNT CARMEL WEST STREET ADDRESS. CITY. STATE. ZIP CODE 10: WEST STATE STREET COLUMBUS, OH 43222 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY INST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG In PROVIDERS PLAN OF CORRECTION PREFIX (EACH CORECTNE ACTION SHOULD BE TAG CROSS-REFERENCEDTOTHE APPROPRIATE DEFICIENCY) A489 Continued From page 1 medical staff IS responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital's organized pharmaceutical service. This CONDITION is not met as evidenced by: Based on Interview and record review. the hospital failed to ensure a system was in place to monitor and prevent large doses of central nervous system (CNS) medications from being accessed from the automated medication dispensing system (AMDS) by overriding the warnings and prior approval from the pharmacist. This affected 27 (Patients #10, #11. #12. #13. #14. #15. #16. #17. #18. #19. #20. #21. #22. #23. #24. #25. #26 and #27) of 27 patient records reviewed. (A491) The failure to prevent patients from receiving a large dose of CNS medications resulted in a deten'ninatlon of Immediate Jeopardy. The facility census was 186. PHARMACY ADMINISTRATION 482.25(a) [?482.25 Condition of Participation: Pharmaceutical Services A 491 policies and procedures that minimize drug errors. This function may be delegated to the hospital's organized pharmaceutical service.] ?482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. The medical staff is responsible for developing A489 A491 FORM Versions EM ID: CPRV11 Facility ID: OHM If continuation sheet Page 2 of 18 PRINTED: 02111I2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE a MEDICAID SERVICES ND. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE AND PLAN OF IDENTIFICATION LUMBER: A. 3.,me CONFLETED 300035 am Bl2ti19 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. crrY. STATE. ZIP com um WEET TSSWEST STATE MOUNT EL COLUMBUS. OH 43222 0:4) In SUMMARY STATEMENTOF In PROVIDERS PLANOF CORRECTION as; PREFIX (EACH MUST BE PRECEDED BY FULL (EACH SHOULD BE comm" m; REGULATORY IDENTIFYING INFORMATION) TAO APPROPRIATE DATE DEFICIENCY) A491 Continued From page 2 A491 This STANDARD is not met as evidenced by: Based on interview and record review. the monitor and prevent large doses of central nervous system (CNS) medications from being accessed from the automated medication dispensing system (AMDS) by overriding the This affected 27 (Patients #10. #11. #12. #13. #14. #15. #16. and #27) of 27 patient records reviewed. This deficient practice had the potential to a?ect all patients receiving services at the facility. The facility census was 186. Findings include: 1. Review Of a document titled "High Risk CNS Med ications". last updated 1 2114/1 8. stated the usual adult dose of Fentanyl was 25 to 100 (micrograms); Dilaudld was one half to four mg (milligrams); and Versed. one half to four mg. 2. Review of the AMDS ?override report". undated. provided by Pharmacist on 01118119. revealed 24 of the 27 patients identi?ed had medications dispensed from the AMDS machine with the override function being used. 3. Review of the "Palliative Ventilator Withdrawal-PowerPlan Medication Reference Document". updated 12(14118. used by the Morphine ?ve to ten mg Intravenous (IV) push once. Dilaudld one half to two mg IV push every and Versed two mg IV push once as soon as possible. Fentanyl was not listed on this hospital failed to ensure a system was in place to warnings and prior approval from the pharrnaclst. #17. #18. #19. #20. #21. #22. #23. #24. #25. #26 pharmacy revealed the dosage ranges consist of 15 minutes when needed for shortness Of breath. i' Previous mt. Event MW ID: OHO2828 If continuation sheet Page 3 of 18 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 81 MEDICAID SERVICES PRINTED: 021112019 FORM APPROVED DMD NO. 0938-0391 STATEMENT OF DEFICIEIIDIES (X1) PROVIDERISUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (x2) MULTIPLE coNsTnucTIoN 013) DATE SURVEY A. BUILDING mm- o1I1slzo1s OF PROVIDER OR SUPPLIER MOUNT CARMEL WEST STEET ADDRESS. CITY. STATE. ZIP CODE 793 WEST STATE STREET COLUMBUS. OH 43222 (X4) ID SUIMIIARY STATEMENTOF mam (EACH must as PREGEDED av Fuu. m3 REGULATORYORLSO IDENTIFYING INFORMATION) ID PROVIDERS PLAN OF CORRECTION (X5) PREFIX (EACH OORREGTIVE ACTION SHOULD BE COMPLETION TAG GROSS-REFERENOEDTO THEAPPROPRIATE DEFICIENCY) A 491 Continued From page 3 A 491 document as a medication to use for palliative ventilator withdrawal. 4. Review of the facility policy titled ?Physician Orders" revealed verbal or telephone orders are to be limited and restricted to: a. emergent situations b. When clinical situations make it Impractical for orders to be entered into the Electronic Health Record (EHR) or written on the appropriate form for the non-EHR cites. c. Situations when physicians do not have access to remote computer devices or the patient's chart. 5. Review of the facility palliative care titled "Palliative Ventilator Withdrawal". dated 05126117. stated "palliative ventilatory withdrawal Is the provision of comfort measures for a seriously ill patient for whom continuing mechanical ventilation has been determined to be clinically inappropriate or unwanted by the patient." Under ?Implementation of Management Medication orders? it stated management medications will be ordered as medically indica 6. During Interview on 01/16/19 at 4:10 P.M.. Physician stated there was no current 'lock out" on the AMDS machine to prevent sta? from continuing to override the system to obtain medications. 7. During interview on 01l17l19 at 3:15 P.M.. PharmacistA (chief pharmacy of?cer) was unable to offer any infon'natlon explaining how sta? had OMS-MM) Versions MID EM ID: CPRV11 Futility I3: Ol-m If continuation sheet Page 4 of 18 PRINTED: 02111I2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8 MEDICAID SERVICES OMB ND. 0935-0391 5 TATEMENT OF DEFICIENCIEs (x1) (x2) MULTIPLE CONSTRUCTION 1X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER- A Bumm COMPLETED 300035 B. WING 0111812019 NAME OF PROVIDERORSUPPLIER CITY. CODE 798 WEST STATE STREET "mum WEST COLUMBUS, OH 43222 (x4) In sum STATEMENT OF DEFICIENCIEs In PROVIDERS PLAN OF CORRECTION mi) (EACH DEFICIENCY MUST BE PRECEDED DY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE common ma REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE WE DEFICIENCY) A 491 Continued From page 4 A 491 been able to override the AMDS system for a long period of time to obtain high doses of CNS medications with no pharmacy approval or intervention. 8. Review of the medical record for Patient #1 revealed the patient presented to the facility on 09110118 with Increasing shortness of breath. Review of Physician A's progress note. dated 09118118 at 2:54 A.M., revealed Physician A was called to Patient #1 's bedside by nursing staff for code status discussion. Patient #1 stated am done and don't want to suffer anymore?. Physician A explained the Options of aggressive treatment versus comfort measures. Patient #1 clearly stated that he did not want to suffer and wanted to be comfortable. On 09118118 at 4:04 AM, Physician A gave a verbal order for Dilaudld four mg IV push. which was administered at 4:04 AM. A second verbal order was received for Dilaudld six mg IV push, which was administered at 4:33 AM. Physician A pronounced Patient #1 dead at 5:00 AM. 9. Review of the medical record for Patient #2 revealed the patient presented to the facility with generalized weakness and confusion on 11125117. A physician note dated 12111117 at 2:48 AM. revealed a "code blue"(cardiac1respiratory emergency) was called; Patient #2 was intubated at that time. placed on a ventilator and transferred to the Intensive care unit (ICU). Review of Physician A's progress note. dated 12111117 at 4:17 AM. revealed Patient #2 was readmitted to the ICU for cardiac arrest and was Intubated during a code blue. Physician A documented the patient's family was updated at the bedside regarding events and decided to withdraw care. At 5:10 AM. Physician A gave a verbal order for FURM 0318-2567(02-99) Previous Versions Obsolete Event ID: GPIW11 Facility ID: 0m If continuation sheet Page 5 of 18 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 0211112019 FORM APPROVED OMB ND. 0938-0391 Fentanyl 1.000 IV push. The order was veri?ed by the pharmacist at 5:14 AM. This medication was dispensed from the AMDS via override and administered at 5:45 AM. Patient #2 was pronounced dead by Physician A at 6:03 AM. There was no documentation in the medical record stating when Patient #2 was removed from the ventilator. 10. Review Of the medical record for Patient #3 revealed the patient presented to the facility on 03111117 with altered mental status. Review Of a physician progress note dated 03111117 at 1:02 PM. revealed Patient #3 was lntubated in the emergency room with agonal breathing. Physician A's progress note. dated 03111117 at 10:58 P.M., revealed a meeting was held at the bedside with the the patient's family and the family wished to withdraw care. Physician A entered an order for Fentanyl 400 mog IV push for agitation on 03111117 at 10:13 PM. The order was veri?ed by the pharmacist at 10:18 PM. The medication was dispensed from the AMDS and administered at 10:36 PM. The physician stated all blood pressure medications were stopped. the patient was extubated and died at 10:50 PM. 11. Review of the medical record for Patient #4 revealed the patient presented to the facility on 07118116 at 6:06 PM. for cardiac arrest at a long term care facility and was lntubated in the ?eld. The nursing progress note dated 07125116 at 8:05 PM. revealed PhysicianAspoke to the spouse of Patient #4 over the phone about changing the patient's code status to do not resuscitate. A physician progress note dated 07125116 at 10:11 PM. revealed at 9:45 PM.. the patient's spouse made the decision to extubate the patient. At 9:46 AM. Physician A gave a verbal order for STATEMENT OF (x1) (x2) MULTIPLE consTRucTION (x3) DATE SURVEY AND PLAN OF OORREOTION IDENTIFIOATION NUABER- OOIIPLETED A. BUILDING 0 360035 a. WING 0111 812019 NAME OF PROVIDER OR crrv. as wear EL WE mum ?In? 5T cOLuueus. OH 43222 (x4) .9 suummr OF ID PROVIDER-s PLAN OF {are} mam (EAOI-I BE PREOEDEO av FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE m" m; IDENTIFYING INFORMATION) TAG To THE APPROPRIATE WE DEFIOIENOT) A491 Continued From page 5 A491 Event ID: CPRV11 ID: If continuation sheet Page 6 of 13 PRINTED: 0211112019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0936-0391 a OF DEFICIENCIES (x1) PROVIDERISUPPLIERIOLIA (x2) MILTIPLE CONSTRUCTION (x3) DATE SURVEY A ND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BULDING COMETED 350035 e. WING 0111612019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. CODE 793 WEST STATE STREET MOUNT CARMEL WEST COLUMBUS. OH 43222 (x4) In SUMMARY STATEMENTOF DEFICIENCIES ID PROVIDERS PLANOFCORRECRON 0:5) mm (EACH DEFICIENCYMUST BE PRECEDED (EACH CORRECTIVE ACTION common m3 RECULATORYORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCEDTOTHE APPROPRIATE WE DEFICIENCY) A 491 Continued From page 6 A 491 Fentanyl 400 IV push. The AMDS system was overridden and the Fentanyl was administered at 9:46 PM. At 9:47 P.M.. Patient #4 was extubated. At 9:50 P.M., medication to support blood pressure was stopped. Patient #4 was pronounced dead at 10:06 PM. 12. Review of the medical record for Patient #5 revealed the patient presented to the facility on 02110115 for septic shock. Review of Physician A's progress note dated 02111115 at 2:32 AM. revealed Physician A explained the grave situation to Patient #4's family members. and after considering all options. the patient's family decided on ?palliative ventilator withdrawal". Physician A ordered Fentanyl 400 IV push and Versed 4 mg IV push at 12:41 AM. These orders were veri?ed by a pharmacist at 12:42 AM. The medications were dispensned from the AMDS vla override and given at 1:05 AM. Patient #4 was pronounced dead at 1:07 AM. 13. Review of the medical record for Patient #6 revealed the patient presented to the facility on 04122115 for a seizure. A physician progress note dated 05110115 revealed the patient's family decided to withdraw care. 0n 05110115 at 11 :23 RM. Physician A ordered Fentanyl 1,000 IV push. The AMDS system was overridden and the medication was dispensed at 11:24 PM. The pharmacy veri?ed the order at 11 :24 PM. stating the medication was compliant with standard tmatment. The Fentanyl was administered at 11 :32 PM. Medications to support blood pressure were stopped and the patient was extubated. Patient #6 was pronounced dead at 11 :40 PM. 14. Review of the medical record for Patient #7 revealed the patient presented to the facility on I OHM Previous Versions Obsolete Event ID: CPRV11 ID: If continuation sheet Page 7 of 16 PRINTED: 0211112019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED FOR MEDICARE a. MEDICAID SERVICES OMB NO. mass-0391 STATELENT OF DEFICIENCIES 0(1) PROVIDERISUPPLIERIOLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION WMBER: A. BUILDING COWLETED 300035 0111312019 NAME OF PROVIDER OR SUPPLIER E: REET ADDRESS CITY STATE. 2m CODE 783 WEST STATE STREET nounr CARMEL was-r comnaus. on 4322: on) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION {x5} PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SI-IOLLD BE OOH-HIGH TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCES TO THE APPROPRIATE DATE DEFICIENCY) A491 Continued From page 7 A491 04130115 for progressive weakness followed by a fall. A nursing progress note dated 05104115 stated that at 11 :28 PM, Patient 114's cardiac monitor showed asystole (absence of a heartbeat). At that time. Patient #4 was given DIIaudId 0.5 mg IV push for comfort. Patient #4 still had agonal breathing at which point Physician Aordered Fentanyi 500 IV push. On 05103115 at 11 :57 PM. a telephone order for Fentanyi 500 IV push was placed. The medication was dispensed via override and given at 11:57 PM. The order was veri?ed bya pharmacist at 11:59 PM. The patients family arrived at 12:05 AM. Physician A ordered Fentanyi 400 IV push due to agonai breathing. 0n 05104115 at 12:10 AM. a telephone order for Fentanyi 400 mog IV push was placed. The medication was dispensed via override and administered at 12:10 AM. The order was veri?ed by a pharmacist at 12:22 AM. Patient #4 was pronounced dead by Physician A at 12:30 AM. 15. Review of the medical record for Patient #8 revealed the patient presented to the facility on 02128115 with a change in mental status. The patient was diagnosed with a muItI-embolic stroke with brain stem involvement. While In the emergency room. Patient #8 went into respiratory arrest and was intubated. Physician A's progress 'note dated 03101115 at 12:47 AM. stated the family wished to pursue ?palliative ventilator withdrawal". The patient had a physician order dated 03101115 at 12:11 AM. for Fentanyi 800 push. The AMDS system was overridden and the medication was administered at 12:11 AM. The patient was extubated at 12:11 AM. and Patient #8 was pronounced dead at 12:42 AM. The pharmacy veri?ed the order at 1:19 FORM Pmlous Version! Event ID: OPRV11 Facility I3: 01102828 If continuation sheet Page 8 of 18 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: FORM APPROVED 0MB ND. [1933-0391 OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 300035 3- WING 0111312019 .NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 79: WEST STATE STREET NT RME ou GA COLUMBUS. OH 43222 (x4) In SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION INTI mam (EACH DEFICIENCY MUST BE PRECEDED SY FULL (EACH CORRECTIVE ACTION SHOULD BE coma-ION m; REGULATORY ORLSC IDENTIFYING INFORMATION) TAO CROSS-REFERENCEDTOTHE APPROPRIATE DATE DEFICIENCY) A491 Continued From page 8 A491 AM. 16. Review of the medical record for Patient #9 revealed the patient presented to the facility on 09/3011 7 for suspected chronic heart failure and had been intubated in the ICU that same day. On 101091171t 8:24 P.M., a telephone order from Physician A was obtained for Fentanyl 1.000 ng. A pharmacy note stated Physician A entered an order for 1.000 mog of Fentanyl IV push for a morbidly obese patient that had been on high dose narcotic drips on whom care was being withdrawn. The pharmacist discussed with Physician A that Fentanyl was on shortage and recommended a dose of 500 mog. The physician agreed. The nursing note stated the patient was taken off the ventilator on 10109117 at 9:00 PM. with the patient's family at the bedside. Fentanyl 500 mog was dispensed from the AMDS system via override and given at 9:03 PM. Physician A's progress note documented Patient #9 died at 9:10 PM. 17. Review of the medical record for Patient #10 revealed the patient presented to the facility on 10I02117 due to a coughing spell that lead to ?nding of probable bronchogeniC cancer. The discharge summary documented the patient had a liver bIOpsy done on 10I0911 7. Shortly after the biopsy. the patient developed a small hematoma. In a few hours. the patient's blood pressure dropped and the patient went into cardiac arrest. Patient #10 was intubated and transferred to the ICU. 0n 01(09117 at 10:22 PM. a telephone order was plaCed for Fentanyl 500 IV push and Versed four mg IV push. The nursing progress note documented the patient was removed from the ventilator at 11 :20 PM. Review of the medication administration reoord FORM VISION Event ID: CPRV11 ID: OH02828 If continuation sheet Page 9 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES FOR MEDICARE 3. MEDICAID SERVICES PRINTED: 0211112019 FORM APPROVED OMB NO. STATEIUENTOF (x1) AND PLAN OF IDENTIFICATION man.- (xa) MULTIPLE A. BUILDING (X3) DATE SURVEY COMPLET- B. WING 01I1 812018 OF PROVIDER OR SUPPLIER MOUNT CARMEL WEST STREET ADDRESS. CITY. STATE. ZIP CODE 793 WEST STREET COLUMBUS. OH 43222 on) In sum OF mm (EAOI-I MUST BE PREOEDED av FULL m3 REOIMTORY OR IDENTIFYING INFORMATION) ID PROVIDERS PLAN OF CORRECTION In) PREFIX (EACH CORRECTIVE ACTION SHOILD BE TAO CROSS-REFERENCE) TO THE APPROPRIATE WE DEFICIENCY) A 491 Continued From page 9 revealed both medications were dispensed from via override and at 11 :34 PM. Review of the physician progress note revealed the patient died at 11 :34 PM. 18. Review of the medical record for Patient #11 revealed the patient presented to the facility on 10108117 due to acute brain swelling and respiratory failure. The patient required emergency intubation. On 10111I17 at 4:01 AM. a verbal order was obtained for Fentanyl 500 IV push. At 4:02 A.M.. the AMDS system was overridden and the Fentanyl was dispensed. On 10711117 at 4:05 AM. Versed six mg was dispensed from the AMDS system via override. The physician didn't enter the order until 4:11 AM. The medication administration record documented the Versed was administered at 4:11 AM. and the Fentanyl was administered at 4:12 AM. Patient #11 was extubated at 4:12 AM. and was pronounced dead at 4:19 AM. 19. Review of the medical record for Patient #12 revealed the patient presented to the facility on 11112118 due to sepsis. 0n 11120117 at 8:13 PM., a physician 11 order for Fentanyl 500 IV push was entered Into the system. The order was veri?ed by the pharmacy at 8:22 PM. and dispensed from the AMDS system at 8:23 PM. The medication administration record documented the medication was given at 8:28 PM. The patient was extubated at 8:34 PM. Patient #12 died at 10:40 PM. 20. Review of the medical record for Patient #13 revealed the patient presented to the facility on 120511? at 12:15 PM. due to unresponsiveness related to having low blood pressure. In the emergency room. Patient #13 was Intubated and A 491 FORM W) Pm Versions MIDI. Event ID: CPRV11 D: OH02B28 lfoonilnua?on sheet Page 10 of 1S DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 3- MEDICAID SERVICES PRINTED: 02I1112019 FORM APPROVED OMB ND. 09343-0391 a OF DEFICIENCIES (x1) PROVIDERSUPPLIERICLIA (x2) MULTIPLE (x3) DATE SURVEY A ND PLAN OF CORRECTION IDENTIFICATION NUIIBER: A. BUILDING COMPLETED 6 330035 e. WING 01" 812019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. crIY. STATE. 793 WEST STATE STREET MOU GARM NT EL WEST COLUMBUS. OH 43222 (x4) In SUMMARY STATEMENT OF DEFICIENCIEs In PROVIDER-s PLANOF CORRECTION {x91 anFIx (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE common m; REGULATORY OR INFORMATION) TAO CROSS-REFERENCEDTOTI-IE APPROPRIATE DATE DEFICIENCY) A 491 Continued From page 10 A 491 placed on a ventilator. On 120517 at 9:23 PM.. a physician order for Fentanyl 1.000 mog IV push was entered and at 9:40 PM. an order for Dilaudld 2 mg IV push was entered. At 9:40 PM. a verbal order for Versed four mg IV push was entered. Fentanyl 1.000 was dispensed from the AMDS with override at 9:27 Dilaudid 2 mg was dispensed with override at 9:35 and Versed was dispensed with override at 9:34 PM. The medication administration record documented the Fentanyl was administered to the patient at 9:37 PM. Patient #13 was extubated at 9:39 PM. Dilaudid and Versed were administered at 9:40 PM. Physician A's progress note revealed Patient #13 was pronounced dead at 9:41 PM. 21. Review of the medical record for Patient #14 revealed the patient presented to the facility on 1210/17 at 5:47 PM. due to altered mental status related to a history of cancer. Physician A's progress note dated 12110"? at 8:52 PM. stated that the decision to intubate was made to hyperventilate Patient #14 to com pensate for extreme acid base Imbalance of the blood. Physician A's progress note dated 12110I1 7 at 11:11 PM. stated the patient's grim prognosis was discussed with the family at the bedside and the family agreed to withdraw care. Review of the physician orders revealed telephone phone orders entered by nursing staff on 12110117 at 10:34 PM. for Fentanyl 500 and Versed four mg lC push. The medications were dispensed from the AMDS system with override at 10:12 PM. The medication administration record documented the Fentanyl was administered at 10:36 PM. and the Versed was administered at 10:36 PM. Patient #14 was pronounced dead at 10:41 PM. There was no documentation in the Previous Willem Oblolell Event ID: CPRV11 Facility ID: m5 If continuation sheet Page 11 of 13 PRINTED: 0211112019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FDR MEDICARE MEDICAID OMB ND. 0938-0391 STATEIIENT OF (x1) PROVIDENSUPPLIERIOLIA (x2) MULTIPLE (x3) DATE AND PLAN OF IDENTIFIOATION NUMBER: A .30an OOMPLETED 380085 3- WING 0111312019 NAME OF PROVIDER OR SUPPLIER ADDRESS. crn'. STATE. mm 793 WEST STATE STREET mum OH 4322: (M) In STATEMENT OF ID PROVIDERS PLAN OF OORREOTION (st mam (EACH MUST BE BY FULL PREFIX (EACH OORREOTNE ACTION SHOULD BE com me IDENTIFYING CROSS-REFERENOEDTOTHE APPROPRIATE DATE DEFICIENCY) A 491 Continued From page 11 A 491 medical record stating when the patient was extubated and taken off the ventilator. 22. Review of the medical record for Patient #15 revealed the patient presented to the facility on 11115118 due to difficulty breathing. 0n 11119118. the patient was transferred to the ICU for further monitoring. On 11120118 at 8:11 P.M.. the patient was intubated and placed on a ventilator. The nursing progress note dated 11120118 at 11 :15 PM. documented the patient's family requested "palliative ventilator withdrawal" at 11 :48 PM. Fentanyi 1.000 was dispensed from the AMDS via override at 11 :28 PM. and 11:30 PM. and Versed 10 mg had been dispensed via override at 11 :29 PM. Review of the physician orders revealed orders at 11 :48 PM. for Fentanyi 2.000 IV push and Versed 10 mg. The medication administration record documented Fentanyi 2.000 IV push was administered at 11 :48 PM. and Versed 10 mg IV push was administered at 11 :49 PM. Patient #15 was pronounced dead at 11:53 PM. There was no documentation in the medical record stating when the patient was extubated and taken off the ventilator. 23. Review of the medical record for Patient #18 revealed the patient presented tothe facility on 11113118 due to inmased dif?culty breathing. After a cardiac catheterization on 11115118. the patient developed an enlarging right groin blood clot. The patient was transferred to the and intubated on 11118118 related to low blood oxygen levels. Review of the phwiclan orders revealed on 11119118 at 12:54 A.M.. Physician A ordered Fentanyi 1.000 and Versed 10 mg iV push. The Fentanyi was dispensed from the AMDS at 12:55 AM. and the Versed was dispensed at FORM Previous Versions Obsolete Event ID: CPRV11 Facility in: 0mm If continuation Sheet Page 12 of 18 PRINTED: 02/11/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8 MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION A BUILDING COWLETED 300035 5- 01/18/2019 NAME OF PROVIDER OR SUPPLIER ADDRESS STATE. EDGE 793 WEST STATE STREET MOUNT CARMEL WEST COLUMBUS. OH 43222 on) In SUMMARY STATEMENT OF DEFICIENCIES In PROVIDERS PLANOF CORRECTION 9:5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE common m; REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCEDTOTHE APPROPRIATE WE DEFICIENCY) A 491 Continued From page 12 A 491 12:58 PM. both via override. The medication administration record documented both the Fentanyl and the Versed were administered at 1:32 AM. Physician A's progress note, dated 11/19/18 at 1:51 A.M.. revealed the patient's and provide comfort care. There was no the patient was extubated and taken off the ventilator. 1000 was dispensed from the AMDS at 10:40 P.M.. both via override. prior to the physician order. On 11/13/18 at 10:57 RM. and at 10:58 P.M.. ordered Versed 10 mg IV push. The medication administration record documented the Fentanyl was administered at 11 :20 PM. by Physician A. patient was transferred to ICU. intubated and placed on a ventilator. On 05/28/18 at 10:59 PM. Fentanyl 1,000 mag and Versed six mg to the physician order. On 05/28/18 at 11:20 1:26 AM. Patient #18 was pronounced dead at family was called to the bedside to discuss the patient's condition and agreed to not resuscitate documentation in the medical record stating when 24. Review of the medical record for Patient #17 revealed the patient presented to the facility on 11/10/18 due to cardiac arrest. The patient was intubated with increasing seizure activity. Nursing progress notes stated Patient #17 was extubated on 11/13/18 at 4:42 PM. On 11/13/18. Fentanyl 10:39 PM. and Versed 10 mg was dispensed at Physician A ordered Fentanyl 1.000 lV push 10:57 PM. and the Versed was administered at 10:58 PM. Patient #17 was pronounced dead at 25. Review of the medical record for Patient #18 revealed the patient presented to the facility on 05/24/18 due to septic Shock. On 05/28/18. the were dispensed from the AMDS via override. prior FDRM Previous Versions Obsolete Event ID: CPRV11 ID: If continuation sheet Page 13 of 18 PRINTED: 02l11l2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED FOR MEDIDARE MEDICAID SERVICES OMB No. crass-0391 STATEMENT OF DEFICIENCIES (XI) (X2) WLTIPLE CONSTRUCTION (X3) DATE SUWEY AND PLAN OF CORRECTION IDENTIFICATION MJMSER: A. 3 ?me COMPLETED saunas mm 0111mm NAME OF PROVIDER OR SUPPLIER ST ADDRESS. CITY. STATE. ZIP CODE WEST STATE STREET Gowns? OH 4322: (X4) ID sum STATEMENT OF DEFICIENCII ID PROVIDERS PLAN OF CORRECTION (XI) (EACH DEFICIENCY WST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE ME DEFICIENCY) A491 Continued From page 13 A491 PM.. the physician ordered Fentanyl 1.000 and Versed six mg IV push. The medication administration record revealed the Fentanyl 1.000 and the Versed 6 mg were administered on 05128118 at 11 :20 PM. Patient #18 was pronounced dead by Physician A at 11 :40 PM. There was no documentation In the medical record stating when the patient was extubated and taken off the ventilator. 26. Review of the medical record for Patient #19 revealed the patient presented to the facility on 041021? at 2:54 AM. due to cardiac arrest. Patient #19 was Intubated before arriving In the ICU. Fentanyl 2.000 was dispensed from the MOS via override; 20 vials were removed at 10:44 P.M.. ?ve vials removed at 11:02 PM. three vials were removed at 11 :03 PM. and four vials were removed at 11:05 PM. Versed 2 mg was dispensed from the AMDS vla override: ?ve vials at 10:45 PM. and ?ve more vials at 11 :02 PM. Dilaudld 10 mg dosages were dispensed from the AMDS via override. one at 10:45 PM. and one at 11:02 PM. Review of the physician orders revealed two orders for Fentanyl 1.000 IV push. one at 10:53 PM. and one at 11 :15 Dilaudid 10 mg IV push were ordered. one at 10:53 PM. and one at 11:15 P.M.: and two orders for Versed 10 mg IV push. one at 10:53 PM. and 11:15 PM. The medication administratIDn record documented Fentanyl was administered at 10:57 PM. and 11 :16 RM: Dilaudid was administered at 10:57 PM. and 11:16 PM: and Versed 10 mg IV push was administered at 10:57 PM. and 11 :10 PM. Patient #19 was pronounced dead by PhysicianAat 11:30 PM. There was no documentation In the medical record stating when the patient was extubated and taken off the ventilator. Pm thlunl Obsolete Event Facility ID: om If continuation sheet Page 14 of 13 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 02/112019 FORM APPROVED 0M5 N0. mass?0391 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIEWCLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED 0111812019 CONSTRUCTION A. BUILDING B. WING NAME OF PROVIDER on SUPPLIER MOUNT CARMEL WEST STREET ADDRESS. crrv. STATE. ZIP com 193 WEST STATE STREET COLUMBUS. OH 43222 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY INST 8E PRECEDED BY TAG REGULATORY OR LSC ID PROVIDERS PLAN OF CORRECTION PREFIX (EACH CORRECT NE ACTION SHOLID BE TAG TO THE APPROPRIATE DEFICIENCY) A 491 Continued From page 14 revealed the patient presented to the facility on drug abuse. Patient #20 was lntubated before an'iving In the ICU. Review of Physician A's progress note revealed overnight Patient #20 remained on maximal doses of medication to at the bedside and decided to withdraw treatment. Fentanyl 800 was dispensed from the AMDS at 2:34 AM. and 200 was dispensed at 2:35 AM. override: Versed 10 mg was dispensed at 2:33 AM. and 2:52 AM. via override; and Dilaudid 10 mg was dispensed at 2:54 AM. vla override. prior to the physician order. Review of the physician orders revealed Fentanyl 1.000 lV push was ordered on 10124118 at 3:00 AM. Dilaudid 10 mg iv push was ordered at 3:05 AM. and two doses of and 3:23 AM. The medication administration and the second dose of Versed was administered at 3:05 AM. Patient #20 was pronounced dead at 3:13 AM. There was no the patient was extubated and taken off the ventilator. revealed the patient presented to the facility on 09130118 at 9:04 PM. due to a collapsed lung. 11:10 P.M.. the physician ordered Fentanyl 600 IV push and Versed six mg IV push. Both these dosages of medications were dispensed 27. Review of the medical record for Patient #20 10122118 due to altered mental status related to sustain blood pressure. The family was updated Versed 10 mg IV push was ordered at 3:00 AM. record revealed Fentanyl and one dose of Versed were administered at 3:00 Dilaudid at 3:05 documentation in the medical record stating when 28. Review of the medical record for Patient #21 The patient was lntubated and chest tubes were placed in the emergency room. On 09130118 at A 491 FFIRM cMs-zsa'rroz-sn) Previous 0mm Event ID: CPRV11 Facility ID: 0H02828 If continuation sheet Page 15 of 18 PRINTED: 0211112019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8 MEQCAID SERVICES OMB N0. 0938-0391 STATEMENT OF DEFICIENCIES (x2) MULTIPLE OONSTRUOTION 0(3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFIOATION NUIIBER- A BUILDING COMETED 380035 B. WING 0111812019 NAME OF PROVIDER OR SUPPLIER ADDRESS. crrY. STATE. 793 WEST STATE STREET MOUNT CARMEL WEST COLUMBUS. OH 43222 (X4) iD SUMMARY STATEIENT OF ID PROVIDERS PLAN OF pm Ian-am (EACH PRECEDED BYFULL PREFIX (EACH CORRECTIVE SHOULD BE comm m3 REGULATORY OR IDENTIFYING INFORMATION) TAG WE A 491 Continued From page 15 A 491 from the AMDS with override at 11 :12 PM. The medication administration record documented both medications were administered at 11 :22 RM. The patient was extubated and taken olf the ventilator at at 11 :30 PM. Patient #21 was pronounced dead at 11 :53 AM. 29. Review of the medical record for Patient #22 revealed the patient presented to the facility on 09117118 due to abdominal pain and fevers. The patient suffered a cardiac arrest on 09125118. was intubated and put on a ventilator. Review of the physician orders revealed Fentanyl 500 IV push and Versed six mg iV push was ordered on 09125118 at 8:00 PM. Both dosages of these medications were dispensed by the AMDS system via override at 8:02 PM. The medication administration record documented both medications were administered at 8:25 PM. Patient #22 was pronounced dead at 9:25 PM. by Physician A. There was no documentation in the medical record stating when the patient was extubated and taken off the ventilator. 30. Review of the medical record for Patient #23 revealed the patient presented to the facility on 07115118 time due to cardiac arrest. The patient was intubated before arriving in the Review of the physician orders revealed Fentanyl 1.000 IV push was ordered on 07115118 at 1:25 AM. Fentanyl was dispensed from the AMDS system via override at 1:17 AM. The medication administration record revealed the medication was administered at 1:25 AM. Patient #23 was pronounced dead at 1:28 AM. by Physician A. There was no documentation in the medical record stating when the patient was extubated and taken off the ventilator. FORM Gus-25mm) Pram Event ID: GPRV11 Facility 0m If 00111.1an Shed Page 15 of 18 PRINTED: 0211112019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE ?it. MQICAID SERVICES 0M3 N0. 0938-0391 TATEMENT DEPIOIENOIES (x1) PROVIDERISUPPLIERIOLIA (x2) MULTIPLE (x3) DATE SURVEY A ND PLAN OF OORREOTION IOENTIFIOATION NUMBER: A BUILDING CONFLETED 360035 WM 0111mm PROVIDER OR SUPPLIER crrY. STATE. ZIP com 103 WEST STATE STREET MOUNT CARMEL WEST COLUMBUS. OH 4322: 0:4) In SUMMARY STATEMENT OF DEFIOIENOIES IO PROVIDER-s PLANOPOORREOTION pa) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE AOTION SHOULD BE OOIIPLETION m; REGULATORY OR LSD IDENTIFYING INFORMATION) TAO CROSS-REFERENOED TO THE APPROPRIATE WE DEFICIENCY) A 491 Continued From page 16 A 491 31. Review of the medical record for Patient #24 revealed the patient presented to the facility on 04101118 at 8:20 PM. due to arrest. The patient was Intubated before arriving in the ICU. The Versed was dispensed from the AMDS system at 9:29 PM. and the Fentanyl was dispensed at 9:30 PM. both via override. prior to the physician order. Review of the physician orders revealed Fentanyl 800 IV push was ordered on 04101118 at 9:35 PM. and Versed six mg IV push was ordered at 9:36 PM. The medication administration record revealed Fentanyl was administered at 9:35 PM. and Versed was administered at 9:36 PM. Patient #24 was pronounced dead at 9:41 PM. by Physician A. There was no documentation In the medical record stating when the patient was extubated and taken Off the ventilator. 32. Review of the medical record for Patient #25 revealed the patient presented to the facility on 03123118 due to cardiac arrest. Patient #25 was intubated before aning at the facility. On 03125118. the physician ordered Fentanyl 500 IV push at 9:20 PM. and Versed six mg IV push at 9:21 PM. Versed was dispensed from the AMDS at 9:23 PM. and Fentanyl was dispensed at 9::25 PM. via override and after pharmacy review. The medication administration record documented the Versed was administered at 9:29 PM. and the Fentanyl was administered at 9:30 PM. Patient #25 was extubated and pronounced dead at 9:45 PM. by Physician A. 33. Review of the medical record for Patient #26 revealed the patient presented to the facility on 01111118 due to Increased liver enzymes. On 01114118 at 7:00 AM. the patient arrested and was Intubated. On 01114118 at 9:30 P.M.. the OMS-258710249) leons Oblolob ID: CPRV11 Facility ID: Om If continuation sheet Page 17 of 1B PRINTED: 0211112019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0935-0391 STATEMENT OF (x1) (x2) MULTIPLE CONSTRUCTION 0(a) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING 380035 3- WING 0111812019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE ZIPOODE 793 WEST STATE STREET MOUNT CARMEL WEST COLUMBUS. OH 43222 (M) In SUMMARY STATEMENT OF DEFIOIENOIES ID PROVIDERS PLAN OF common: (to) (EAOH DEFIOIENOY MUST BE PREOEDED BY FULL (EAOH AOTION SHOULD BE comm 1m REGULATORY OR LSO IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 491 Continued From page 17 A 401 physician ordered Versed mg IV push and at 9:31 P.M.. Fentanyl 1.000 was ordered IV push. Fentanyl was dispensed from the AMDS at 9:33 PM. and the Versed was dispensed at 9:34 P.M.. both Via override. The medication administration record revealed the medications were administered at 9:51 PM. Patient #28 was pronounced dead at 10:05 PM. by Physician A. There was no documentation in the medical record stating when the patient was extubated and taken off the ventilator. 34. Review of the medical record for Patient #27 revealed the patient presented to the facility on 01113118 at 5:52 P. due to a brain bleed. Patient #27 was intubated in the emergency room before being transferred to ICU. Fentanyl was dispensed from on 01113118 at 11:47 PM. with override. The physician ordered Fentanyl 1.000 IV push on 01114118 at 12:02 AM. The medication administration record documented the medication was administered on 01114118 at 12:02 AM. Patient #27 was extubated at 12:03 AM. Physician A pronounced Patient #27 dead at 12:19 AM. During interview on 01118110 between 10:00 AM. and 2:00 P.M.. all ?ndings were con?rmed by Nurse G. H, and M. FORM Mlle Event ID: CPRV11 Facility D: OHOZBZS If continuation sheet Page 18 of 18 Regulatory T0961 45642410 02/00/2010 17:50:63 #22305 Mount Cannel West access Plan ofCorrectlon Tag 0000- Inltlal Cormnems Initial Comments :?pglration land euewtion of this plan of correction doesnii-ot constitute an admission or agreement of the facts alleged or Operating Officer conclusions set forth on the Statement of Deficiencies. This plan of correction is prepared and executed solely because it Is required by federal/state law. The following constitutes Mount Carmel West's credible allegation of compliance. Raaporlaible man 'i"Con1IrI?e?on I Date President and Chief izla'ri'e . Mount Carmel Health System. CMS Authorised Individual Tag oIIas- Pharmaceutical gel-vices Condition 'Correctlve Action Inseam. Person Completion Date Finding 1- Proper_ conuoi a?nd use of ca?ntralI nervous system medications I . _RefeIr to Lag 0491 [arms Tag 0491: Pharmuy Administration Corrective Action Responsible Person Complaina? Finding 1- Accessing CNS medications from the automated mediation dispensing system (AMOS) Removed ability to override oplolds from inpatient care units throughout the hospital Including limited availability of override of Fentanyl in the AMOS except for a single vial of Fentanyl 250 injection in ICU for emergency procedures only and a single morphine injection of preservativevfree vial for emergency procedures in the NICU only. Evaluated all medications available in the AMDS and reduced the number of all medications available for override by approximately 55%. Revised policy. "Automated dispensing system: Medication Override Policy? (Attachment A) de?ning limitation of over- ride functions to categories of emergency life sustaining treatment. emergent supportive care. antidotes, rescue and reversal agents including definitions for each category. Approved by Pharmacy Policy and Procedure Committee, then by the Mount Carmel Health System Pharmacy and Therapeutics (ran Committee. The Health System Committee is authorized by the Health system Medical Executive Committee to approve the pharmacy policies. Pharmacy Of?cer. Final approval for Implementation was by the System Chief I Dill_ I Chief Pharmacy i tuna/19m Officer Chief Pharmacy 1728/19 Officer Chief Pharmacy 2/2/19: Officer Approval via Committee structure Mount Carmel West CCN 360035 793 West State Street, Columbus. Ohio 53222 Regulatory 02/08/2010 17:51:18 #22385 I ?ectlvehcdon Completion Date h? implemented a hard stop in units that have pro?led AMOS Chief Pharmacy (nurses are not provided the option to remove). prohibiting Officer access by registered nurses to all AMDS override medications except for approved drugs for management of three emergency scenarios (life threatening, supportive emergent care. antidotes/reversal/rescue agents) as de?ned in policy, II'Automated dispensing system: Medicatioqugrrice'L_ . Education: Developed and distributed communication to all Chief Pharmacy registered nurses providing direct patient care in the acute Of?cer hospital environment, all physicians on the medical staff (active, courtesy/consulting/house officer. he, providers with inpatient clinical privileges). medical residents and pharmacists on new reduction of central nervous system high risk medications available in the AMOS and limitations Chief Nursing Officer for override of medications and expectations for compliance. Communicated via daily safety huddies and tiered accountability structure (A daily management system designed so problems can be quickly identified. Front-line staff are empowered to fix the problems that they can, and problems that the front-line staff cannot fix are escalated and countermeasures created quickly. Dally tiered meetings are an integral element of a daily management system. The . objective of the tiered meetings is to have an alignment across the organization to achieve a common goal.) Nursing and pharmacy staff on leave or off the current schedule. prior to return to work, will be required to review and I attestjg thjgucatlon. Mount Carmel West CCN 360035 793 West State Street, Columbus. Ohio 43222 1/23/19 ms/ts pharmacy staff completed 1/28/19 - nursing sta? education implemented . and ongoing HogulatoryTO:9614684241B 02/00/2019 17:61:33 #22365 Co?mcthActlon' nslbie Person Education:? Communicated requirements and expectations Vice President of of the updated va policy to a subset ofcritlcal care Medical Affairs physicians via electronic noti?cation. All medical staff were provided with communication about Chief Clinical Officer AMDS emergency override changes including a list of the AMDS emergech override medications via electronic notification All medical staff were provided with communication about Chief Clinical Of?cer high risk CNS Intravenous drug guidelines discussing restrictions for maximum single and cumulative doses of high risk CNS medications via electronic notification For medical staff members with inpatient clinical privileges, an electronic noti?cation with read receipt veri?cation requested will be sent by the Chief Clinical Officer outlining changes to the WW policy. AMDS override restrictions. and restrictions for maximum single and cumulative doses of high risk CNS medications. A second noti?cation will be . disseminated by the Chief Clinical OfficerNice President of Medical Affairs ifthe hospital determines the first request I ?091,390!" ooened as received our the email recioients. Completion Toms 2/1/19 2/4/19 '5 217119 notification sent with read receipt requested Mount Carmel West CCN 360035 793 West State Street. Columbus, Ohio 43222 Regulatory ?19614564241 6 02/06/2019 17:51:47 #22365 Responsible Person Monitoring Plan: Implemented daily pharmacist monitoring of post-administration medication orders of high risk CNS medications removed from AMDS via emergency override for validation of compliance with revised policy I'ltuton'lated dispensing system: Medication Override policy?. 10096 of high risk CNS emergency overrides are reviewed daily, with non-compliance routed through nursing or provider drains of command for correction. Numerator: it of overrides of high risk CNS medications revierrved and escalated if not appropriate per policy Denominator: it of overrides of high risk CNS medications reviewed Goal: 100% Data will be reviewed at the Quality Safety council. then sent to the Quality Board and Board of Directors every other month. Monitoring will continue until the Quality Safety Council determines sustained compliance has been achieved. Generally this is a 3 month period of compliance at the established goalftarget: however, the Quality Safety Council has the discretion to determine sustained I compliance. At the time of this determination, the committee will determine further periodic monitoring as appropriate ie.g., soot checks}. adherence H?n? ltlail ens Med?lon domino The hospital removed the physician from the schedule, and then removed physician A's ability to provide patient care. Add itionaiiy, the medical group terminated physician A's employment. The hospital also placed 20 staff on administrative leave pending further investigation. Mount Carmel West CCN 350035 793 West State Street. Columbus, Ohio 43222 Chief Pharmacy Officer Completion" pate 12/17/13 ongoing President of the Medical Group and Chief Human Resources Officer I 1 lie?m?s'l of physician from schedule 11?21/18 Physician employment term date: 12/5/18 Staff suspension dateis): 12l12/18 to . Reguhtory ?108145042416 02/ 00/2010 17:52:05 #22305 P0061015 5 l?Correcthre Action emails Person completion? esteem and implementedapollcy. "Pharmacist Chief PharmaCy :lm 12mm Documentation and Escalation'I (Attachment ii) de?ning Officer documentation and escalation requirements for any concerns related to medication ordering or administration (including dosage of CNS medications). Approved by Pharmacy Policy and Procedure Committee. Final approval for implementation was by the System Chief Pharmacy Office?r. B?eviewed and upd?ated the hospital's s"Chain of Command? Chief Nursing Officer 12/17/18 and policy which outlines escalation steps for care providers Chief Pha mtacy ongoing when perceived varia noes in care identified. The policy was Of?cer revised to include pharmacists? actions for chain of command escalation. Reviewed by Chief Pharmacy Officer and Director of Clinical Practice. Approved by the Chief Nursing Officer. There were no changes to chain of command for nurses, I 2/6/19 however all registered nurses providing direct patient care ongoing will be refreshed on the chain of command policy via I individual shift unit huddles, unit meetings and one-on-one - iiscussions with slgn- in sheet vaiidotion. Education: Provided education to pharmacists on Chief Pharmacy 1/4/19 requirements and expectations for compliance as speci?ed Officer in Policies: ?Pharmacist Documentation and Escalation? with signed understanding of performance expectations attestations. . Chain of ?m_mmam issues are entered into the faciilty's Chief Pharmacy 1/24/19 event management system and are reviewed daily by Officer leadership. Mount Carmel West CClii 36:09.5 793 West State Street, Columbus. Ohio 43222 Regulatory T0381 46642416 02/ 08/201 9 17:52:22 #22366 016 6 Fri-?nale?; Responsible Person . Date Monitol'lng Plan: Implemented on-going monitoring of Chief Pharmacy 12l17l18 pharmacists' compliance with ?Pharmacist Documentation Officer Ongoing and Escalation" policy for target high risk CNS medications outside the acceptable range with sign-off by pharmacy leader. Numerator: daily review of ii of high risk CNS medication orders with appropriate dosing with signoff by pharmacy leader Denominator: daily review of ii of high risk CNS medications orders outside acceptable range I Goal: 10096 compliance . Numerator: daily review of it of high risk CNS medication orders datumented per policy Denominator: daily review of ii of high risk CNS medication orders with required documentation Goal: 100% compliance Data will be reviewed at the Quality Safety Council, then sent to the Quality Board and Board of Directors every 5 other month. Monitoring will continue until the Quality 1 Safety Council determines sustained compliance has been achieved. Generally this is a 3 month period of compliance at the established goal/target; however. the Quality Safety Council has the discretion to deten?l'line sustained compliance. At the time determination, the committee will determine further periodic monitoring as appropriate leg. random audits. spot checks). Ji Educated pharmacists and medical?station implementation Chief Pharmacy .. Pharmacists of process for maximum single and cumulative doses for I Officer. Chief Clinical completed high risk CNS medications for pharmacist reiection of Of?cer. Vice President 2/4/19 medication orders that exceed established dosing with of Medical Affairs signed attestations by pharmacy staff. Evidence of Medical Staff communication with medical sta? via email memorandum. implemented 2/4/19 Mount Carmel West CCN 360035 793 West State Street, Columbus. Ohio 43222 Regulatory ?108146042410 02/08/2010 17:52:40 #22305 usu- In PII- - I Corrective Action Responsible Person i Finding 3- Adherence to Palliative ventilator Mmlicv Revised policy.? Palliative Ventilator? (Attachment C) which Vice President of specifies palliative ventilator withdrawal Is for comfort Medical Affairs and measures only, with stipulations mandating use of the Chief Nursing Of?cer Terminal Ventilator Withdrawal (TVW) order set that . Includes limited medications and dosage parameters, . prohibits use of verbal orders for implementation of WW order set, and includes requirement for physician to receive permission from a Medical Director or a Vice President of Medical Affairs who are available at any time for use of medications outside of dosing range of the medications included in the WW order set. Reviewed by the VP of Medical Affairs. Chief Pharmacy Officer, and the Medical Director of Palliative Care. Approved for implementation by the Chief _Nursing_ Officer. . . .. Developed a PowerPoint presentation, High Reliability President, Vice Organization,? (Attachment E) as an education vehicle President of Medical covering ZeroI-iarm/Culture of Safety expectations (included Affairs, Chief Nursing chain of command and escalation of concerns). "Palliative Of?cer and Chief I Ventilator" policy requirements, mandated use of WW Pharmacy Officer order set, appropriate medication dosages, verbal order limitations, required pharmacy review of orders. and registered nurse documentation requirements on the Signi?cant Event Form in the medical record related to ventilator withdrawal for dissemination to clinical care providers. .. Philemon: Provided focused education 13 critical care President and Chief physicians. ICU registered nurses. advanced practice nurses, Operating Of?cer, and pharmacists via "High Reliability Organisation" Vice President of PowerPoint presentations conducted by hospital Medical Affairs. Chief leadership, with signed attestations of understanding of Nursing Of?cer and requirements and expectations for compliance by these Chief Pharmacy c?roviders. Officer Developed and distributed communication to all registered Chief Nursing Of?cer nurses providing direct patient care in the acute hospital environment regarding the WW Policy and order set. . Communicated via daily safety huddhs and tiered 7 accountability. Nursing staff on leave or off the current schedule. prior to return to work, will receive and attest to . the education. .. Mount Carmel West CCN 360035 793 West State Street. Columbus. Ohio 43222 12/ 11118 1 12/10/13 12/14/13 Regulatory 02/00/2010 17:53:02 #22365 a Corrective Action" I. Responsible Person Completion .. Date Education: Communicated requirements and expectations Vice President of 12/11/18 of the updated va policy to a subset of critical care Medical Affairs physicians via electronic noti?cation. All medical staff were provided with communication about Chief Clinical Of?cer 2/1/19 AMOS emergency override changes including a list of the AMDS emergency override medications via electronic notification . All medical staff were provided with communication about Chief Clinical Officer 2/4/19 high risk CNS Intravenous drug guidelines discussing restrictions for maximum single and cumulative doses of high risk CNS medications via electronic notification I For medical staff members with inpatient clinical privileges. 2/7/19 an electronic noti?cation with road receipt verification notification requested will be sent by the Chief Clinical Officer outlining i sent with read changes to the WW policy, AMDS override restrictions, and receipt restrictions for maximum single and cumulative doses of requested high risk CNS medications. A second notification will be disseminated by the Chief Clinical Officer/Vice President of Medical Affairs if the hospital determines the ?rst request not been opened as received lay the email recipients. . Education: Educated internal medicine and surgical Vice President of 121171'18 rasldents on use of WW order set with signed attestations Medical Affairs. GME acknowledging receipt and expectations for compliance. Program Directors. and Chief Nursing . Of?cer 2f? 19 noti?cation An electronic notification will also be sent to all residents Regional Director of sent with read with required read receipt requested by the Chief Clinical Graduate Medical receipt Of?cer. The resident's program director will follow-up with Education requested the resident if no receipt response is received. I Added to New resident orientation will include this education. resident Residents rotating into a program will be educated by the I orientation program director prior to starting the rotation. checklist .. 21'3le I As an additional fail safe. all TVW order sets will be Chief Nursing Officer arena reviewed by the charge nurse prior to Implementation to identify any Instances of noncompliance. with escalation to I hospital leadership for intervention as necessary I Mount Carmel West CCN 360035 793 West State Street, Columbus, Ohio 43222 Regulatory 02/00/2019 17:53:22 #22385 :Correctlve scan-1' Responsible Person. Completion Monitoring Plan: initiated daily monitoring of compliance to Vice President of use of the Palliative Ventilator Withdrawal Order Set for all Medical Affairs and Ongoing patients being palliatlvely weaned from a ventilator with Chief Nursing Officer requirement for immediate escalation to hospital leadership for any Instance of non-compliance. All instances where approval was given by the Medical Director or Vice President of Medical Affairs 'to prescribe outside the limits of the order set. now require noti?cation to the Mount Carmel Health System Chief Clinical Of?cer or . designee, for review within 43 hours for appropriateness of dosage approval. Additionally, instances of approval will be forwarded to peer review process for physician pro?ling. tracking and trending. . I Numerator: it palliative ventilator withdrawals compliant with the power plan Denominator: it palliative ventilator withdrawals Goal: 100% compliance Data will be reviewed at the Quality Safety Counc?, then sent to the Quality Board and Board of Directors every other month. Monitoring will continue until the Quality Safety Council determines sustained compliance has been achieved. Generally this is a 3 month period of compliance at the established goal/target: however. the Quality Safety Council has the discretion to determine sustained compliance. At the time of this determination, the committee will determine further periodic monitoring as _a_ppropriate random spot checksi. Mount Carmel West CCN 360035 793 West State Street. Columbus, Ohio 43222 Regulatory 02/08/2010 17:53:30 #22365 Corrective Action Rationsihle Person?. 10 .- "mam"?lon Dalia Monitoring Plan: initiated on-going monitoring for Vice President of validating compliance of registered nurse docmnentation Medical Affairs and on Significant Event Form of Palliative Ventilator Cilief Nursing Officer Withdrawal. Numerator: a of complete nursing documentation (all elements) on event form for palliative ventilator withdrawal 3 Instances Denominator: it of palliative ventilator withdrawal instances Goal: 100% compliance Data will be reviewed at the Quality Safety Council, then sent to the Quality Board and Board of Directors every other month. Monitoring will continue until the Quality Safety Council determines sustained compliance has been I . achieved. Generally this is a 3 month period or compliance at the established goal/target: however, the Quality Safety Council has the discretion to determine sustained compliance. At the time of this determination, the committee will determine further periodic monitoring as appropriate (ego random audits, snotghecksi. I Finding 4- Proper use of verbalitelaphgne orders Reviewed and updated policy, "Medication l?ilrderI Chief Pharmacv (Attachment D) for clarity of requirements for verbal and Of?cer telephone order expectations. Reviewed by Pharmacy Policy and Procedure Committee, Administrative Policy Committee, and Chief Pharmacy Of?cer. Approved for implementation by Mount Carmel Leadership Accreditation .. Revised Palliative Ventilator" policy which specifies Vice President of palliative ventilator withdrawal is for comfort measures Medical Affairs and only, with stipulations mandating use of the WW order set Chief Nursing Of?cer that includes limited medications and dosage parameters. prohibits use of verbal orders for implementation or'rvw order set. and Includes requirement for physician to receive permission from Medical Director or Vice President of Medical Affairs for use of medications outside of medications included in the order set. Reviewed by the VP of Medical Affairs, Chief Pharmacy Of?cer, and the Medical Director of Palliative Care. Approved for implemerlation the chief Moraine Officer. Mount Carmel West CCN 360035 793 West State Street. Columbus, Ohio 43222 I 11/11/1sby 12124113 Ongoing CND Regulatory ?108146642416 02/08/2010 11:64:04 #22386 11 Corrective Action Responsible Person Completion Date Developed a PowerPoint presentation, "High Reliability Vice President of 12/10/18 Orga nization.? as an education vehicle covering Medical Affairs and I ZeroHarnVCuiture of Safety expectations, "Palliative Chief Nursing Of?cer I Ventilator" policy requirements. mandated use of WW I order set, appropriate medication dosages. verbal order limitations, required pharmacy review of orders, and registered nurse documentation requirements on the Signi?cant Event Form in the medical record related to ve_ntl ator withdrawal for dissemination__ to clinical providers .. Ed?ucation: Educated critical care physicians. registered Vice President of 12/14/18 nurses. advanced practice nurses. and pharmacists via Medical Affairs and ?High Reliability Organization" PowerPoint presentations Chief Nursing Officer conducted by hospital leadership. with signed attestations of understanding of requirements and expectations for compliance. . Education: Developed and distributed communication to all Chief Nursing Officer 2/6/19 registered nurses providing direct patient care in the acute ongoing hospital environment regarding the Policy and required use of order set. Communicated via daily safety buddies and tiered accountability. Nursing staff on leave or off the current schedule. prior to return to work. will recoive and attest to the education. Education: Developed and distributed communication to all Chief Nursing Officer implemented registered nursing providing direct patient care in the acute 2/8/19 . hospital environment regarding limitations on use of verbal ongoing i and telephone orders. Communicated via daily safety buddies and tiered accountability. Nursing staff on leave or off the current schedule, prior to return to work, will ?genetic and attest to the education. .. I In?? Mount Camel West CCN 360035 793 West State Street. Columbus. Ohio 43222 Regulatory 02/08/2010 17:64:22 #22365 12 Corrective Action Responsible Person Completion Date Education: Communicated requirements and expectations Vice President of 12/11/18 I of the updated WW policy to a subset of critical care Medical Affairs physicians via electronic noti?cation. All medical staff were provided with communication about Chief Clinical Of?cer 2/ 1/19 AMOS emergency override changes including a list of the AMDS emergency override medications via electronic i noti?cation All medical staff were provided with communication about Chief Clinical Officer 2/4/ 19 high risk CNS intravenous drug guidelines discussing restrictions for maximum single and cumulative doses of high rial: CNS medications via electronic notification For medical staff members with inpatient clinical privileges. Chief Clinical Of?cer 2/7/19 an electronic noti?cation with read receipt verification Vice President of notification I requested will be sent by the Chief Clinical Of?cer outlining Medical Affairs sent with read changes to the WW policy, AMDS override restrictions. and receipt restrictions for maximum single and cumulative doses of requested high risk CNS medications. A second noti?cation will be disseminated by the Chief Clinical Of?cer/Vice President of i - Medical Affairs If the hospital determines the first request has not been Opened as received by the email recipients._ Monitoring Plan: Pharmacy department is collecting Chief Pharmacy 1/ 14/19 medication order data. Of?cer ongoing Numerator: total verbal and telephone medication orders Denominator: total medication orders . Goal: 510% verbal and telephone orders for medications i Data Is reviewed by the Mount Carmel Health System . Medication Safew Task Force twice per month. Data will be reviewed at the Quality Safety Council, then sent to the Quality Board and Board of Directors every other . month. Monitoring will continue until the Quality Safety Council determines sustained compliance has been achieved. Generally this is a 3 month period of compliance at the established goal/target: however. the Quality Safety Council has the discretion to determine sustained compliance. At the time of this determination, the committee will determine further periodic monitoring as leg, randomguditsgo? checks}. Mount Carmel West CCN 360035 793 West State Street, Columbus, Ohio 43222 Regulatory ?106146842418 02/08/2010 17:64:42 #22366 13 email, CorrectiveAction .. I "Mic Person Flnd?s- Phahnacy approvinglaJI doses of opioid:? Completion i . Developed and implemented a "Pharmawst Documentation Chief Pharmacy and Escalation Policy" de?ning documentation and Of?cer escalation requirements for any concerns related to medication ordering or administration (Including dosage of CNS medications) Education: Provided edtication to MCHS pharmacists on Chief Pharmacy rennirements and expectations for compliance as specified Of?cer in Policies: "Pharmacist Documentation and Escalation" and "Chain of Command" with signed understanding of performance a mutations attestetlons. Chain of command issues are entered Into the facility?s Chief Pharmacy event management system and are reviewed daily by Officer _i_e_a_gershin. . . Monitoring Plan: implemented on-going monitoring of Chief Pharmacy pharmacists' compliance with ?Pharmacist Documentation Officer and Escalation" policy for target high risk CNS medications outside the acceptable range with sign-off by pharmacy leader. Numerator: daily review of a of high risk CNS medication orders with appropriate dosing with slgnoff by pharmacy leader Denominator: daily review of ii of high risk CNS medication orders Goal: 100% compliance Numerator: daily review of it of high rislr CNS medication orders documented per policy Denominator: daily review of it of high risk CNS medication orders with required documentation Goal: 100% compliance Data will be reviewed at the Quality Safety Council. then sent to the Quality Board and Board of Directors every other month. Monitoring will continue until the Quality Safety Council determines sustained compliance has been achieved. Generally this is a 3 month period of compliance at the established goalltarget: however. thenuallty Safety Council has the discretion to sustained compliance. At the time of this determination. the committee will determine further periodic monitoring as appropriate to 3., random audig. spot checksi. Mount Carmel West CCN 360035 793 West State Street, Columbus, Ohio 43222 12117713 1l4I19 {sz? taliriia Ongoing . HegulatoryTO:9614-564241B 02/08/2019 17:55:03 #22385 Corrective Milan Educated pharmacists on'i'mplementatlon of process for maximum single and cumulative doses for high risk CNS meditations for pharmacist rejection of medlcatlon orders 1 that exceed established doalng with signed understanding I of performance expectations attestation: by pharmacy staff. .u I II-I I- Mount Camel West can 360035 793 West State Street, Columbus, Ohio 43222 Responsible Pusan Chief .Pha'r'macy Of?cer I C?mpl?lon PIE 2/4/19 Regulatory 02/04/2010 16:30:42 #22274 MOUNT CARMEL A POLIOYIPROOEDURE DEPARTMENT OVERSIGHT AND MAINTENANCE: Pharmacy PURPOSE: To de?ne the appropriate use of the override function. and identify the best practices to keep patients safe. POLICY: The use of the override function In the automated dispensing machine is minimized by limiting lfris type of access to emergency situations. Emergent situations Include 3 general cougar-lea: life sustaining. emergent supportive care. and antidoteslrescuefreversal agents. RESPONSIBLE PERSONS: Phamracists. Registered Nurses (RN). Licensed independent Practitioners (UP) (Physicians. Advanced Practice Registered Nurse Practitioners). Physician Assistants (PA) SPECIAL COMMENTS: Override medications are medications that can be accessed by nursing staff before review of an order by the pharmacist. The purpose of the override function is to allow for quick administration of medications in emergency situations to prevent patient harm. However. best practice includes prospective pharmacist review of all medication orders prior to administration of the drug. The override function can only be used In emergency situations when time does not permit the phanneoist review. such as circumstances when patient harm could result from delay in administration of a medication. including situations In which the patient experiences a sudden clinical decline. The override function Is speci?c to profiled Pyxis machines (inpatient units). The override function will not be utilized In patient care areas where non-pro?led machines are used. such as the Emergency Department. Oath Lab. Endoscopy. OR. and other procedural areas. Automated Dispensing System downtime and critical override is reviewed in the ?Automated Dispensing System Downt'me Procedures For Pyxis There will be Instances where removals using the override function will be necessary to facilitate normal process of care (Le. drug shortages. kits. etc). These will not be included in the override addendum as they are often transient due to unexpected drug shortage replacements. PROCEDURE: 1. in most areas. automated dispensing systems (Pyxis) are Interlaced with the pharmacy system so that all new orders entered are viewable under each patient In the Pyxis medication pro?le. 2. Override medications are customized based on the level of care provided on a specific patient care universe. a. Additional safety features will be utilized for medications that are identified as having a higher risk for harm pop-up alerts in nurse witness. restrictions to certain patient populations). M1017 Regulatory 02/04/2010 16:30:08 #2274 RM 8/072 MOUNT CARMEL 3. Any changes made to the override medications (Refer to Addendum) will be reviewed by the Pharmacy and Therapeutics Committee for approval. Adjustments to the override medications. related to drug supply challenges. will require Pharmacy and Therapeutics approval if a permanent change in drug supply option occurs. 4. The ovenide function will only be utilized to access medications in emergency situations to prevent patient harm. Prior to administration of a medication that has been removed'by the ovenide function the following must be reviewed for appropriateness prior to administration: a. Verification that the medication selected for administration is correct based on the order and product label. b. Drug. dose, frequency. and route of administration are verified. c. Veri?cation that the medication is stable based on visual examination for particulates or discoloration and the medication is not expired. d. Contraindications to consider prior to administration: a Real or potential allergies or sensitivities - Therapeutic duplication - Real or potential interactions between the prescription and outer medications. food. and laboratory values - Variation In dosing or administration from organizational criteria for use. such as Guidelines 5. Prompt documentation of order and admlt'listralion must occur. 6. override monitoring is an important safety task for the Responsible Pharmacist and. in their absence. assigned to their pharmacy leader team: a. Annually: The ovenlde medication lists in Addendum will be reviewed for appropriateness. b.Weekly: review of Pyxis override trends will be conducted and communicated to hospth leadersh . c. Daily (Except weekends and holidays): Targeted review of high risk CNS medication overrides as well as high risk CNS medication multi-dose override removals will be reviewed daily (or day following weekends and holidays) and reported to hospital leadership. Any inappropriateness will be noted. evaluated. and escalated to the appropriate department leader for review and resolution. DEFINITIONS: Automated dispensing cabinets (ADCs) - Computerized storage devices or cabinets that allow medications to be stored and dispensed near the point of care while controlling and tracking drug distribution. They also are called unit based cabinets (UBCs). automated dispensing devices (ADDs). automated distribution cabinets or automated dispensing machines (ADMs). Mount Carmel currently uses for automated dispensing cabinets. Override - The process of bypassing the pharmacists review of a medication order to obtain a medication from the Pyrris. when assessment of the patient irrdreetes that a delay in therapy (to allow for a pham'raclst's review of the order) would harm the patient. Pro?led Pyitle - An ADCiPyxis that allows a practitioner to select a drug from a list on the ADC screen and obtain a medication only after the order has been verified by a pharmacist. Pageiof? Regulatory 02/ 04/2010 18:30:32 #22274 MOUNT CARMEL PDLICWPROCEDURE Emeggancy Situations Antidotes. rescue. and administration. patency of an Lila Sustaining Emergent supportive care reversal agents Blood pressure control In medical Acute disorder: Anaphyiaxis; respiratory amemencms (AMI. AC8. stroke. Severe Agitation emergencies: allergic sepsis. intubation. etc.i reactions Blood pressure control for emergent I Chest Pain Buplvaceine or hypertensive pregnant patient rcpivacalne toxicity Emergent intubation Emergent procedure gg?g?um sulfate Fluid bolus. Blood Emergency reversal of rocuronium (unable to Uterine Bleading P'eeclam?i? ?mm? (RDS) Iv. required concurrent . intubate patient following compatible infusion paralytic administrationj_ Plasma volume expansion Reversal of oplaMs magma? of acuteiemergent for open heart post?op patient Post-partum hemorrhage; Severe Seizures Prevention of labor cardiac (Le. bradycardia, PSVT. Rapid Ventricular Responsen critical hypoglycemia EXPECTED OUTCOME: Safe and accurate medication management and administration. REFERENCE: Institute for Safe Medication Practices (ISMP) Guidance on the Interdisciplinary Safe Use of Automated Dispensing Cabinets ASHP Practice Resource for Automated Dispensing Cabinet Oventdes Joint Commission Standards MM.2.30: MM.OB.01.01 KEYWORDS: ,1 i- Deveioped By: Pharmacy Policy 8: Procedure committee maul? Regulatory ?106146042410 02/04/2010 16:30:52 #22274 MOUNT CARMEL POLICYIPROOEDURE BY: Pharmae'y Policy 3. ORIGINAL ISSUE DATE: new. 9103: MOE, Procedure Team 9108: MCSA. 9108: MONA 5110 I REVIEWIREVISION DATE: 10108(eddendum). 1109. 3109 (addendum). 7109 (addendum). 3110 (addendum). 8110 Policy and addendum: 5114. 9115. 811 1118, 1119. 2119 REPLACES: Medlcation Overrides REVIEWED Pharmacy Pulley and Procedure Team BY: I APPROVAL FOR IMPLEMENTATION BY: .- I Penna-r Regulatory 02/04/2010 18:40:02 #22274 MOUNT CARMEL ADDENDUM m'lEIiT encasem- el'rum'lorls ?mm" EMERGENCY FOR DRUG mull 1. INPATIENT PYXIB 3- MIMW Anephylaxts' respiratory up I a mm s. rescue. and ems nc I . reversal agents ?ags?: so malt mL in: 1' 2' 3 rescue. and Bupiveceine or mphreseine Fat Emulsion 20% infusion. numeral agents toxicity 250mL 1' 2' a A dates. rescue. and . . . al in" Magneslum sulfate 3 . Reversal of rocurcnlum only - Antldotes. rescue. and if unable to intubate a patient Sugemlnadex reversal sgenls following paralytic 500mgl5 mL in] (4 vieie)? 2 . A tidctea nd . administration . rescue. a 1 mm, agar?: Reversal of opiates Neloxone 0.4mgl1 OLANZepine 10 mg in]. merg pportlve care Acute dlaorder my 11': 1. 2 1 thORmpem Eme nt so We care ureIAglt'atlon ma pp Severe ?mm" 1 LORszepem 2 malt ml in] 2 1' 2' 3 vials' . 1 Nitroglycenn'ng mp 8L tabs . Eme nt su ortive ca 5" I p? wt Nllroglycerln 50 mouse mL 1' 2 infusion Fluid bolus. Blood administrellon. sun of . 1 Emergent supportive care lV. required gemucrzent an IV solutions (plaln) 1. 2. 3 . mna?ble lntuslon . . lasms volume expansion lor Albumin 12.5 Emergent support". we open heart postal: patient . mL in?leicn 2 Erne ant su ille csre Neonatal L- '9 . ?mm 5 H1910 mL vial 2 1' lcu only A Erne nt su rllve rgent i Em? mm? 250 mggfirnL In] 1* 2 1 LORuepsnt SeizureIAgillI?on Kit 1. 2. 3 Emergent supportive care Seizures LORWJQ: 2 PHENebarbilei Neonatal 65 rug/1 mL In] x1' only Pause? MOUNT CARMEL POUGYIPRDCEDURE Regulatory T0361 46042418 02/04/2010 16:40:24 #22274 EMERGIIGY CATEGORY HERGT BITUATIONS FOR INPATIENT PYXIS DRUG WWII Writ-1. ?U-z LID-3 Life Sustaining Blood pressure control in medical emergencies (AMI. A08. stoke. sepsis. intubation. etc) DOP?hine inhalion 1 mg?) mL syringe NiCARdipine 2D infusion Nitrogiycerin 50 "191250 mL intuaion Noraplnapgriflu'lef mm mL um 1000 mogi'lo ml sunnga 1.2.3 Life Sustaining Blood pressure control for emergent hypertensive pregnant patient 20 mg" mL in]; Labetalol 20 m4 ml. Swing? Life Sustaining Management of awteIeMargent acidosis Sodium bicarbonate 5i) mEqi?D mL syringe Life Sustaining Emergent Intubation RBI: Rapid uenoe Intuhatlon Kltilcu I MONA) 1x Propotoi 200 mL in] 1 it Emilie 200 m0 mL in] 2 Suooinylohollne 200 mg per 10 mL ini ZuRoouroniurnGOmgISmLinj 1 Etomldate 40 mm ml. in] 3xMidezolam2mgI2mLinj *(Etomioate can be sub to 2 vials of 20W10ml with all kite} intimation Kit (MedISurg unite and Lab) 2 Etomidaie 20 in] 2 Midazolem 2mgl9mL in] 1.3 Life sustaining critical hypoglycemia 50% 25gmf50mL in] syringe 1.2.3 Life Sustaining Lung aurfaotant (RDS) Poractant Alia (Curosw?i) mL and 3 mL vials Hmld7 Regulatory ?2206146842416 02/04/2010 18:40:41 #22274 MOUNT CARMEL POLICYIPROCEDURE I annai'rm" EMERGENT srrunmoaa - cameos? FOR onus annuity-1. In I INPA11EHT PYXIS mm Leo-s 03 Emergency Hemorrhage Kit (L210) 1 Ga'rbo?rozt 251Post-pertum hemorrhage: 1" yletuonovine Life Sustaint . 0.2 1 1111.. "g 3mm 5 "scum-{I zoo 11:19 tabs. 3 Oxytocln 10 01111011 mL In] Trenexamls Acid 3 1 0111110 ml il'lJ_ Magnesium Bullets 2 Grn1100 mL Lite Sustaining Preeolempeia 3 Magnesium Sulfate 6 ammo mL Adenosine a mL in] Cardiac Adenoslne 300mm kit 3 . . . (Le. hradyoardie. (Neonatal tau 0an) 5mm? PSVT. rapid ventiioular Atrophe1rngi1valal 1' 2' 3 response) 25 111915 mL {bolus} inj vlel' Lite Sustaining Emyenuen o1lebor Tubutaiine 1 111911 mL 3 I Sterile wear and 0.9% Other Other Sodium Chloride for irrigation 1.2.3 I . 500rnL and 1000mL . Sodium Chloride in]. flush syringes Sterile water 111:. tesethen 1-2'3 I . mom for mugglutlun Unlock refrigerator Other I Other Unlock 92W . 1.2.3 I *edditional safety features in place (to. pop-up alerts in Pyxis. nurse witness. restrictions to certain patient populations). Page'roi? Addendum updated: 101912008. 112212000. 3117109 (approval PltT. 212nm: Med Exes. 3117109). 7123109. 310110. 10110. 5111. 2114. 5114. 2115. 4115. 4117. 1113. 1119. 2119 Regulatory ?196145342416 02/04/2019 18:41 :00 #22274 MOUNT CARMEL 6 POLIGYIPROGEDURE DEPARTMENT OVERSIGHT AND MAINTENANCE: Pharmacy POLICY: Pharmacist Documentation and Escalation Process Pharmacists have a responsibility to intervene with prescribers for situations where orders need to be clari?ed. Clinical interventions are defined as actions taken to improve patient outcomes and prevent medication errors or patient harm. RESPONSIBLE PERSONS: Pharmacists. Pharmacy Leadership Team SPECIAL COMMENTS: Pharmacist medication consult documentation is outlined in the pharmacy Drug Therapy Consult Agreement policy Scope of Practice Pharmacist are responsible for compliance with the Ohio Board of Pharmacy rules and regulations. the Joint Commission. Ohio Department of Health. DEA. USP. and other federal requirements. PROCEDURE: Pharmacist Escalation: t. For urgent patient safety concerns immediately escalate per the PCS "Chain of Command: Clinical Operation? policy a. After escalation. documentation in chart. and VOICE report should be entered for escalated events. 2. Non-urgent escalation should be verbally brought to the attention of pharmacy leadership team with corresponding pharmacy escalation form filled out and handed ofl' in person or via entail). a. Verbal communication is expected. at earliest convenience of the colleague. (to. if event occurs over the weekend. verbal communication should occur as soon as the colleague and leadership team are able to touch base). Pharmacist Documentation: Clarification of orders in EMR: 1. If a situa?on is identi?ed that requires prescriber clarification of an existing order. the pharmacist will document the discussion In EMR outlining details of the conversations. a. This would include dosing outside of current guidelines that cannot be vedi'led by evidence based literature. b. Documentation should ensure full understanding of the problem the pharmacists is attempting to resolve and speci?c details_regarding the clinical intervention. c. Documentation should occur before the end of the current shin. d. It documentation does not occur before the and of the current shift. every effort should be made to add documentation before patient discharge. If documentation Frigate? Regulatory ?198145642416 02/04/2019 16:41 :21 #22274 072 MOUNT CARMEL POLICYIPROCEDURE is not added before patient discharge. it should be documented as soor'i as possible. it documentation rs added after current shift. pharmacist should communicate this to pharmacy leadership team as an escalation. 2. After discussion. if there is still a safety concern Phamracist will communicate with prescriber using the Zero Harm error prevention tools. (example: Pharmacist could use the safety phrase have a concern and need to escalate this up the chain of command") a. Afar stating concern. inmediately escalate (to. verbal or in person) a direct escalation for immediate guidance per the referenced PCS "Chain of Command: Clinical Operation" policy b. If escalation was needed. VOICE report will be entered before and of the current shift. 3. If situation required STAT resolution. Refer to PBS "Chain of Command: Clinical Operation" Policy. a. Additional verbal or In person updates will be provided to the site andlor regional pharmacy leader if these Individuals were not involved in the ?rst escalation step. Clinical interventions: 1. Pharmacist clinical Intervention to prevent patient harm will be documented in the EMR. if a clinical intervention made to prevent patient harm is not accepted. it should be documented and escalated. 2. Restricted medications should have an Intervention documented to ensure appropriate utilization. 3. Non-formulary medication use should have an intervention documented. 4. Clinical interventions should be documented before the end of the current shift. a. if documentation does not occur before the end of the current shift. every effort should be made to add documentation before patient discharge. If documentation is not added before patient discharge. it should be documented as soon as possible. it documentation is added after current shift. pharmacist should communicate this to pharmacy leadership team as an escalation. Fagalofe Regulatory ?100145042410 02/04/2010 10:41:30 #22274 MOUNT CARMEL POLICYIPROGEDURE REFERENCE: DEVELOPED BY: Pharmacy Policy 8. Procedure Committee ORIGINAL ISSUE DATE: December 17. 2018 REVIEWIREVISION DATES: REPLACES: REVIEWED BY: Pharmacy Policy 3. Procedure Committee APPROVAL FOR IMPLEMENTATION BY: Ja Sigmtma on File 12mm Pug-sun Regulatory 02/04/2019 18:41:48 #22274 RHIOTZ MOUNT CARMEL Phalanx-y Escalation Sltua?on Patient Info: Summary: Involved: ?mum I Nurse Involved: mm I LI URGENT - VOICE I Pharmacist Name: Date of Escalation: Person who was contacted for Escalation: RETURN COMPLETED FORM TO SITE CLINICAL COORDINATOR Pharmacy Follow up: Pl?l4d4 Regulatory 02/04/2010 18:41:60 #22274 acuu'r cmuer. DEPARTMENT OVERSIGHT AND MAINTENANCE: Palliative Care Services POLICY: Palliative Ventilator Withdrawal (PVW) is the provision of comfort measures for a seriously ill patient for whom continuing mechanical ventilation has been determined to be clinically inappropriate or unwanted by patient RESPONSIBLE PERSONS: Critical Care Units. Acute Palliative Care Units, Physicians. Advanced Practice Registered Nurse (APRN). Physician Assistant (PA). Palliative Medicine Consult Team. Pharmacy. Chaplaincy. Respiratory Services PROCEDURE: initial Guided Discussion to Establish a Plan 1. Review the clinical picture. 2. Establish that goalsierrpectations of PVW are uni?ed. 3. Review the plan with the attending physician or critical care physician. other involved physicians. nurses and therapists. 4. Consult with system Ethics Committee as needed. Follow-Up Discussion to implement the Plan .Clarlty the DNR status and the rationale for not re-intubatlng. identity treatments to be continued and these treatments to be discontinued. Determine the patient/family decision maker's understanding of what will happen after extubatlon. Review the palliative management of likely to occur during PVW Determine when the PVW will occur and if the patient will remain In the or be transferred to the APCU. - Allow a minimum of one hour after PVW before transferring to APCU - Provide seamless hand-off of care through corrununication and collaboration between transferring and receiving units 6. Determine who will be present during the PVW. 7. Discontinue medications that require ventilator support. including but not limited to. paralytic agents. Versed. propotol B. After discontinuation of above medications. confer with pharmacy regarding the length of time needed prior to extirpation. to ensure discontinued medications are no longer active. on 999 Immediately Pn'orto PVW 1. Facilitate private time for patient and family 2. Offer the presence of a spiritual/religious professional implementation of Management Medication Orders 1. Physician. APRN. andfor PA is required to utilize Palliative Ventilator Withdraw (PVW) PowerPlan 1013 Regulatory "396146642418 02/04/2010 18:42:10 #22274 raps?!- MOUNT CARMEL PDLIOYIPROGEDURE {its - . I Physician. RN. an or PA 'l'nust electronically enterr Power-Plan orders. No PVW orders may be verbally entered by RN. If there is a clinical indication for medication dosing outside of the Power-Plan. or a medication not In the Power-Plan. the physician. APRN andior PA must obtain approval from the Critical Care Medical Director and document the medication dosing approved and by whom: - If Critical Care Medical Director unavailable. obtain approval from Palliative Physician if they are involved. - if palliative team is unavailable. or not involved. obtain approval from Vice President of Medical Affairs (VPMA). - If a clinical provider does not utilize the Palliative Ventilator Withdrawal Power Plan in cationic who are being treated accordingly. nursing staff should ?rst remind the provider of the reguirements of the Palliative Ventilator Withdrawal Policy. if the provider condnues to decline to use the Power Plan. the campus specific VPMA should be contacted immediately and notified of the situation Physician. APRN. and/or PA or RN may not administer PVW Power-Plan medications until medications reviewed and veri?ed by pharmacy. Discontinue unnecessary monitors such as ventilator alarms. cardiac monitors. blood pressure monitors. and pulse oxlrnetry. Medications for management will be ordered as medically indicated. Ventilator will be discontinued and the endotracheal tube if present. will be removed by the physician. APRN. andIor PA. respiratory therapist. or RN. Patient's response to medications In managing and anxiety will be reviewed. Post Palliative Ventilator Withdrawal: When death occurs . Provide privacy and support for family. . Maire referrals for bereavement support as appropriate. Post Palliative Ventilator Withdrawal: If patient resumes resplrailons 1. 2. Continue to monitor and provide comfort measures. identify appropriateness for transfer to APCU. REFERENCE: Chan. J.D. et.al. (2004). Narcotic and Benzodlezepine Use After Withdrawal of Life Support. Chest. 128( 1). 280-293. Huynh TN. Walling AM. Le TX. et of. Factors associated with palliative withdrawal of mechanical ventilation and time to death after meal. Journal of Palliate Medicine 2013; 16:1368. Robert R. Le Gouge A. Kantian-?ames N. et at. Terminal weaning or 'snmedlate extubatlon for withdrawing mechanical ventilation in critically ill patients (the ARREVE observational 2 of 3 Regulatory ?106146642410 02/04/2010 16:42:41 #22274 MOUNT CARMEL PDLIOYIPROGEDURE may). Int'amlve Care Med 2017; 43:1793. DEVELOPED BY: Care Services ORIGINAL ISSUE DATE: 3104 REVIEWIREVISION DATE: 4N5. 2107. 6?09. 1114. 5117. 12m REPLACES: PIP 3of3 Regulatory 13:42:48 #22274 MOUNT CARMEL POLICWPROGEDURE REVIEWED BY: Martha Reigel. MD. VPMA St Ann's 12110118 Mark Hackman. MD VPMA Mount Camel East 12110118 Larry Swanner. MD VPMA Mount Cannal West 12110118 Janet Whitley. Chief Pharmacy Of?cer 12110118 Phillip Santa-Emma. MD 12110118 APPROVAL FOR IMPLEMENTATION BY: Linda Breediove MBA. BSN. RN. NEA-BC. FACHE Vice President of Patient Care Services and Chief Nursing Officer. MCE Date: 12111118 agavBush. MHA. BSN. RN Vice President of Patient Care Services and Chief Nursing Oil?ieer Date: 12111118 Donald Lanllette. MBA. BSN. RN Vice President of Patient Care Services and Chief Nursing Officer MCSA Date: 12111118 Susan Schultz. MSN. BSN. RN. FACHE RN Vice President of Patient Care Services and Chief Nursing O?iosr MCNA Date: 12111118 40f3 Regulatory ?108145642410 02/04/2010 16:42:59 #22274 H'ii'ockmen?i' MOUNTCARMEL t) POLICYIPROCEDURE sewer .mmnuaamm?a DEPARTMENT OVERSIGHT AND MAINTENANCE: Administrative POLICY: 1. Medication orders for patients are written on the prescriber?e order form or via electronic order entry by the prescriber. or physician agent (employed by physician) per applicable law. a. Any hand-written or electronically entered medication order that presents with an unapproved abbreviation will not be accepted and must be clarified with the prescriber: a new order must be written. 2. Orders shall be forwarded to the pharmacy on a regular basis. 3. The Phannecy processes medication orders for hospitalized patients prescribed by credentialed providers (including physicians. residents. interns. medical sta?. physician assistants. APRN). A physician must countersign all niedicatlon orders prescribed by medical students before they are ?lled by the hospital pharmacy. 4. Before dispensing or removing from floor stock. or from an automated dispensing machine. a pharmacist reviews all medication orders unless a licensed independent practitioner controls the ordering. preparation and administration of the medication or when a delay could cause harm to the patient in an urgent situation (including sudden decline of a patients clinical stahis). 5. At a minlrnum. the following patient Information Is available to those colieegueslprescribers involved in medication management: The patient's age The patient's sex The patient's current medications The patient's diagnoses. co?rnorbiditiss. and concurrently occurring conditions The patient's relevant laboratory values The patients allergies and past sensitivities Height and weight . Pregnancy and lactation status is also available as appropriate PROCEDURE 1. REQUIRED ELEMENTS OF A COMPLETE ORDER: e. A medication order contains the patient name. date and time of order. the drug name. dosage when applicable. frequency. route and preecriber's signature. The order may also contain medication strength or concentration. when applicable. and quantity and/or duration as applicable. (This includes verbal and telephone orders) 1. Oxygen is considered a medical gas and a complete order must contain medical gas (oxygen). mode of therapy (nasal cannula. etc.) and dosage (liter flow). Generic names or brand names are acceptable for medication orders. The indication for use is required for any as needed or medication. err HegulatoryTO:9614564-2418 02/04/2010 16:43:21 #22214 MOUNT CARMEL MEQIQAIIDN ORDERS d. Orders to ?titrate" (increasing or decreasing a dose in response to tire patient's status) need to have parameters prescribed. "a heart rate "a diastolic blood pressure (Not applicable to hospice) 1. The order must specify the sequence of medication titration and discontinuation. If there Is more than one medication with the satire titration parameter(s) and Infuslng simultaneously. 2. The order must Include an objective parameter use to titrate the medication including the endpoint. e. All orders for intravenous. oral liquids. and compounded medications for the neonatal/pediatric population will be reviewed and veri?ed using a neonatal! pediatric reference. Weight-based dosing will be used for all medications requiring weight-based dosing. 2. TRANSCRIPTION OF ORDERS: a. All medication orders will be entered onto the patients medication administration record (MAR). A copy of the prescriber's order will be sent to the pharmacy when applicable. The RN will reconcile the prescriber order with the MAR b. Any printedipaper prescrber?s order sheets must be labeled with at least the patient's narna and date of birth. No medications will be dispensed by the pharmacy without a valid medication order. except In emergency situations when delay may cause patient harm. c. Medication orders must have the tollowirtg information on the MAR: 1. Start date of the order Name of medication Dose of medication Route of administration Administration times military time Stop date. if appropriate PRN reason for which a PRN dose is to be administered). If written as PRN. Dosage form of the medication If a liquid dosage form is used. the dose should be expressed In both miilhrams (or grams) and the volume to be administered (not necessary for antacids or topical throat sprays). d. Any changes in patient information such as newly Identi?ed allergies. additional diagnoses. etc. will be provided to the pharmacy and documented so that the medication regimen may be reviewed. 3. PROCESSING OF AN ORDER: a. Upon receipt in the pharmacy. the medication order is reviewed and veri?ed by the pharmacist against the patients profile for the following information before releasing the medication order for dispensing: 1. Patients allergies or sensitivities 2. Existing or potential interactions between the medication ordered and food and medications the patient ls currently taking (dnrg-drug Interaction or drug- Fage 2 ct to we ?gpeww Regulatory ?196146642416 02/04/2010 18:43:43 #22274 P0321072 MOUNT CARMEL POLICYIPROCEDURE autism: food Interaction) Appropriateness of the medication. does. frequency and route of administration Cunent or potential impact as Indicated by laboratory values Over-utilization or under-utilization Therapeutic duplication Drug-disease state contraindication Abuselmlsuse . Inappropriate duration of treatment b. The edlcatlon order shall be entered into the patients medication profile. The medication pro?le ls available and accessible by all staff responsible for the pa?ent'a care. a. The medication pro?le contains: . Patient's name Physician's name (attending) Room number Drug andlor food allergies Diagnosialcomplalnt Age (or birth date) Sex . Currant medications d. information about the patient's recreational andlor use of illegal drugs. misuse of prescription medications. use of investigational drugs. creatinine clearance values for patients 65 years or older. height and weight for dosage calculation. and body surface area for patients undergoing chemotherapeutic regimens. and home supplies of over the counter (OTC). vitamins and herbal products may be used to assess the medication order. a. Upon veri?cation that the medication order is appropriate for the patient. the medication wil be prepared for dispensing. A minimum supply of medications sufficient until the next medication exchange shall be dispensed to meet patient need. Labels affixed to a manufacturer's container ophthalmic drops) should not cover up vital intonation on the manufacturer's label. The prepared medication shall be checked by a pharmacist or robot technology before being delivered to the patient care area. All medications dispensed shall contain a minimum of the name of the medication. dosage. and expiration date. Any required precautionary labels shall be included. i. After sending the initial medication supply. the order shall be evaluated to determine if subsequent doses will be needed. A sufficient supply of medications shall be placed in the appropriate secured medication area. Medications are dispensed in quantities which minim-e diversion yet are still consistent with patient needs. g. Drugs dispensed from the pharmacy shall have the following information: 1. Patients? last name. ?rst name. and room number 2. Drug name. strength. and diluent (if applicable). h. When applicable. the following will be included: 1. Beyond use dating (If other than manufacturer?s expiration date) - Beyond or; date refers to the date in which it is no longer safe to administer this uct. ww?ewe mwpeewpd Pmadl?l? HegulatoryTO:001460424-10 02/04/2010 16:44:00 #22274 Rose/on W: MOUNT CARMEL POLICYIPROCEDURE 2. Expiration time when expiration occurs in less than 24 hours 4. STANDARD ADMINISTRATION TIMES: Dailr 0900 BID ?Twlcea gay 0900. 2100 'gzh ?_Even_.r twelve hours coco, 2100 -_Three times a day 000014002100 08h - every eight hours 0000. 1400. 2200 QID - four times a day 0900. 1300 1100. 2_10_0 08h - every six hog; 0600. 1200. 1800. 2100 OHS evegg hour of sleep: every bedtime 2100 ACHS before meats_and at bedtime 0730. 1130. 1030. 2100 . PCHS - after meals_and at bedtime 0830. 1230. 1730. 2100 i a. Medication orders will be scheduled for administration at standardized routine times 99? unless alternate times are specified In the order. Neonate orders are not subject to standard administration times. Administration of medications that have special administration considerations may be schedqu by a pharmacist to ensure optimal dnig delivery such as medications timed to be given with or without meals or food. medications not to be given concurrently. hypoglycemics given before meals. avoiding diuretics prior to bedtime. etc. The administration times of intravenous antibiotic regimens may be scheduled by the pharmacist to facilitate multiple intravenous therapies. Pharmacy consultation orders may necessitate use of non-standard tirnee. Other exceptions to standard medication times may be necessary to order to comply with hospital initiatives and programs. Pharmacist will use professional Judgment regarding adjusting start times for medications. The nurse will use professional Judgment regarding administration of the first dose of medication based on information supplied by the patient. 5. BLANKETIRESUME ORDERS: The use of blankettresume orders for medications. such as "continue previous made?. 'give home meds". ?resume preoperative meds". and ?discharge on current mode". are not acceptable orders. . The prescriber must be contacted by either nursing or pharmacy to clarify the blanketfreaume order. 6. CLARIFYING MEDICATION ORDERS: It Is the responsibility of the prescricet'. pharmacist andlor the nurse to assure that medication orders are complete to promote the safe use of the medication. Pharmacist intervention may be necessary to document the intent of the prescriber andtor assist with adjusting the proposed therapy to obtain the intended results. A medication should be clari?ed prior to being dispensed If the potential exists for patient harm or lack of therapeutic effect due to problems with or lack of order completeness. Fag-eerie Regulatory ?106146042410 02/04/2010 10:44:31 #22274 m1 MOUNT CARMEL POLICYIPROCEDURE rage 9- . patron h. There are times when speci?c patient conditions warrant administering medications outside of the usual dosing parameters (Le. obesity. pain control In tolerant patients. palliative care). These medication orders require pharrnaclst review to determine if it is acceptable to administer: a reference will be required to support Its use Up-to-date. primary literature). It a reference cannot be located or provided by the preecrlberrpharmacy. the RN may not administer the medication unless special approval is received. All medication order requests outslde of the usual dosing parameters should be vetted through pharrnaoy leadership: pharmacy leadership will coordinate appropriate approval path based on the medication In question. If the medication Is delayed or cannot be administered. RN must notlfy the ordering LIP. document that the medication was not administered. and a new order will need to be written. It a situation is Identified that requires clari?cation. the pharmacist andror nurse must contact the prescriber as soon as possible to detennlne the Intent of the medication order. Attempts to contact the prescriber must be documented. If the prescriber cannot be contactedrreached within a reasonable amount of time. or there is still a safety concern at'br discussion with prescriber. see the chain of command policy for next steps. The pharmacist must communicate any delays in therapy to the nurse caring for the or charge nurse. if any change is necessary to an existing order. a new order must be obtained. 7. DISCONTINUING OR CHANGING A MEDICATION ORDER: b. When a medication is discontinued. the medication discontinuation will be re?ected on the MAR and doses returned to the Pharmacy. Changes in medication therapy should be addressed in the same manner as medication discontinuation. The previous order will need to be discontinued and a new medication order provided. If the order on the phan'nacy medication pro?le can be changedlmoditied in a manner that allows for an audit trail to the original order. this method can be performed. Once the changed medication order is prepared. It must be checked as if a new order. Medication can be discontinued per a previous active order using the order oomrnunlcatlon type of "Department? when a new order supersedes a previously dated active order. If there Is a question about the appropriateness the previous order. the prescrbar should be contacted. (Trinity Health ?Management of Electronic Orders" system policy rr 17-05). B. CONCENTRATION OF AN INTRAVENOUS MEDICATION: a. b. Refer to IV Guidelines for approved concentrations of IV medications. When an increased or decreased concentration is desired and the drug has two approved concentrations. the prescriber can order to maximize or minimize the concentration of the drug. PageooHo Regulatory 02/04/2019 16:44:66 #22274 MOUNT CARMEL POLICYIPROCEDURE coarser: c. When an Increased or decreased concentration ls desired and the drug has more than two approved concentrations. a prescriber must specify the speci?c concentrations to be used. 9. ORDER PRIORITIY: Order Pn'o?' Timeil'emsT STAT To be administered within 30 minutes? be administered within 80 minutes Routine To be administered within 2 hours or next 10. 11. . scheduled time medication orders - to include sequential antbiolics wh'oh needs to have the Initial Antibiotic administered within 30 minutes. For drugs that must be mixed. large volume intravenous (IV) ?uids and iv administration. the timelrame of administration is within 60 minutes. STAT medications: This designation ls reserved for highest priority orders Lite threatening situations). Although STAT orders have a maximum tumeround time of 30 minutes. in many cases they need to be ?lled immediately. depending on the situation. The prompt distribution of the medication from the pharmacy Is essential in these cases. When a prescriber?s order tor a medication ls ordered it should be processed imrnadiately. The nurse and the pharmacist decide upon the best method of delivery to avoid delay. Any written orders should be retrieved and reviewed as soon as possible by the pharmacy. ASAP medica?ons (as soon as possible): This designation is meant for situations that are not life-threatening. but where completion of the order will have signi?cant clinical or throughput implications. Historically. the term 'now' has also been used. and this should also be interpreted to be in the ASAP order priority. Routine medications: This designation is for non-urgent orders MULTIPLE ADMINISTRATION ROUTES: If multiple administration routes are prescribed. the following sequence should occur: 1. Ascertain that all options are viable for the patient (is. Ability to swallow. level of consciousness. presence of IV access. presence of nausea and vomiting) 2. The IM route is the least preferable for most medications due to patient discomfort and ?uctuations In absorption 3. If rapid response Is needed (Le. severe pain level. new post-operative patient) consider absorption time of IV versus oral administration 4. Consider patient prelorence and effectiveness of previously administered doses. PRN MEDICATION ORDERS: Pagetiolts Regulatory 02/04/2010 16:46:10 #22274 MOUNT CARMEL POLICYIPROCEDURE SUBJECT: HEW The phan'neclst is responsible for assuring appropriate and safe procedures are followed. The frequency with which ?as needed' medications may be administered must be monitored to avoid interactions with other medications and to avoid exceeding maximum recommended dosing. a. b. medication prior to administration. All PRN medication orders must state frequency and indication for use of the PRN if two or more PRN medications for the same Indication are ordered. the order of administration or parameters must be clearly stated. 1. Example for antlemetic medication Promethazine (Phenergan) 6.25 mg iv every 6 hours as needed for nausea. if nausea is unrelieved by Promethezlne. give Ondansetron (Zofran) '4 mg iv every 24 hours as needed for nausea. Example for pain medication Acetaminophen (Tyienoii?i) 325 mg 1-2 tabletis) orally every 4 hours as necessary for mild pain 5 mgIAcetamincphen 325 mg (Narcoiai) 1-2 tablet(s) orally every 4 hours as necessary for moderate pain Morphine sulfate 2 mg IV every 4 hours as necessary for severe pain PRN ain medications Patients Pain Score . PRN indication 1to3 4108 7to10 12. a. i Mild Pain Moderate Pain Severe Pain . 1 RANGE ORDERS: (Not applicable to Hospice) When an order is written that includes a dosage range. the instructions on how the nurse determines what dose to administer should be included in the physician's order. in the absence of specific instruction. the nurse will administer the medication according to the following guidelines: (Refer to Administrative Policy: Pain Management). Refer to Patient's Pain Score table in if 11c. r. Patient's Pain Score Acilontobetaiten 1 to 3 (mild pain) 4 to 6 (moderate pain) 7 to intimate pain) Administer lowest dosage in the prescribed dose to Administer the lowest dosage that has been effective. if necessary. there will be escstated upward. not to exceed the upper limit of the .mrl??dmse rinse Administer the highest dosage in the prescribed dosage range 10 (Pain unresolved sitar administering the hig hest dose1_ 10 (acute pain. new onset. unknown etiology) Contact the prescriber for reassessment of the patients needs Contact the prescriber for reassessment of patients needs Pagerdls RegulatoryTO:9814-6642416 02/04/2019 16:45:43 #22274 MOUNT CARMEL POLICYIPROCEDURE b. When a medication is ordered that Includes a range of frequency every 4 6 hrs). the order will be interpreted as the shortest interval every 4 hours). Bennett ?12qu Transom entire M255. _Every 3-4 hours Em 3 hours Every 6-8 hours Every 6 hours I Morphine 24mg IV every 4-6 ho_u_r Morphine 24mg IV every 4 hour PR?painM c. For other medications anti-pyrotlcs. anti-emetics. laxatives. antacids. stool softeners. sntl-?stuience. sedatives. hypnotlcs. sleep aids. antihistamines) give the lowest dose range prescribed and reassess for desired effects as appropriate for the medication. if relief is not obtained. the subsequent doses should be administered. 13. STANDING ORDERS: (the same as "protocoi') Standing orders are de?ned as written instruction to administer a medication In circumstances speci?ed without a prescription. These are not to be confused with pro-printed orders. Standing orderiProtocoI is further de?ned as: 1. A definitive set of treatment guidelines that include de?nitive orders for drugs and their speci?ed dosages which may have been authorized by a prescriber (as de?ned by Administrative Code 4729-5-15) and have been approved by the state board of pharmacy to be used by certi?ed or licensed health care profusslonals when providing limited medical services to in an emergency situation when the services of a prescriber are not immediately available. or; 2. A de?nitive set of treatment guidelines that include de?nitive orders for drugs and their speci?ed dosages which have been authorised by a presonber (as de?ned by Administrative Code 4729-5-15) and have been approved by the state board of pharmacy to be used by certi?ed or licensed health care professionals when administering biologicals or vaccines to Individuals for the purpose of preventing disease: or 3. A de?nitive set of treattnent guidelines that include de?nitive oders for drugs and their specified dosages which have been authorized by a prescriber (as de?ned by Administrative Code 4729-5-15) and have been approved by the state board of pharmacy to be used by certi?ed or licensed health care professionals when administering vitamin for prevention of vitamin de?cient bleeding in newborns: or 4. A de?nitive set of beatrnent guidelines that include de?nitive orders for drugs and their specified dosages which have been authorised by a prescriber (as de?ned by Administrative Code 4729-5-15) and have been approved by the state board of pharmacy to be used by certi?ed or licensed health care Psgeboi'ts HegulatoryTO:98146642418 02/04/2010 16:46:00 #22274 WEI: MOUNT CARMEL POLICWPROCEDURE professlonals when administering for prevention of necnstorum; or A de?nitive set of treatment guidelines that include patient speci?c and dose speci?c orders for the administration of a speci?c drug that have been authorized by a prescriber to be used when the services of that prescriber are not immediately available. The state board of pharmacy must approve the treatment guidelines prior to implementation. b. Appropriate use of standing ordersiprotocols: A protocol may only be used In a true emergency or for reasons outlined The protocol from the authorized prescriber must speci?cally de?ne the intended patient population: list the drug name and strength. and for purposes of emergency protocols. give specific instructions on how to administer the drug. including dose and frequency: for purposes of biologicais or vaccines. give speci?c instructions for use of the dmg. c. The use of standing ordersiprotocoi must be documented as an order In the patiemt's electronic health record (EHR). as soon as appropriate. d. Standing are approved by the medical staff. a. Standing ordersiprotocols cannot be altered without a prescrber's order. f. The only standing used at Mount Camel are outlined in the chart below: Drug Intended Purpose Order Patient DetailsiDomnrente Population - Ery?iromycin 0.5% Newboms i Prevention of ophthalmia 1 application to each ointment neonatorurn . :1 within first hour alter I birth Phytonadione 1 mg Newborns Prevention of Vitamin 1 mg at injedicn de?cient bieeding in within ?rst hour after birth . newhoms in?uenza Vaccine inpatients Disease pro-53mm 0. 5 mi IM :1 Pneumococcsi Inpatients Disease prevention 0.5 mi :1 vaccine .. In?uenza Vaccine Mobile Coach! Disease prevention 0.5 mi iM art Street Medicine .. patients .. - Pneumococcsi Mobile Coach! Disease prevention 0.5 ml lid :1 Vaccine Street Medicine . .. patients Tdap vaccine Mobile Coach! Disease prevention 0.5 ml iM art Street Medicine patients g. Prior to administration of a vaccine. the patient will receive education regarding the vaccine and the RN will document that education was provided In the EHR. 14. HOLDING A MEDICATION: Regulatory 02/04/2019 18:46:31 #22274 MOUNT CARMEL POLICYIPROCEDURE some HEW 15order ls written to hold a dose of medication based upon conditions. the order will remain active. (example: hold for SBP less than 120. hold for HR less than 60. hold single dose of b. if an order is to hold a medication with no criteria to restart. the medication will be discontinued and a new order will be required. AUTOMATIC STOP ORDERS: a. Some medications have strict recommendations not to exceed a certain length of therapy. Fon'nulary medications with hard stops include: 1. Dseltamivir- 5 days 2. Ketorolac-ti days 3. Pantoprazole injection- 3 days b. Other medications have a soft stop of 30 days unless a speci?c time or number of doses has been prescribed. Weaningrrapering medication orders must include the process for weaningltapering the amount the dose is to be decreased for each step and the frequency (not applicable to Hospice). The order must specify the sequence of medication titration and discontinuation if there is more than one medication with the same titration parameterts) and infusing simultaneously. Orders for compounded medications or medication mixtures not commercially available will be accepted by phan'nacy. Medications will be compounded according to Pharmacy's standardized approved fomtulas unless othemisc speci?ed in prescriber's order. ELECTRONIC ORDER MANAGEMENT: c. There are special considerations when managing electronic medication orders. It is important for healthcare professionals to understand the electronic health record (EHR) functionality and to use it correctly. b. There are various Medication Order Communication types in EHR. Some communication types are designed for use by particular healthcare professionals. Some communication types require a physician signature while others do not. See Addendum A which outlines ?re proper use of Medication Order Communications. c. Within Medication Manager (the Pharmacy part of EHR). pharmacists may take certain pro?le actions on medication orders. See Addendum which outlines the proper use and purposes of various pro?le actions. 19. OUTPATIENT PRESCRIPTIONS GENERATED FROM ELECTRONIC HEALTH a. All non-controlled substances prescriptions created in the EHR by a LIP must include the following for (pursuant of GAG 4729-5-30): i. issue date ii. Full name. professional title. and address of the prescriber Ili. Full name. residential address of the patient iv. Drug name and strength v. Quantity to dispense nanometre Regulatory ?196145642416 02/04/2010 16:46:54 #22274 MOUNT CARMEL JSUBJE vi. Appropriate and explicit directions for use vii. Number of re?il. maximum of 1 1. outltatient prescriptions need to be manually signed on the day issued by the prescriber in the same manner as heIshe would sign a check or legal document or other approved method of positive identi?cation. b. All controlled substances prescriptions created In the EHR by an LIP must include the following in addition to the non-controlled substances requirements: i. Quantity to dispense In numerically AND alphabetically. ii. Number of re?il, a. Category II. no re?ll. D. Category and IV. maximum tit of 5. c. Category V. maximum of 11. Ill. Drug Enforcement Administration (DEA) number. iv. Diagnosis code c. The "agent? of prescriber is de?ned as a person who has an employer-employee relationship with the prescriber. regardless whether controlled or non-controlled substances. d. Only LIPs or the prescriber's agent are authorized to create an out-patient prescription using the EHR prescription writer. e. Hospital employed colleagues are not permitted on behalf of a prescriber to create and print or fax. create and transmit electronically or call to a pharmacy a verbal prescription as an agent of the LIP. f. In the event an electronically generated prescription needs voided after electronic transmittal. the LIP needs to contact the pharmacy where the prescription was transmitted electmnically. in addition to voiding the prescription in the EHR. g. In the event a prescription printed and manually authenticated by an LIP needs to be voided. then "void" needs written across the prescription. Ensure the voided prescription is placed with other health care documents for submission into the EHR. This action is completed by LIP. a pharmacist or nurse. h. Preferred method for generating cut-patient prescriptions is through the electronic ordering process (e-prescribe) to avoid diversion opportunities. with exceptions being. no prefenled Identitled by patient or EHR downtime. RESPONSIBLE PERSONS: Pharmacy. Nursing. Prescribers REFERENCES: Admitistretive PIP ?Physician Orders? MCHS iv Guidelines DEVELOPED BY: Medication Management Team ORIGINAL ISSUE DATE: 5MB Page" ct15 Regulatory "106146342418 02/04/2019 18:47:14 #22274 MOUNT CARMEL POLICYIPROCEDURE MT: JIEDICATIQPLQEQE BS. REVIEWIREVISION DATES: BIOS. 11MB, 2M9. W09. 310. 8110. 9?10. 12110. 4H1. 3111. 4I12. 1W12, 2/13. 8H4. 9114. 216.9116. W17. 1I1I REPLACES: Administrative PolicyIProcedure ?Medication Orders" REVIEWED BY: Pharmacy Pollcy and Procedure Team 1110119 Admlniatratlva Policy Team via email vote W19 Mr mm Chlaf Pharmacy O?lcar Date APPROVED FOR IMPLEMENTATION BY: Mount Carmel Leadership Accredltatlon Councll DATE: via email vote ?16119 Page?lchw Regulatory 02/04/2010 10:47:23 #22274 MOUNT CARMEL POLIGYIPROOEDURE WT: ADDENDUM A: Proper use of Medication Order Communication Types In Corner Emumcation Description Entered by licensed? heelthcare Requires Twill II professional as slowed within their physician in respective iewi scope of practice. signature All AHP Cir-sign Used by heeiih care who are not Anesthesia Assistant Yes licensed or credentialed to Independently car-gm Registered um. Dependent preecrlie. Anesthetist on scope of Prescriptive . - auntie-rite AHP Orders entered from Surgical Anesthesia Anesthesiologist No Module (SAM). Certified Registered Nurse Anesthetist (SAM med orders) Deperlment Used when. there is an mpmved policy and or Dietician (enteral therapy related" 'No guidelines to manage a patients medication products ONLY) lh-rapv. Pharmacist Respiratory therep'lt- modality of reepirem medications 0.9%Na0liheparin flushes all users with IV line monument as scope of practice Viemiri 1mm.5ml in] raid . oph?'ielmic dint 0.5% 1 gram Discentinueticnts) ONLY per this policy for all users with medication Management as scope or practice tired given in One time medication order when'a medication is Cardiovascular Scnoprepher No error. No order given to a patient without an order and in error. The Radiology Technologist RegisteredNuree WM Resummeraplat PhoneIRepe Order received over the phone. The process must Advanced Practice Nurse Yes continued - include entering the order into the system and Cardiovascular Socceruher reading it back to the prescrher unto continue it Dieticlan has been correctly received. Pharmacist Physician Assistant Radiology Technciopm Registered Nurse Respiratory Therapist Prescribing Any student (Med. PA. APRN) with the atlhority to Student with medication ordering Yes Student cc-slgn prescribe enters the order. (Betcretheordersere aeecopeofprectice processed end visible to other heelthcere professionals requires cc-sipneture by prescritier) Pug-rem: Regulatory T0381 46642418 02/04/2019 16:47:44 #22274 MOUNT CARMEL POLICYIPROCEDURE m1: EDIGA Communication Description Entered a; "cased hedthoere Requiree Tm- II ee eiiowed within their physician displayed In reepeclive iegel ecope of practice. signature Corner . Protocol No use of this communication type for medicetions . Yes I in the Mount GerrneI Byetem . Transcribed Ordere entered into the wow when it verbal Carnality?ohm? Sonoprepher Yes Verbal 1mm" ellthorized heelih core though not Phenneciet entered into the system by the person. Primarily Radiology edinologi need to enter orders alter a downtimeidisruption. m: It order entered electronically by heelihcere protesslonel other than phanneciet. phenneciet must have source document to cheat order entry. ?eneoribed Provider electronically enters (writee) an older?into cardioveeculer Bonemepher No Written the eyetem OR documents and signs written orders Dieilolan on phyeicien ordering paper or paper prescription. Phermeciet Note: if order entered electronically by heelthcere . professional other than phenneclet. phenneo'et I must have source document to check order entry. ?g?mm Therapist Verbal Repeated Order verbally received and entered Into the Advanced Practice Nurse You a con?rmed mien. The must Include entering otthe Cardiovascular Smograpnar ?if ?'10 0?01?" I?d 11 back to the Dieticien prescriber who oon?nne it nee been correctly Pharmacist mm Phyeicien Aeeiltent Homology Technologist I Regieiered Home .. Respiratory Therapist Written Order entered or Mittenielgned on with No layer by prescriber. Moth *"The following communication types are not to be used by pharmacists In MedManaoer: Planned order. Nursing intervention? Regulatory ?338146642416 02/04/2019 16:48:03 #22274 MOUNT CARMEL POLICYIPROCEDURE Mr Proper Use of Medication Pro?le Actions "some ?Hum-$Jeane} bypaes actions meted error Verifies review. Approprieteto ueeforordere that have been dleoontlnued In Accept Powerohert b1 greecrlherregent of the preso?ber canoe! en un-diepeneed order lor which charges were credited all future leek: on MAR will he removed and overdue leeks (un- Cancel administered doeui remein on the MAR Cop! In Inviting dboonilnueo order as temgleie to ?giggly!? grger dieoontinuee an order and removes future take (done) from MAR end overdue teak: (uh-administered doses) remain on the MAR Dieoontlnue remain on the MR Hilton-L .. review ell end diloen?llieluw for an order inquire review deteite for en exieilno order Intervene intervention documentation Willi Ell generate labels as rat-quiet! Modify eILogg certarl'l ?elds or the order to he changed. Pele .. allows for lebel to print for Lon rejection of on order means there is oonoern with the order (drug. done. Mum!) No order details will he ehovm or time of rejection. Reject Phenneov must oontegt?e woman for follow up Renew renew an order that hes angled-lg slop due for a new period Hmhedule ediuet the iirnee reeled en Orderfor on drilling slop date for a new period Snead .. A Elitdtl orderilgn On Hold statue Vern: on themes patient. wrong drug. ore neworder . needs to be changed. This notion removes all overdue leeke (un-edminieiered dam) end future Void PegelSoHd Regulatory ?196146642416 02/04/2019 18:48:24 #22274 MOUNT CARMEL DEPARTMENT OVERSIGHT AND MAINTENANCE: Care Services POLICY: Palliative Ventilator Withdrawal (PWV) is the provision of comfort measures for a seriously ill patient for whom continuing mechanical ventilation has been determined to be clinically inappropriate or unwanted by patient. RESPONSIBLE PERSONS: Critical Care Units. Acute Palliative Care Units. Physicians. Advanced Practice Registered Nurse (APRN). Physician Assistant (PA). Palliative Medicine Consult Team. Pharmacy. Chaplaincy. Respiratory Services PROCEDURE: Initial Guided Discussion to Establish a Plan 1. Review the clinical picture. 2. Establish that goalsiexpectaiions of PVW are unified. 3. Review the plan with the attending physician or critical care physician. other involved physicians. nurses and therapists. 4. Consult with system Ethics Committee as needed. Follow-Up Discussion to implement the Plan .Clarlfy the DNR status and the rationale for not re-intubating. identify treatments to be continued and moss treatments to be discontinued. Determine the palientli'amily decision maker's understanding of what will happen after extubation. Review the palliative management of likely to occur during PVW Detennine when the PVW will occur and if the patient wit remain in the or be transferred to the APCU. 0 Allow a minimum of one hour after PVW before transferring to APCU - Provide seamless hand-off of care through communication and collaboration beMeen transferring and receiving units 6. Determine who will be present during the PVW. 7. Discontinue medications that require ventilator support. including but not limited to. paralytic agents. Vetsed. propofol 8. After discontinuation of above medica?ons. confer with pharmacy regarding the length of time needed prior to extubltlon. to ensure discontinued medications are no longer active. Immediately Prior to PVW 1. Facilitate private time for patient and family 2. Offer the presence of a spirituallreligious professional Implementation of Management Medication Orders 1. Physician. APRN. andior PA ls required to utilize Palliative Ventilator Withdraw (PVW) PowerPlan 1of3 Regulatory ?10614564241 8 02/04/2010 16:48:44 #22274 .LNDOW weal-l Emu; Jo mule? u\ SiHb?i? NOLLVZINVEDEI HDIH Regulatory ?106146642418 02/ 04/2010 16:40:53 #22274 JASMEIAOHJNOD CINV EIDNEITIVHC) .LV NVLS HHEIHM 10:8 GNV NI EIH EIHEIHM SI NVW EIHHSVEW awwm-n .LVHJ. SDNIHL 3M AVG 0.L NIDEIS rm? AGENDA S.B.A.R. - High Risk Medicatidn Dosing ZeroHarm Culture Principals 5- High Reliability Organizations i- Behavior Expectations/Error Prevention Tools Power Gradient Scope of Practice] Nursing - Pharmacy Palliative Care Ventilator Withdrawal Power Pla n/Policy Pharmacy Review vs. Override . Verbal Order Policy Pain Scale for Intubated Patients - Documentation Regulatory ?3138145642418 02/04/2019 18:49:!5 #22214- Situation: High doses of medication were administered outside of Mount Carmel's IV guidelines. Background: The Palliative Ventilator Withdrawal policy provides guidance for the provision of comfort measures for a patient for whom continuing mechanical ventilation has been determined to be clinically inappropriate or unwanted by the patient. Assessment: A review of our opportunities revealed a need for consistency around treatment of palliative patients being terminally weaned from a ventilator: Recommendation: Provide education to clinicians regarding appropriate comfort care for palliative patients who are being weaned from a ventilator. Regulatory 02/04/2010 16:40:16 #22274 STARTS ?1.th PATIENT 1 I SAFETY -I- EXPERIENCE THE CARE EXPERIENCE Mount Carmel?s care experience plus our staff's engagement are how we deliver on our promise? to put people at the center of Zero is the only acceptable goal everything we 110- -Beoouse one is too mam: Reamorces - - - Em?hasize: that awor lIll'l'l-I eat one 0 us Expectations YOU is accountable Connects to our Because oi YOU brand to further strengthen Consistent way to visually tie together recognition education and communications People are at the center of evewthinq we GOAL: Eliminate preventable harm throughout do and that means safety is our first responsibility our system for patients and colleagues Regulatory T0301 46842410 02/04/2010 10:40:30 #22274 Zerol-larm HIGH-RELIABILITY ORGANIZATION PREOCCUPATION WITH FAILURE Don't i nore any failuirae,I no matter how small, they think a out how things can i . SENSITIVITY T0 OPERATIONS Focus on the actual situation and rely on their frontline for the best picture of the situation. RELUCTANCE To Don?t explain away problems, they ask questions and dig deep to find answers. COMMITMENT To RESILIENCE - Never give up even when it?s hard, they adapt and bounce back. DEFERENCE To EXPERTISE Recognize that expertise is not based on authority. "?lersegi'lg :P-a Jean-Jesus $33-34 a. Regulatory ?396146642418 02/ 04/2019 16:49:43 #22274 P151 I 072 STA RT zenmgHARM ??11 IE BEHAVIOR EXPECTATIONS ERROR PREVENTION TOOLS 9 SPEAK UP in Alla: II Up Comm. chaln Hammad} 0 TEAMWORK mm" b- sun-m 0 ATTENTION TO DETAIL sun Ism. Think. nun-um a RELIABLE COMMUNICATIONS II- sun (summamm. Ir- 37"? Blunt-8 Hard-35d: using Clu??cltlans 0 THINK IT THROUGH Regulatory ?19814584241 8 02/04/2019 18:49:68 #22274 POWER GRADIENT Geert Hofstede?s Power Distance - Extent to which the less powerful expect and accept that power is distributed uneq uallv - Leads to strong Authority Gradients, which is the perception of authority as perceived by the subordinate United States - Moderate to low Power Distance (38th of 50 countries) Er . In Healthcare - High between certain professional groups: - Some Practitioners and nurses - Some nurses and other clinical staff - Some leaders and staff Regulatory 02/04/2010 18:50:11 #22274 072 .. . ARCC it Up to escalate concerns - We all have a responsibility to protect our patients and coworkers from harm. - If you see or hear something that is a safety issue, escalate your concern in a mutually respectlul manner. Assert yourself, but don't be aggressive or rude. Ask a question Request a change offer another alternative Still no response? Voice a Concern - use Safety Phrase: have a If no success, Escalate up Chain of Command Regulatory ?106146842416 02/ 04/2010 16:60:42 #22274 . SITUATION - The Practitioner enters a medication order and pharmacist reviews the order. The nurse is now ready to obtain the medication from Pyxis and realizes that it will take numerous vials to complete the dose. The nurse is concerned about this and tried to clarify the order with the Practitioner but the Practitioner still wants the medication given. What should the nurse do? A-RCC it up 10 Regulatory 02/04/2010 15:50:58 #22274 SITUATION Under the Nurse Practice Act - when clarifying an order, the RN shall, in a timely manner: 1. Consult with an appropriate licensed practitioner; 2. Notify the ordering practitioner when thefRN makes the decision not to follow the order or administer the medication or treatment, including the reason for not doing so, and; 3. Document that the practitioner was notified of the decision not to follow the order or administer the medication or treatment, including the reason for not doing so; and 4. Take any other action needed to assure the safety of the patient 2.1 Regulatory 02/04/2010 16:51:10 #22274 Na WAYS TO ARCC iT DIRECT COMMUNICATION SUPERVISORICHARGE NURSEIHOUSE SUPERVISOR FRONT LINE MANAGER LEADER ADMINISTRATOR ON CALL ?Hospital and System" 24x7 PATIENT SAF OFFICER - Katie Barga MCWIMCGC EXECUTIVE TEAM Sean McKihben, President lean nette Canasta. Director of HR Larry Swanner, MD, VPMA Chellee Hamilton, VP Operations Dina Bush, VPICNO Rosa Shi?nan, Quality Business Partner - System Executive Team Ed Lamb, CEO Marv LaFrananis, Senior VP HR Rick Streak, MD, Chief Operations Officer Katrina Trimhle, VP Compliance and Integri'wr Dan Haclett, VP Legal Tauana McDonald. Chief Administrative Of?cer Hollyl Reardon, VP of (nullityr VOICE REPORTING SYSTEM MCITRINITY INTEGRITY HOTLINE Regulatory 02/04/2010 10:51:23 #22274 .. Na, SCOPE OF PRACTICE - Scopes of practice describes the services that a qualified health professional is deemed to perform, and permitted to undertake in keeping with the terms of their professional license - We are held to the American Nurses Association, Nurse Practice Act and State Law, The Joint Commission, Ohio Department of Health, DEA 13 Regulatory ?106145842418 02/04/2010 16:51:38 #22274 P1501072 ?g SCOPE or PRACTICE - - Nurses Responsible for: Pharmacists Responsible for: Compliance with the American Compliance With the Ohio Board Nurses Association, Nurse 0f Pharmacy rules _and Practice Act and State Lainr, regulations, il'he The joint Commission Ohio Commissmn, 0th Department of Health, DEA, and other Department of Health, DEA Federal requirements Compliance ?_With all . Medication order prospective documentation requirements drug utilization review per Ohio of the Ohio Board of Nursing State Board of Pharmacy . Hospital-based Standards and - Compliance with all Policies documentation requirements per Ohio Board of Pharmacy - Hospital-based Standards and Policies 14 Regulatory ?106146842418 02/04/2010 18:51:47 #22274 L. VERBAL ORDER POLICY TJC Standard MM.O4.01.01 (element A6) The hospital minimizes the use of verbal and telephone medication orders. (Departments with 24/7 Practitioner coverage should not use ?verbal orders function with the exception of medications used in emergencies i. e. ACLS) MCHS Practitioner Orders" Policy; VERBAL OR TELEPHONE ORDERS Verbal or telephone orders are to be limited and restricted to: El Emergent situations. El When clinical situations make it impractical for orders to be entered into the EHR or written on the appropriate form for the non-EHR sites. CI Situations when Practitioners do not have access to remote computer devices or the patient?s chart. 15 HegulatoryTO:06146842418 02/04/2010 16:52:02 #22274 $133, PALLIATIVE VENTILATOR WITH DRAWAL POWER PLAN ADVISORY: Evaluate need for sedation in the comatose patient. Titrate medications to achieve desired comfort level and sedation prior to removing ventilator. ADVISORY: Goal of medication management in withdrawal of support is titration of medication to assure patient comfort. Patient should appear to be resting comfortably with no pain behaviors or grimacing. Consider using heart rate greater than 100 or respirations greater than 30 as objective ?ndings of distress. Prepare for withdrawal of ventilator support Communication Order Patient Care Withdrawal ventilator support when level of comfort is within desired limits (no grimacing, no agitation, comfortable respiratory rate (30 breaths/minute or less) Communication Order Patient Care For increased distress or agitation administer opioids or anxiolvtics as ordered. Communication Order Patient Care Organ Procurement Agency must be noti?ed prior to ventiiator removal. :5 Regulatory ?19814564241 6 02/ 04/2010 16:62:18 #22274 P.031 l072 PALLIATIVE VENTILATOR WITHDRAWAI. POWER PLAN EVIDENCE: Guide for Withdrawing Terminal Patients From Ventilator Support, Principle of Double Effect. Pha rmacv Communication Order Morphine (Morphine Inj.) 10 mg, IV Push, Inject Once Morphine {Morphine Inj.) 1 mg, IV Push, Inject, (115mm, PRN, Shortness of Breath Morphine (Morphine Inj.) 2 mg, IV-Push, Inject, th, PRN, Shortness of Breath HYDROmorphone (-Dilaudid Inj.) 0.5 mg, IV Push, Inject, 0.15min, PRN, Shortness of Breath Morphine 100 mL N5 (std2)* Titrate See Comments, 100 ml, Infusion Morphine 200 mL NS (std2)* Titrate See Comments, IV, 100ml Midazolam (Versed Inj?) 2 mg, IV Push, Inject, Once, ASAP Regulatory "338145642416 02/04/2019 18:62:38 #22274 PALLIATIVE VENTILATOR WITH DRAWAL POWER PLAN ADVISORY: Continuous Infusion Rate Should be 50% of Bolus Dose Per Hour Versed 50 mg/SO mL NS IV, 50 mL, Infusion (std2}* LORazepam (Ativan 0.5 mg, m, lject, (115min, PRN, Agitation LORazepam (Ativan lnj?) 0.5 mg, IV, Inject, 04h, -PRN, Agitation Atropine (Atropine-0.1 mg/mL 0.5 mg, Subcut, Inject, 0.1h, PRN Syringe 10 mL) 13 Regulatory 02/04/2010 18:52:67 #22274 3' PALLIATIVE VENTILATOR WITHDRAWAL - Key Updates to Palliative Ventilator Withdrawal (PVW) Policy Effective 12/12/2018 1. WW Power Plan must be utilized Practitioner must electronically enter their own PVW Power Plan orders E2 verbal orders for PM Power Plan Medication dosing outside of Power Plan, or medications not included on Power Plan, Practitioner-must obtain approval per policy Practitioner or RN cannot administer PVW medications until verified 19 Regulatory T0381 45642418 02/04/2019 16:63:12 #22274 P.064I072 3% PYXIS OVERIDE Joint Commission Standard requires pharmacist review of all medication orders. Two exceptions are allowed: a. When a licensed independent Practitioner controls the ordering, preparation and administration of the medication; or b. When a delay would harm the patient in an urgent/emergency situation including sudden changes in a patients clinical status. Examples of appropriate emergency situations: - Code Blue, Anaphylaxls Examples of sltua trans that require pharmacist review: - Palliative Extubatlon EU Regulatory ?108145642416 02/ 04/2010 16:63:24 #22274 PYXIS OVERRIDE EXAMPLES Override Medications are not to be used for the purpose of non-emergent situations including Palliative Ventilator Weaning - Over-ride is appropriate in unplanned emergency situations, such as intubation 21 Hauulatury T0361 45842416 02/ 04/2010 16:63:37 #22274 CPOT PAIN SCALE - in the ICU, the Critical Care Pain Observation Tool (CPOT) is used for non-verbal patients - For non?verbal patients, this is the appropriate tool to use for documentation of patient pain assessment 22 Regulatory ?198146642416 02/04/2010 18:53:47 #22274 indicator Wen Soon Facial Wu Humanitarian! observed helix-d, mutrai brunt orbit tightening, Tense and Manor contraction All at the am facial movements pin eyeld ti?itly Grinathg closed Mm manual-ems absence oi pain) Slow, menu. tending or rubbing the Protection will me. reeling attention throum ms tulle. attempting to sit up. running 1 th mm thrashing, not following ?unmade. sitting at still. trying todiinb out oi lied allude temion Ho resistance to penile movements Relaxed emneion or upper unremes Strung resistance to passive merits. liability to Very m0! rigid mmplete them Compliam with the Alarms mt med. earmmatinn ventilator or (minted mm ?lm Alarms mp spontaneously (angling but tolenthg OB Wm: blunting ventilation. alarm frequently liming ventilator mm mma terminated patients] Talking in nannal tone er no mud Tilting In normal tone or no mind "Will"! ?ying. maxing Crying out, sobbiig Cm out, sobbiig Tail, range 0-3 23 BogulatoryTO:96146642418 02/04/2019 18:53:56 #2274 Documentation Requirements: Practitioner Conversation prior to DNR-CC order with family, or POA Order placed in Power Chart Post procedure note Comprehensive death note 2-1 Regulatory 02/04/2019 16:64:16 #22274 DOCUMENTATION REQUIREMENTS: - If a situation is identi?ed that requires prescriber clari?cation, the pharmacist will document the discussion; After discussion and if the pharmacist still has a safety concern, the pharmacist will communicate with prescriber using the safety phrase have a concern and need to escalate this up the chain of command? 25 Regulatory T131081 4664241 02/04/2010 16:54:25 #22274 P0701072 . DOCUMENTATION REQUIREMENTS: NURSING - Documentation should reflect (example PVW): 0 Prior to intervention - assessment of patient pain, agitation level, respirations and airway Post intervention assessment of patient pain, agitation level, respirations and airway to monitor effectiveness of intervention 'If you identify an order that causes you concern, review your concern with the Practitioner and document expressed concern After discussion, if there is still a safety concern, nurse will communicate with Practitioner the safety phrase have a concern and need to escalate this up the chain of command? Family present and support offered to the family/care partner 25 HegulatoryTO:96146642A-16 02/04/2019 16:54:35 #22274 o.c mmjozmw w. .3 ?324 WEE - .I.Islil .F: 111111n11 . i .12.: a Hag-??aw; pm w??iam ..