Every finding on record at Willamette Healthcare LLC

Based on interview and record review, it was determined that the hospice agency failed to check medication side-effects before administering a medication for 1 of 3 patient records reviewed (Patient #2). Findings: The review of documentation in the medical record revealed that Patient #2 was admitted on 3/5/2022 with a primary diagnosis of late effect cerebrovascular accident with vascular dementia. The review of undated documentation titled "Patient Information Report" revealed Patient #2's allergies to medication as follows: "AMBIEN, AUGMENTIN, CYMBALTA*, GUAIFENESIN, MIRTAZAPINE*, NICOTINE, OLIVE OIL, SOMA, SULFA." The document also indicated the guaifenesin allergy was entered on 1/4/2022 at 5:13:16 PM. The review of documentation on "HOSPICE PHYSICIAN ORDER," dated 3/30/2022, timed 11:22 AM, under "Current Ordered Medications:" revealed "ADD guaifenesin 100 mg/ml oral liquid... Start Date 3/30/2022 End Date 4/4/2022... Dose 10 ML 4 TIMES DAILY...ORAL... Reason: for 5 days for cough. Disp 1 bottle refill x 1." During an interview with Employee #1 and Employee #2 on 7/7/2022 at 1:00 PM, Employee #1 confirmed guaifenesin was administered to Patient #2 by the med-tech who worked at the facility Patient #2 resided. Employee #1 also stated "After the med-tech administered we were notified." When asked about the timeline the medication was administered to Patient #2, Employee #2 stated "I think it was on 3/30, if I am correct. When we got the phone call, it was at night so it may have carried to 3/31, that is when they notified us that they gave the dose. We were en route to assess [the patient] because [he/she] was complaining of symptoms of shortness of breath, but they had taken [him/her] to the hospital before we arrived." During the interview, Employee #1 stated "It is standard to be checking for the allergy before putting [entering] the medication in our EMR... The nurses are supposed to be checking the allergy list before writing orders...The order is given and signed. When it goes to our pharmacy, Onepoint looks at it and it is supposed to alert... it would say there is a medication to medication interference or allergy. Somehow that got missed. We are not sure how that happened. It also happened with the pharmacy that gave the medication to the facility we are not sure again how that got missed...The whole team including the medical director and the nurse practitioner [who ordered the medication] were notified of what had occurred and the safeguard in place did not alert us. That is why we did the education of the potential of this happening again. We have not had an incident like this in the past. We did also talk to our IT team that deals with our EMR to see if there is there a different way with the EMR to have an alert with allergy pop-up... I am not sure where they are at with that but our goal is really educating the nurses with signing and writing the orders. An email was sent that morning at 9:10, so there was a reminder education asking when writing or entering orders to check the patients' allergies. After that the next nursing meeting was on the 7th and it was a mandatory one in-person nursing meeting... A lot of education was also done with talking amongst the nurses because it became a huge thing after it happend." During an interview with Employee #1 and Employee #2 on 7/7/2022 at 1:30 PM, Employee #2 stated "We go over medication errors like as a general but it wasn't implemented into our QAPI meeting forward." When asked about the process of receiving medication orders, Employee #2 stated "The nurses get the order from the provider, they will input it in our EMR, it will go to the provider to get signed, and then that is when it gets sent to two pharmacies, which is our overseeing pharmacy, Onepoint, and then the dispensing pharmacy." Employee #1 stated "The nurse who wrote the order is not one of our regular nurses [he/she] is an agency nurse who still works with us, we have done more education with [him/her] on that. [He/she] is a traveler who we have as a contract. [He/she] was with us for quite a few months by this time and had known our process of checking and looking at things." During an interview with Employee #1 and Employee #2 on 7/7/2022 at 1:38 PM, Employee #1 stated "There is a tab within the system where it says allergies that people can look at. Employee #2 stated allergies list is located "In the medical record. It will also pop-up in the order after the order is written." The review of documentation on the "PLAN OF CARE UPDATE," dated 4/20/2022, timed 11:14 AM, revealed "HOSPICE NURSE TO ASSESS MEDICATION RESPONSE AND INSTRUCT ON SCHEDULE, ACTIONS, PURPOSE, SIDE EFFECTS, COMPLIANCE AND NEED TO REPORT SIDE EFFECTS TO HOSPICE STAFF." The review of the agency's policy and procedure with approved date of October 2020 and titled, "SAFE/EFFECTIVE USE OF MEDICATIONS," stipulated "2. The components of the medication assessment used to determine patient and family/caregiver knowledge and skill related to medication administration will include, but not limited to: A. Name, dosage, route, duration, time, and usage of medication, intended use as well as expected actions of drug therapy... E. Significant side effects, adverse reactions/interactions (including drug-to-drug and drug-food interactions) as well as contraindications and how to avoid and respond to such factors... 4. Using the written information, the clinician will review the key points required, based on patient knowledge and skills, as well as identified needs. This may include... A. teaching the patient the purpose and side effects of medications, and the patient's role in identifying and preventing medication errors."