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PRINTED: 11/19/2018FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDING(X3) DATE SURVEYCOMPLETEDC440039B. WINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1211 MEDICAL CENTER DRIVEVANDERBILT UNIVERSITY MEDICAL CENTER(X4) IDPREFIXTAG11/08/2018NASHVILLE, TN 37232SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)A 000 INITIAL COMMENTSPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EA 000An unannounced onsite survey was conducted10/31/18 to 11/8/18 to investigate complaint #TN00045852.An entrance conference was held with theRegulatory Officer, Accreditation Specialist andthe Senior Quality and Patient Advisor. They wereinformed of the nature of the complaint.A telephone exit conference was held on 11/8/18at 2:00 PM. The Regulatory Officer, AccreditationSpecialist and the Senior Quality and PatientAdvisor, and the Accreditation RegulatorySpecialist were notified of Immediate Jeopardy inthe areas of 482.13 Patient Rights, 482.23Nursing Services. They were afforded theopportunity to ask questions of the survey team.A 115 PATIENT RIGHTSCFR(s): 482.13A 115A hospital must protect and promote eachpatient's rights.This CONDITION is not met as evidenced by:Based on policy review, medical record review,and interview, the hospital failed to ensurepatients' rights were protected to receive care in asafe setting and implemented measures tomitigate risks of potential fatal medication errorsto the patients receiving care in the hospital.The failure of the hospital to mitigate risksassociated with medication errors and ensure allpatients' received care in a safe setting to protecttheir physical and emotional health and safetyplaced all patients in a SERIOUS andIMMEDIATE THREAT and placed them inLABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE(X6) DATETITLEAny deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined thatother safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 daysfollowing the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continuedprogram participation.FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: NVYT11Facility ID: TNP53127If continuation sheet Page 1 of 56

PRINTED: 11/19/2018FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDING(X3) DATE SURVEYCOMPLETEDC440039B. WINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1211 MEDICAL CENTER DRIVEVANDERBILT UNIVERSITY MEDICAL CENTER(X4) IDPREFIXTAG11/08/2018NASHVILLE, TN 37232SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)A 115 Continued From page 1PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EA 115IMMEDIATE JEOPARDY and risk of seriousinjuries and/or death.The findings included:1. The hospital failed to ensure all patientsreceived care in a safe setting and staff followedstandards of practice and utilized their nursingskills and training to ensure the correctmedications were administered to all patients.Refer to A-01442. The hospital failed to ensure patients were freefrom neglect.Refer to A-0145A 144 PATIENT RIGHTS: CARE IN SAFE SETTINGCFR(s): 482.13(c)(2)A 144The patient has the right to receive care in a safesetting.This STANDARD is not met as evidenced by:Based on standards of practice, documentreview, review of hospital policies andprocedures, medical record review, and interview,the hospital failed to ensure all Critical CareRegistered Nurses (RN) implemented medicationpolicies and procedures pertaining to theadministration and monitoring of medications,including high-risk medications, and patientsreceived care in a safe setting for 1 of 5 (Patient#1) patients reviewed for medication errors.The failure of the hospital to ensure all nursesfollowed medication administration polices andprocedures resulted in a fatal medication error forPatient #1 and placed all patients in a SERIOUSand IMMEDIATE THREAT of their health andFORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: NVYT11Facility ID: TNP53127If continuation sheet Page 2 of 56

PRINTED: 11/19/2018FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDING(X3) DATE SURVEYCOMPLETEDC440039B. WINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1211 MEDICAL CENTER DRIVEVANDERBILT UNIVERSITY MEDICAL CENTER(X4) IDPREFIXTAG11/08/2018NASHVILLE, TN 37232SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)A 144 Continued From page 2PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EA 144safety and placed them in IMMEDIATEJEOPARDY for risk of serious injuries and/ordeath.The findings included:1. Review of the Lippincott Manual of NursingPractice 10th Edition documented, ".Watch thepatient's reaction to the drug during and afteradministration. Be alert for major adverse effects,such as.respiratory distress.NURSINGALERT.The nurse is ultimately accountable forthe drug administered."Review of the hospital's High Alert Medicationspolicy documented, ".High Alert Medications Medications that bear a heightened risk ofcausing significant patient harm when used inerror.Medication orders are reviewed by apharmacist prior to removal from floor stock or anautomated dispensing cabinet unless.A delaywould harm the patient (including suddenchanges in a patient's clinical status.Additionalstrategies are followed for a specified list of HighAlert Medications.Higher level decisionsupport.Independent Double-Check whereelectronic clinical systems prompt dual signoff."The medication Vecuronium (a neuromuscularblocking medication that causes paralysis andsubsequent death if not monitored accordingly)was listed in the policy as a high alert medication.There was no documentation in this policydetailing any procedure or guidance regarding themanner and frequency of monitoring patientsduring and after medications were administered.Review of the document ISMP List of High-AlertMedications in Acute Care Settings.ISMP 2018FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: NVYT11Facility ID: TNP53127If continuation sheet Page 3 of 56

PRINTED: 11/19/2018FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDING(X3) DATE SURVEYCOMPLETEDC440039B. WINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1211 MEDICAL CENTER DRIVEVANDERBILT UNIVERSITY MEDICAL CENTER(X4) IDPREFIXTAG11/08/2018NASHVILLE, TN 37232SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)A 144 Continued From page 3PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EA 144documented, ".High-alert medications are drugsthat bear a heightened risk of causing significantpatient harm when they are used inerror.Classes/Categories ofMedications.moderate sedation agents, IV[Intravenous] (e.g.[for example].midazolam[Versed].neuromuscular blocking agents(e.g.rocuronium, vecuronium)."Review of document Paralyzed by Mistakes:Reassess the Safety of Neuromuscular Blockersin Your Facility documented, ".Neuromuscularblocking agents are high-alert medicationsbecause of their well-documented history ofcausing catastrophic injuries or death when usedin error.Because neuromuscular blockersparalyze the muscles that are necessary forbreathing, some patients have died or sustainedserious, permanent injuries if the paralysis wasnot witnessed by a practitioner who couldintervene. After a patient receives aneuromuscular blocker, progressive paralysisdevelops, initially affecting the small musclegroups such as the face and hands, then movingto larger muscle groups in the extremities andtorso until all muscle groups are paralyzed andrespiration ceases. However, full consciousnessremains intact, and patients can experienceintense fear when they can no longer breathe.They can also sense pain. The experience can behorrific for patients.The most common type oferror with neuromuscular blockers appears to beadministration of the wrong drug.Practitionersthought they were administering a different drug,so patients may not have been supported withmechanical ventilation."Review of document titled Joint Commission eyesoverrides of dispensing cabinets dated May, 2018FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: NVYT11Facility ID: TNP53127If continuation sheet Page 4 of 56

PRINTED: 11/19/2018FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDING(X3) DATE SURVEYCOMPLETEDC440039B. WINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1211 MEDICAL CENTER DRIVEVANDERBILT UNIVERSITY MEDICAL CENTER(X4) IDPREFIXTAG11/08/2018NASHVILLE, TN 37232SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)A 144 Continued From page 4PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EA 144in the American Journal of Health-SystemPharmacy documented, ".vice president at theInstitute for Safe Medication Practices (ISMP)said her organization has long considered ADC[automated dispensing cabinet] overridespotentially problematic. One of the big problemswith automated dispensing cabinets is thatsometimes staff are overriding without having anorder." she said. "There's no verbal order writtendown, or they're anticipating an order, so they geta drug from the cabinet"."Review of the document titled Evaluation ofMedications Removed from AutomatedDispensing Machines [ADMs] Using the OverrideFunction Leading to Multiple System Changesdocumented, ".The override function allows anurse to remove a medication from the machinebefore a pharmacist reviews the order. Thepurpose of the override function is to allowaccess to medications in urgent/emergentsituations.Administering medications prior to apharmacist review increases the risk ofmedication errors.The challenge with ADMs is toprevent medication overrides in nonurgentsettings and to avoid administering medicationsfrom orders that have not been reviewed by apharmacist."Review of the document titled The DrugSummary for Midazolam Hydrochloride (Versed).Retrieved from PDR, 2018, http://www.pdr.netdocumented, ".CLASSES AnxiolyticsBenzodiazepine Sedative/Hypnotics OtherGeneral Anesthetics.Administration ofmidazolam requires an experienced cliniciantrained in the use of resuscitative equipment andskilled in airway management.Monitor patientsfor early signs of respiratory insufficiency,FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: NVYT11Facility ID: TNP53127If continuation sheet Page 5 of 56

PRINTED: 11/19/2018FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDING(X3) DATE SURVEYCOMPLETEDC440039B. WINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1211 MEDICAL CENTER DRIVEVANDERBILT UNIVERSITY MEDICAL CENTER(X4) IDPREFIXTAG11/08/2018NASHVILLE, TN 37232SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)A 144 Continued From page 5PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EA 144respiratory depression, hypoventilation, airwayobstruction, or apnea (i.e., via pulse oximetry),which may lead to hypoxia and/or cardiac arrest.Review of the Centers for Medicare and Medicaid(CMS) Interpretive Guidelines documented,".Hospital policies and procedures are expectedto address how the manner and frequency ofmonitoring, considering patient and drug riskfactors, are determined, as well as theinformation to be communicated at shift changes,including the hospital's requirements for themethod(s) of communication. Policies andprocedures related to IV medicationadministration must address those medicationsthe hospital has identified as high-alertmedications and the monitoring requirements forpatients receiving such drugs intravenously."Review of the hospital's policy titled MedicationAdministration documented, "[Named Hospital]staff validate the five rights of medicationadministration to minimize medicationerrors.Right patient; Right medication; Rightdose; Right route.Right time to adhere to theprescribed frequency and time ofadministration.Document medicationadministration in the electronic medical record toinclude, at a minimum, the following.Date andtime of administration; Medication name andstrength; Dosage of medicationadministered.Route of administration." Therewas no documentation in this policy detailing anyprocedure or guidance regarding the manner andfrequency of monitoring patients during and aftermedications were administered.2. Medical record review for Patient #1 revealedthe patient was admitted to the hospital onFORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: NVYT11Facility ID: TNP53127If continuation sheet Page 6 of 56

PRINTED: 11/19/2018FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDING(X3) DATE SURVEYCOMPLETEDC440039B. WINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1211 MEDICAL CENTER DRIVEVANDERBILT UNIVERSITY MEDICAL CENTER(X4) IDPREFIXTAG11/08/2018NASHVILLE, TN 37232SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)A 144 Continued From page 6PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EA 14412/24/17 with diagnoses of IntraparenchymalHematoma of the Brain, Headache,Homonymous Hemianopia (vision field loss ofboth eyes)-Left, Atrial Fibrillation, andHypertension. The record revealed the patientwas awake, alert and oriented and spent timeshopping prior to hospitalization.The record revealed Patient #1 was transportedto Radiology for a PET (Positron EmissionTomography) scan on 12/26/17 for a full bodyscan. The procedure was scheduled for 2:00 PM.There was no documentation in the medicalrecord the time the patient arrived in Radiology.Patient #1 was alert and oriented. While inRadiology Patient #1 requested something foranxiety before the PET scan procedure due tobeing claustrophobic.Review of the medication order #60651186 dated12/26/17 at 3:00 PM revealed the physicianordered Versed 2 milligrams (mgs) intravenouslyfor the patient's anxiety during the PET scanprocedure.Review of the Automatic Dispensing Cabinet(ADC) detail report revealed the order wasentered on 12/26/17 at 2:47 PM. Pharmacy hadverified the order at 2:49 PM.Review of the ADC detail report dated 12/26/17revealed at 2:59 PM Registered Nurse (RN) #1took the medication Vecuronium 10 mgs (aneuromuscular blocking agent which causesparalysis) from the ADC located in the NeuroIntensive Care Unit (ICU) using the overridefeature, instead of taking the Versed medicationthat was ordered for Patient #1. There was nophysician order for Patient #1 to receiveFORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: NVYT11Facility ID: TNP53127If continuation sheet Page 7 of 56

PRINTED: 11/19/2018FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDING(X3) DATE SURVEYCOMPLETEDC440039B. WINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1211 MEDICAL CENTER DRIVEVANDERBILT UNIVERSITY MEDICAL CENTER(X4) IDPREFIXTAG11/08/2018NASHVILLE, TN 37232SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)A 144 Continued From page 7PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EA 144Vecuronium. The override was not verified byPharmacy. There was no documentation in thepatient's medical record the RN had administeredthe Vecuronium to the patient.Review of a physician note dated 12/26/17 at3:45 PM revealed the physician documented,"Called for code in PET scanner, patient waspulseless and unresponsive on arrival. patientwas emergently intubated and retrieved ROSC[return of spontaneous circulation] after 2 - 3rounds of chest compressions. Patienttransferred to Neuro ICU".Review of the Nurse Practitioner's (NP) notedated 12/26/17 revealed the NP documented,"Patient was doing well and transferred to thestepdown unit. On 12/26/17, patient wasreadmitted to NCU [neuro critical care] aftersuffering cardiac arrest while while off the unit toundergo PET scan."Review of the physician's note dated 12/27/17revealed the physician documented, "I discussedthe case with the neurology team and it is felt thatthese changes in exam likely representprogression towards but not complete braindeath.very low likelihood of neurologicalrecovery, we made the decision to pursuecomfort care measures. [Patient #1] was made aDNR [do not resuscitate]." The physiciandocumented the patient was extubated (removedfrom mechanical ventilation) on 12/27/17 at 12:57AM and expired on 12/27/17 at 1:07 AM.3. Telephone interview with RN #1 on 11/5/18beginning at 4:41 PM, RN #1 was asked todescribe the circumstances leading up to Patient#1's death beginning on Tuesday 12/26/17. RNFORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: NVYT11Facility ID: TNP53127If continuation sheet Page 8 of 56

PRINTED: 11/19/2018FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDING(X3) DATE SURVEYCOMPLETEDC440039B. WINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1211 MEDICAL CENTER DRIVEVANDERBILT UNIVERSITY MEDICAL CENTER(X4) IDPREFIXTAG11/08/2018NASHVILLE, TN 37232SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)A 144 Continued From page 8PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EA 144#1 stated, "I was in a patient care role, I was thehelp-all nurse. A help-all nurse is a resourcenurse and I had an Orientee"RN #1 stated that RN #2 had asked her to godownstairs to Radiology PET scan and administerthe medication Versed to Patient #1 because thepatient was not able to tolerate the PET scanprocedure or they would have to send the patientback and reschedule it.RN #1 stated he/she searched for the Versedunder her profile in the ADC and he/she couldn'tfind it. The RN stated he/she then chose theoverride setting on the ADC and searched for theVersed.RN #1 stated she was talking to the Orienteewhile he/she was searching the ADC for theVersed and had typed in the first 2 letters ofVersed which are VE and chose the 1stmedication on the list.RN #1 stated he/she took out the medication vialout of the ADC, and looked at the back of the vialat the directions for how much to reconstitute itwith. RN #1 verified he/she did not re-check thename on the vial.RN #1 stated he/she grabbed a sticker from thepatient's file, a handful of flushes, alcohol swabs,a blunt tip needle. RN #1 stated he/she put themedication vial in a baggie and wrote on thebaggie, "PET scan, Versed 1-2 mg" and went toRadiology to administer the medication to Patient#1.RN #1 was asked how long it took her to get tothe Radiology department PET scan, and RN #1stated, "5 minutes or less, it was my first time togo to PET scan, I had to ask for directions". RN#1 stated, "I saw one patient [who was Patient#1] on one of our beds, I checked the patient forhis/her identity, and told her I was there to givehim/her something to help him/her relax".FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: NVYT11Facility ID: TNP53127If continuation sheet Page 9 of 56

PRINTED: 11/19/2018FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDING(X3) DATE SURVEYCOMPLETEDC440039B. WINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1211 MEDICAL CENTER DRIVEVANDERBILT UNIVERSITY MEDICAL CENTER(X4) IDPREFIXTAG11/08/2018NASHVILLE, TN 37232SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)A 144 Continued From page 9PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EA 144RN #1 stated, "I reconstituted the medication andmeasured the amount I needed"The RN stated Radiology Technician #1 wasthere at the time he/she administered themedication IV to Patient #1. RN #1 stated he/sheleft the Radiology PET scan area after he/shehad administered the medication to Patient #1.RN #1 was asked how much medication didhe/she administer to Patient #1, and the RNstated, "I can't remember, I am pretty sure I gave[him/her] 1 milliliter.RN #1 was asked what was done with any leftover medication, and the RN stated, "I put the leftover in the baggie and gave it to [Named RN#2]."RN #1 was asked what he/she did afteradministering the medication to Patient #1, andthe RN stated he/she left Patient #1 in Radiology.RN #1 confirmed that he/she did not monitorPatient #1 after the medication was administered.RN #1 was asked what happened next and theRN stated, "Patient #1's family was standingoutside in the hallway.we heard a rapidresponse call for PET scan. That was a red flagsince the patient was ours, so [Named RN #2]called down there [to the PET scan] but there wasno answer. The family looked at us and said"ours?" [Named RN #2] said "we are going tomake sure." We tried to call PET scan again, wewere being responsible to go to see if it was ourpatient".RN #1 stated that he/she and RN #2 went to PETscan and when they arrived Patient #1 wasintubated and had regained a heart rate. The RNstated he/she, Physician #2, and the ChargeNurse moved Patient #1 back to the ICU.RN #1 stated, "I told [Named Physician #2] that Ihad given [Patient #1] Versed a few minutesago.I reminded the Nurse Practitioner thatFORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: NVYT11Facility ID: TNP53127If continuation sheet Page 10 of 56

PRINTED: 11/19/2018FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDING(X3) DATE SURVEYCOMPLETEDC440039B. WINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1211 MEDICAL CENTER DRIVEVANDERBILT UNIVERSITY MEDICAL CENTER(X4) IDPREFIXTAG11/08/2018NASHVILLE, TN 37232SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)A 144 Continued From page 10PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EA 144Patient #1 was awake but unmonitored when Igave the Versed".RN #1 stated RN #2 approached him/her andasked, "Is this the med you gave [named Patient#1]?" and RN #1 responded "yes". RN #1 thenstated RN #2 said, "This isn't Versed, It'sVecuronium."RN #1 stated, went into Patient #1's room andinformed Physician #2, and the NP that he/shehad made a mistake and administeredVecuronium to Patient #1 instead of Versed.RN #1 was asked if it was documented he/shehad administered the Vecuronium in Patient #1'smedical record. RN #1 stated, "I did not. I spokewith [Named Nurse Manager] and he/she told methe new system would capture it on the MAR[Medication Administration Record]. I asked and[the Nurse Manager] said it would show up in aspecial area in a different color."RN #1 was asked if he/she could remember howmuch Vecuronium she administered to Patient#1, and RN #1 stated, "I would have given 1milligram."RN #1 was asked if he/she talked to anyone atthe hospital in the days after the event, and theRN stated, "I did have some conversations withrisk management. I don't remember all I said. Itwas on the phone. I came back on the 3rd[January] and saw [Named Nurse Manager]. Thatis when I was terminated. They sent me to anemployee resource counsellor for my ownpersonal wellbeing."RN #1 was asked about the "help-all nurse" roleand was there documentation of what was donewhile working a shift, and the RN stated, "If youdo something, you just chart it for that patient".The RN stated there was not an actual jobdescription for the role of a "help-all nurse"FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: NVYT11Facility ID: TNP53127If continuation sheet Page 11 of 56

PRINTED: 11/19/2018FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDING(X3) DATE SURVEYCOMPLETEDC440039B. WINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1211 MEDICAL CENTER DRIVEVANDERBILT UNIVERSITY MEDICAL CENTER(X4) IDPREFIXTAG11/08/2018NASHVILLE, TN 37232SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)A 144 Continued From page 11PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EA 1444. Interview with Radiology Technician (RT) #2on 11/2/18 at 1:30 PM the RT was asked aboutthe events surrounding [Named Patient #1's]medication error in December. RT #2 stated,"[Patient #1] was an inpatient brought down byTransport, and was dropped off in a hallway. Meand another girl went to get the patient and put inan injection room. [Patient #1] said he/she wasclaustrophobic so the other girl called thepatient's nurse.a transporter walked by thepatients room and noticed he/she wasunresponsive. We were in the control room, wehave cameras that we can view but not to thepoint of seeing if they are breathing."RT #2 was asked how long the patient was in theroom by him/herself before the transporternoticed him/her. RT #2 stated, "If I was going toguess, maybe 30 minutes. I don't knowspecifically. I ran to call the code and [Named RT#1] started CPR."Telephone interview on 11/5/18 at 9:29 AM withRN #2 (Patient #1's primary care nurse prior tothe Event) the RN #2 was asked to describe theevents surrounding Patient #1's death. RN #2stated, ".[Patient #1] was scheduled for a PETscan and was nervous.PET scan called me andtold me the doc [doctor] had ordered an IV med[medication] for anxiety.I relayed to the help allnurse and [Named RN #1] agreed to go andadminister it. I don't remember the timing, I heardthe code, they brought [Patient #1] back to anICU room. I went over to ICU to give report to thenurse taking care of the patient and [Named RN#1] handed me a vial in a bag.I went back to mydesk to do some charting and then I realized it[Vecuronium had been administered instead ofVersed] I went and told my charge nurse and Igave the bag to him/her. That was the end of myFORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: NVYT11Facility ID: TNP53127If continuation sheet Page 12 of 56

PRINTED: 11/19/2018FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONA. BUILDING(X3) DATE SURVEYCOMPLETEDC440039B. WINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE1211 MEDICAL CENTER DRIVEVANDERBILT UNIVERSITY MEDICAL CENTER(X4) IDPREFIXTAG11/08/2018NASHVI

ID PREFIX TAG (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 000 INITIAL COMMENTS A 000 An unannounced onsite survey was conducted 10/31/18 to 11/8/18 to inv

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