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pill-bottlesIn the last C&A newsletter, we presented a case study related to medication management. The TJC surveyors arrived for a four-day survey at a local hospital. On the second day of the survey, the TJC team leader requested a meeting with senior leadership to discuss concerns. Some of the survey findings were:

• In Labor/Delivery, the medical record contained an order for Oxytocin to be administered. The order referred to a protocol in terms of titration and the end point to titrate the drip to. The protocol was not in the paper or electronic medical record. Additionally, it was only in the form of a policy.

• During tracer activity and review of the medical record of a vented patient, the patient had been placed on a Propofol protocol for sedation. According to the protocol, the rate could be increased 5-10mcg/kg/min every 5-10 minutes until the “desired level of sedation” is reached. Although the Riker Sedation-Agitation Scale is being utilized, the desired level of sedation had not been defined within the order.

• During review of the patient’s care, it was noted that contrast material was used in a CT scan of the chest but an order for the contrast material could not be found, nor an order for a protocol for the procedure.

• A patient had an order written for Morphine 1-4mg IV for severe pain. The medical record documentation indicated that the patient had a pain scale of 5 (defined as moderate pain) at 1900 and was given Morphine 4mg at 1931. This medication administration did not follow the order as written in the medical record by the prescriber.

Due to the multiple findings, in various departments, which also contain range and double range orders, the surveyors are considering scoring HR.01.02.07, which relates to scope of practice. The team leader asks the leadership team to demonstrate that this is not a scope of practice concern.

Readers were asked to answer the following questions related to the case study:

1. True or False
The team leader is correct in her decision to score these findings as a scope of practice?

Historically, TJC may have scored this as a scope of practice. Recently, however, TJC has been scoring findings such as these in the provision of care standards under PC.02.01.03, which states that the most current order is followed.

2. Putting on your surveyor hat, where would you score these findings?

a. MM.04.01.01 – clear and accurate medication orders
b. PC.02.01.03 – provide care, treatment, and services as ordered or prescribed
c. RC.01.01.01 – complete and accurate medical record

Technically, the surveyor could score the findings under any one or a combination of these standards. In recent surveys, we’ve seen these issues cited at PC.02.01.03.

3. The best approach for the leadership team to take is:

a. Call the Chicago office immediately; TJC has not scored this as scope of practice in years
b. Argue with the surveyors that this is not a scope of practice issue
c. Present policies and procedures that demonstrate requirements for protocols, medication orders and pain management. Let the surveyors know that these concerns will be corrected immediately.

We always encourage organizations to work with the surveyors while they are onsite. Take the opportunity to work collaboratively with the survey team to, when appropriate, demonstrate compliance with the standard or to identify potential solutions for gaps in practice.

Jill Ryan

Author Jill Ryan

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