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pill-bottlesOn the second day of a four day survey with three surveyors, the team leader approaches you and asks to meet with you and the leadership team. The team leader shares that she and her colleagues have the following concerns and issues:

  • In Labor/Delivery, the medical record contained an order for Oxytocin to be administered. The order referred to a protocol for titration and the end point to titrate the drip to. The protocol was not available in the paper or electronic medical record. Additionally, upon further review it was noted that the protocol was only in the form of a policy, not an “order set.”
  • During tracer activity and review of the medical record of a patient on a ventilator, 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 (RASS) 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 media 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 indicates 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 is scope of practice. The team leader asks the leadership team to demonstrate that this is not a scope of practice concern.

Based on the information in the above scenario, please answer the following questions:

  1. True or False

The team leader is correct in her decision to score these findings as a scope of practice.

  1. Putting on your “surveyor hat,” where would you score these findings?
    1. 04.01.01 – clear and accurate medication orders
    2. 02.01.03 – provide care, treatment, and services as ordered or prescribed
    3. 01.01.01 – complete and accurate medical record
  1. The best approach for the leadership team to take is:
    1. Call TJC’s Chicago office immediately; TJC has not scored this as scope of practice in years
    2. Argue with the surveyors that this is not a scope of practice issue

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 through enforcement of policy, staff education and development and leadership oversight and accountability.

Sharon Dills

Author Sharon Dills

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