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Based on record review and interview, it was determined that the facility did not ensure that the patients right to formulate advance directives and to have hospital staff who provide care in the hospital comply with these directives for 1 of 4 patients (#4) on the survey sample. This practice may cause a delay in treatment that may lead to potential adverse outcome.

Findings Include:

1. Patient #4 was admitted to the facility on 7/28/10 with a diagnosis of abdomen and back pain. According to record review the admission assessment/history dated 7/28/10 documented that the patient had advance directives. However; there was no documented evidence of any advance directives on the medical record at the time of the review. On 7/29/10 at 1:10pm the surveyor interviewed the risk manager and asked if there were advance directives on the medical record for this patient. The risk manager verified that there were no advance directives on the medical record. The risk manager stated if the facility where the patient lives has advance directives for the patient, they will fax them over, and will ask the patient her/his intent. At that time the case manager called the facility where the patient lived and asked them to fax over advance directives for the patient.

A review of the facility policy and procedure for Advance Directives-Obtaining and Formulating documented that if the individual had an Advance Directive, but does not have it with them, the Registrar will offer the patient the option to complete a new Advance Directive. Additionally, it documented that the nurse at the time of admission will also inquire as to the status of the patient's Advance Directive. If the patient has an Advance Directive, but is not able to provide the hospital with a copy, the patient will be offered an opportunity to complete another advance directive or be offered and opportunity to discuss the intent of their Advance Directive specifically related to their wishes.

On 7/29/10 at 1:45pm patient #4 was interviewed in the room regarding Advance Directives. The patient was asked if he/she had Advance Directives and stated to the surveyor "yes, they have a copy on file here, my family member and my physician also have a copy". This patient was identified by the Director of the unit as alert and orientated.

Based on record review, staff interview and patient observation, it was determined that the facility failed to ensure that medications were administered as ordered by the physician for 2 (#1,#4) of 4 sampled patients. This practice does not ensure safe and therapeutic medication administration.


Findings include:

1. Patient #1 was admitted to the facility on 4/7/10 with the diagnosis of pneumonia. In addition, the patient has chronic pain as a result of spinal injury and is on chronic narcotic and benzodiazepine therapy. This information was obtained from the history and physical and specialty consultations. Review of physician orders dated 4/9/10 revealed an order written by the pain management physician for Duragesic patch 50 micrograms topically every 48 hours. Review of the Medication Administration Record revealed the patch was applied as ordered on 4/9, 4/11 and 4/13. A nurse's note dated 4/13/10 revealed that the patient summoned a nurse to report the patch was leaking. The patch was removed. Initially, the patient was assessed as being disoriented, but on reevaluation, was found to be alert and oriented. There is no evidence in the medical record that the physician was notified regarding the removal of the patch. The patch was not reapplied. The pain management physician wrote an order to hold the medication on 4/14/10 at 9:00 p.m. The Duragesic patch order was not addressed for nearly 24 hours. During interview on 7/29/10 at approximately 2:30 p.m., the Risk Manager confirmed the above findings.

2. Patient #4 was admitted to the facility on 7/28/10 with a diagnosis of abdominal and back pain. The patient's vital signs on admission were documented as pulse 81, respirations 18, blood pressure 150/66 and temperature 96.7. The patient's initial pain assessment from the emergency room documented a pain score of 10, and was given morphine sulfate for pain. The patient was transferred to the medical surgery floor at 2:00 p.m. According to the admission assessment the patient had a fall on 7/9/10 at home. The Cat Scan (CT) of thoracic and lumbar spine was performed without contrast on 7/28/10. The results documented a fracture of T12 and L4, which were new since 7/9/10 prior CT. The physician ordered Lidoderm patch 1 or 2 patches topical every evening and remove patch after 12 hours. A review of the Medication Administration Record (MAR) revealed on 7/28/10 the patient received the lidoderm patch at 6:00 pm. There was no documented evidence on the MAR (7/29/10) that the lidoderm patch was removed at 6 a.m. An interview was conducted on 7/29/10 at 1:40 pm with the primary nurse assigned to care for the patient. The nurse stated to the surveyor that the patch was still on the patient from 6:00 pm last night. The surveyor proceeded to follow the nurse into the patient ' s room and observed the nurse remove the patch from the patient.