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Based on staff interview, medical record review, and policy review it was determined nursing staff failed to follow policy and procedures for unusual occurrence reporting (i.e., fractured arm). This affected one (Patient #1) of ten medical records reviewed. The active census was 308.

Findings include:

Review of the Unusual Occurrence and Medication Error Reporting Policy No: P-100.043 issue date 01/18/13 and reviewed 01/27/15 provides for immediate reporting of any event that results in patient injury or adverse patient outcomes. An unusual occurrence is any potentially harmful event or patient outcome that is inconsistent with normal or unexpected operation of the hospital. Actual injury need not occur; the potential for injury is sufficient to be considered an unusual occurrence. It is the expectation that unusual occurrences and medication errors are reported by the person or persons most directly involved or by those who observed or discovered the event.

Review of the medical record for Patient #1 revealed the patient was admitted on 12/15/14 for further evaluation of a gastrointestinal bleed. Review of the history and physical revealed the patient was non-communicative, past history of cardio vascular accident (stroke). During the course of the hospital stay the patient became hemodynamically unstable and required a blood transfusion. A left internal jugular central venous catheter was placed and confirmed by portable x-ray on 12/15/14 at 3:50 PM.

Review of Patient #1's medical record revealed a physician's assessment note on 12/21/14 at 1:33 PM that revealed swelling was noted to the patient's left shoulder. The physician's orders included a venous doppler study to the left upper extremity. The venous doppler findings identified a deep vein thrombosis (DVT) of the basilic vein. A comparison x- ray from 06/10/14 was ordered and two views of the left humerus were obtained. The finalized radiology report dated 12/22/14 at 2:36 PM noted findings that included an acute oblique fracture of the neck/proximal shaft of the left humerus with an old healed fracture deformity of the mid-shaft of the left humerus. Findings on the radiology reports indicated Patient #1 had osteopenic bones.

Review of the ortho trauma consultation addendum in the medical record dated 12/26/14 at 8:17 AM indicates it is unknown when the fracture occurred and its mechanism.

Staff K, registered nurse, stated in an interview on 02/24/15 at 2:45 PM the family had reported the patient had an old fracture and requested to talk to the physician.Venous doppler and x-rays were completed related to pain to the left shoulder. The x-ray confirmed a new fracture over an old fracture to the left arm. The physician was immediately notified and discussed finding with the patient and family. Staff K received the report from the radiologist and no incident report was documented.

Staff B stated in an interview on 02/24/15 at 2:55 PM the family was concerned due to swelling to the left shoulder. An x-ray was ordered and and confirmed an acute fracture over an old healed fracture to the left arm. This finding was faxed to the registered nurse on the unit. The physician was rounding on the unit and immediately went in and discussed the finding with the patient and family. An orthopedist saw the patient and determined the patient was not a surgical candidate and the patient was treated conservatively. There were no fall and/or abuse concerns surrounding the unexpected finding. The radiologist determined it was an unexpected finding. Staff B stated this unexpected finding would not be reason to follow the unusual occurrence policy and procedures.

Based on staff interview and medical record review, the facility failed to ensure nursing staff developed a nursing care plan for two of ten patients reviewed. (Patients #3 and #5)The facility census was 308 patients.

Findings include:

1) An electronic medical record review (EMR) was conducted for Patient #3 with Staff H on 02/23/15 at 2:37 PM. Staff E and F were present during the record review. The EMR revealed Patient #3 was admitted on 02/19/15 with a critically low blood sugar of 20, and diagnoses of altered mental status, anemia, hypoglycemia (low blood sugar), urinary tract infection, chronic kidney disease, and acute renal failure. The physician's orders included blood sugar checks before meals and sliding scale insulin depending upon the patient's blood sugar level.

The plan of care lacked evidence of blood sugar management, diabetes, and nutrition needs for Patient #3. This was confirmed with Staff H during the medical record review.

2) An electronic medical record review was conducted for Patient #5 on 02/24/15 at 11:15 AM with Staff J. Patient #5 was admitted on 02/11/15 with diagnoses of fractured femur and diabetes mellitus. On 02/13/15 the physician was notified of a critically elevated lab result of blood sugar of 364. The physician ordered insulin at that time. The physician's orders also included two types of insulin during the patient's hospitalization. The EMR contained documentation of the patients' consistent elevated blood sugars during the hospitalization.

A review of the nursing care plan revealed a lack of care planning for the diabetes, nutritional needs, insulin, and elevated blood sugars for this patient. This was confirmed with Staff J during the EMR review.

Based on observation, staff interview, electronic medical record review, and policy review, the facility failed to ensure staff administered medications and biologicals in accordance with physicians' orders. This included one of ten patients reviewed out of a total census of 308. (Patient #3)


Findings include:


On 02/23/15 between 1:45 PM and 2:15 PM, Staff I was observed administering medications to Patient #3. The medications included a topical circulatory system medication (Nitropaste), a blood pressure and heart rate medication (Minoxidil) used to slow a fast heart rate, and a peripheral intravenous normal saline flush. A review of the electronic medical record (EMR) at the time of the medication administration revealed these medications were ordered by the physician as follows: Nitropaste 2% ointment three times a day starting at 12:00 PM beginning 02/19/15, normal Saline intravenous flush 5 ml every eight hours, and Minoxidil 2.5 mg by mouth two times a day. The EMR for 02/23/15 contained medication administration times of 9:00-10:00 AM for these medications and intravenous solution. Staff I confirmed these medications and solution had not been given at the ordered times and stated the administration of medications was late for the following reason: "been busy".


On 02/23/15 at 2:14 PM, just prior to applying the topical Nitropaste medication to the patient's left chest, Staff I was observed removing a gauze dressing from the patient's right chest. The dressing was observed with a date and time of 02/21 and 2050 (8:50 PM) and staff initials. Staff I confirmed the date and time of the dressing at the time of removal, confirming it as the Nitropaste medication. Staff I was observed applying the new dressing (which was dated, timed, initialed) to the patient's left chest. During this medication administration, Staff I was also observed administering the normal saline flush to the patient's intravenous line in the left arm, and administered the oral Minoxidil medication. Staff I was observed documenting "gave to patient at later time" as the reason the Nitropaste, Minoxidil, and normal saline flush were not given as ordered.


The EMR review, on 02/23/14 at 2:37 PM, conducted with Staff H, in the presence of Staff E and F, revealed the patient was admitted on 02/19/15 with a critically low blood sugar of 20, and diagnoses of altered mental status, anemia, hypoglycemia (low blood sugar), urinary tract infection, chronic kidney disease, and acute renal failure. During the EMR review, Staff H confirmed the Nitropaste medication was not given in accordance with the facility policy times of 09:00AM, 3:00PM, and 9:00PM as follows: on 02/19/15 at 3:00PM (was not given), on 02/20/15 at 7:27PM (scheduled time was 9:00PM), and on 02/22/15 at 6:07PM (was scheduled for 9:00PM). Staff I confirmed the Nitropaste medication was not administered to Patient #3 from 02/22/15 at 6:07PM until 02/23/15 at 2:15PM.


According to review of the policy titled Rx-910.010, effective 11/24/14, medications ordered to be given three times a day should be administered at 9:00 AM, 3:00 PM, and 9:00 PM and twice at 9:00 AM and 9:00 PM. The policy stated non-critical medications were to be given within one hour before or after the scheduled dose.

On 02/24/15, at 3:30 PM Staff B confirmed this policy is to be used for medication administration times unless a different time was specified by the physician. Staff B stated he/she was made aware of Patient #3 not receiving medications timely as ordered by the physician and per facility policy.