HospitalInspections.org

Based on record review and staff interview it was determined that the registered nurse failed to supervise and evaluate care by not ensuring physician orders were implemented for neurological check assessments for one (#4) of five sampled patients. This practice does not allow for changes in condition to be identified.

Findings include:

Patient #4 was admitted to the facility on 3/16/11 with the diagnosis of altered mental status. The physician ordered neurological checks every 4 hours. Review of the medical record revealed that the neurological assessments were performed at 7:59 p.m. on 3/16/11, at 2:07 a.m. on 3/17 and at 9:50 a.m. on 3/17/11.

During interview on 3/17/11 at approximately 3:00 p.m., the medical surgical director confirmed that the staff was not performing the checks every 4 hours as ordered.

Based on record review, policy review and staff interview, it was determined that the facility failed to provide medication as ordered by the physician for one (#1) of five sampled patients. This practice does not ensure safe and effective medication administration.

Findings include:

Patient #1 was admitted to the facility on 2/2/11 with diagnoses that included hypertension. Review of physician orders revealed an order dated 2/3/11 at 9:45 a.m. to start Micardis 20 milligrams every day now. A stamp on the order sheet indicated the order was faxed at 10:00 a.m. Review of the medical record revealed no evidence the medication had been administered.

The facility's policy "Guidelines for Medication Management", #MM-19, last revised 10/10, required that the Pharmacy is to process orders specifying "now" within 60 minutes of receipt of the order.

The Director of Pharmacy was interviewed on 3/17/11 at approximately 1:00 p.m. She presented documentation that the order was received in the pharmacy at 9:59 a.m. on 2/3/11. She indicated that the nursing staff had not alerted the pharmacy that there was a "now" order. She agreed the facility did not comply with their policy.