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Based on medical record review and staff interview, the hospital failed to ensure the nursing care needs of 1 of 7 patients was sufficently evaluated for the need of continuous cardiac and respiratory monitoring when recieving sedation medication. Failure to sufficiently evaluate all the needs of a patient places all patients at risk for not recieving a higher level of care when appropriate.

Findings include:

1. Patient #1 had had frequent admissions to the hospital for the treatment of Crohn's disease, complications, and pain control. The patient's medical records for 4 admissions during the time frame of October 1, 2010 and December 1, 2010 were reviewed on February 23, 2011. In all of the admissions the patient had been admitted to a general medical /surgical nursing unit that did not provide continuous cardiac or respiratory monitoring. During 3 of the admissions the patient received intravenous sedation medication via a central line venous catheter. The unit staff were only able to provide continuous oxygen saturation monitoring that would have had limited value if complications from the sedation medication administration were to occur.

2. The director of nursing was interviewed on February 17, 2011. The director stated s/he talked to the patient ' s physician when s/he ordered the sedation to be given to the patient on a general nursing unit and asked for the patient to be transferred to the critical care step down unit which provides continuous monitoring. However, the patient refused the transfer as s/he disliked the constant monitoring. The physician then wrote an order that the patient did not require continuous monitoring while receiving the sedation on the general nursing unit.

The director stated the hospital did not have a policy/procedure for giving the sedation medication on a general nursing unit or whether a patient needed to have continuous monitoring when individual doses of a sedation medication were given. The director stated s/he has no authority to stop the physician from ordering the sedation medication on a general nursing unit.

3. A nurse manager of a general medical/surgical unit where Patient #1 is often admitted was interviewed on February 17, 2011. The manager stated that the majority of the nursing staff working on that unit were not ACLS (advanced resuscitation) certified to provide critical interventions should complications of the administration of sedation medications should occur.

4. A senior medical director was interviewed on February 17, 2011 regarding the administration of a sedation medication to a patient on a general medical/surgical unit. The medical director stated that this practice would not be tolerated in the hospital as it was inappropriate and would not provide adequate cardiac and respiratory monitoring.

Based on medical record review the hospital failed to ensure physician medication orders were complete according to accepted practice standards for 1 of 7 patients. Failure to ensure complete medication orders places all patient at risk for medication errors.

Findings include:

1. Patient #1 has had frequent admissions to the hospital for the treatment of Crohn's disease, complications, and pain control. The patient's medical records for 4 admissions during the time frame of October 1, 2010 and December 1, 2010 were reviewed on February 17, 2011.

2. The medical record for the patient's admission to the hospital on October 1, 2010 to October 6, 2010 was reviewed. The medical record contained 17 original orders for medications. 13 of the medication orders did not include the reason or indication for the administration of the drug.

3. The medical record for the patient's admission to the hospital on October 14, 2010 to 10/20/2010 was reviewed. The medical record contained 16 original orders for medications. 16 of the medication orders did not include the reason or indication for the administration of the drug.

4. The medical record for the patient's admission to the hospital on November 8, 2010 to November 12, 2010 was reviewed. The medical record contained 10 original orders for medications. 9 of the medication orders did not include the reason or indication for the administration of the drug.

5. The medical record for the patient's admission to the hospital on November 22, 2010 to December 1, 2010 was reviewed. The medical record contained 22 original orders for medications. 19 of the medication orders did not include the reason or indication for administration of the drug.