HospitalInspections.org

Based on review of the Registered Nurse (RN) job description, hospital policy and procedure, direct observation of a med (medication) pass, medical record and interviews, it was determined that medications were not administered according to accepted standards of practice, hospital policy/procedure and/or physician orders, as evidenced by:

1. RN staff documenting administration of medication prior to actual administration, and failing to observe that patients swallowed their medication, for 2 of 2 adolescent patients (Pt #s 23 and 24). The potential risk is that medications documented as given prior to actually being given could be inadvertently assumed to be administered by another nurse, therefore not given; a patient could "cheek" and save medications for later ingestion if not observed to have swallowed the medication;

2. RN staff failing to document administration of medication ordered for alcohol withdrawal for 1 of 1 patient with a history of withdrawal seizures who required transfer to an acute medical center (Pt # 25), posing a risk of overmedication of the patient; and

3. RN staff administering medication for anxiety, without an order, for 2 of 2 patients who were receiving treatment for alcohol withdrawal (Pt #s 28 and 29), posing a risk to patient health and safety if the wrong dosage of medication was given.

Findings include:

The RN job description revealed: "...Maintains a safe...working and treatment environment...."

The "Medication Administration" policy revealed: "Medications are administered safely and accurately by the professional staff listed below within the specifications of approved job descriptions, licensure, certifications and scope of practice...Registered Nurses...H. Once a patient has taken an oral medication, the administering nurse checks the patient's mouth to assure the medication has been consumed. J. The administering nurse will then document in the patient's MAR (Medication Administration Record) the medication (s) administration or refusal...2. A. Each dose of medicine is recorded on the Patient's Medication Administration Record (MAR) by the person who administers the drug, stating the...time given...."

1. Direct observation of a med pass, conducted on 05-11-16, at 9:00 A.M., on the Child and Adolescent unit, revealed Staff #17, a contracted RN, conducting a medication pass.

Observation revealed medications being passed for Patients # 23, and # 24, both adolescents. Observation of the paper medication record for each patient revealed that the 9:00 A.M. medications had been documented prior to actual administration of the medications.

Observation of the administration of medications to Patient # 23, and # 24, respectively, revealed that the RN failed to observe the adolescents swallow the medications.

Staff #17 acknowledged, during interview conducted on 05-11-16, at 9:30 A.M., that she should not have documented that medications that had not yet been administered had been given, and acknowledged that she should have observed that the medications had been swallowed by the adolescents.

2. Review of Pt # 25's medical record revealed:

On 4/29/16, at 1018, MD # 8 wrote medication orders:
"...Librium 50 mg PO BID (by mouth twice a day) for ETOH WD (alcohol withdrawal), 1st dose now, last dose evening of 4/30/16, X2 days, hold for oversedation...Librium 50 mg PO q AM (every morning) x 2 days for ETOH WD, 1st Dose 5/1/16 AM, last dose 5/2/AM, hold for oversedation...."

Review of the Medication Administration Record for Pt # 25 revealed documentation of 50 mg of Librium on 4/29/16, at 2100 and on 4/30/16, at 0900 and 2100. The "now" dose for 4/29/16, at 1018 was not documented. Pharmacy provided a report from the automated medication dispensing station that 50 mg was removed on 4/29/16, at 1043.

Review of the Medication Administration Record for Pt # 25 revealed that it did not contain documentation of administration of 50 mg Librium on 5/2/16, as ordered.

Pharmacy provided a report from the automated medication dispensing station that 50 mg was removed on 5/2/16, at 0803.

RN # 30 and the Acting Director of Nursing confirmed, during interview conducted on 5/5/16, the nursing did not document administration of medication as required by policy/procedure.

3. Patient # 28

Review of Pt # 28's medical record revealed:

On 5/3/16, at 1330, an RN recorded a telephone order from MD # 1: "...Vital Signs:...Q 4 (hrs) and repeat (after) 1 (hr) if medicated SSWD (Signs/Symptoms of Withdrawal)...Ativan 1 mg po/IM Q 4 (hrs) SSWD, BP 150/90 P>100...."

An RN documented, on the Medication Administration Record (MAR), clarification of SSWD from the physician: "Ativan 1 mg po Q 4 hr S/S (Signs/Symptoms) of withdrawl (sic)-diaphorsis (sic) tremors...Prn BP >150/90 P >100".

On 5/3/16, at 1455, an RN documented administration of Ativan 1 mg po for Reason: "Anxiety 10/10" and Response: "Anxiety 5/10" at 1530.

Pt # 28's medical record did not contain an order for Ativan for anxiety.

Patient # 29

Review of Pt # 29's medical record revealed:

On 5/3/16, at 0920, an RN recorded a telephone order from MD # 1: "...Vital Signs:...Q 4 (hrs) VS (Vital Signs) and 1 (hr) (after) each W/D (Withdrawal) medication...Ativan 1 mg po or IM prn (as needed) Q 4 (hrs) if BP (Blood Pressure) above 150/90 P (Pulse) above 100...Ativan 1 mg IM Q (hr) prn SZ (Seizure) for 5 days Q 1 (hr)...."

An RN documented, on the Medication Administration Record (MAR), clarification from the physician: "Ativan 1 mg po Q 4 hr prn S/S (Signs/Symptoms) of W/D symptoms DBP (Diastolic Blood Pressure) >90, SBP (Systolic Blood Pressure >150 T (Temperature) >101 (degrees) & tremors, diaphorsis, visual disturbances"

On 5/3/16, at 2100, an RN documented administration of Ativan "1" for Reason: "Anxiety 6/10" and Response: "2/10" at 2200.

Pt # 29's medical record did not contain an order for Ativan for anxiety.

The Acting Director of Nursing confirmed, during interview conducted on 5/4/16, that Ativan was ordered for Pt # 28 and 29 for elevated vital signs and other S/S due to alcohol withdrawal. S/he confirmed that nursing administered the Ativan for "anxiety" and the medical records of Pt #s 28 and 29 did not contain orders for administration of Ativan for anxiety.

Based on review of hospital policy/procedure, Intake assessment records and interviews, it was determined that the hospital failed to implement a system of coding and indexing the medical records of patients who received an assessment in the Intake Department and referral to an outside hospital and/or agency without being admitted to an inpatient unit of the hospital for 5 of 6 patients (Pt #s 16, 18, 20, 21 and 22).

Findings include:

Review of hospital policy/procedure titled Medical Record Content, revealed: "Policy: the medical record must contain sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers. The medical record must be complete for the purposes of facilitation of patient care, to serve as a financial and legal record, aid in clinical research, support decision analysis, and guide professional and organizational performance improvement. Purpose:...To provide continuity in the evaluation of the patient's condition...To document communication between the patient care providers...To assist in protecting the legal interest of the patient, facility, and health care providers...To provide data for use in continuing education and research...A medical record is maintained for every individual assessed or treated...The medical record must address the presence, accuracy, timeliness, legibility, and authentication of the following data and information:...The record and findings of the patient's assessment and health screen...the diagnosis or diagnostic impression, including a statement on the course of action planned for the patient for this episode of care...the reasons for admission or treatment...evidence of informed consent and patient rights...."

Cross reference Tag 0438 for information regarding the Intake Department assessment records for Pt #s 16, 18, 20, 21 and 22.

The Director of Performance Improvement and Risk Management confirmed, during interview conducted on 5/11/16, that the Intake records of Pt #s 16, 18, 20, 21 and 22 were stored in a locked file cabinet in her office. S/he stated that these records and records of other patients who were seen in the Intake Department but not admitted to the hospital, are not maintained in the medical records department/system. They are not coded and/or indexed by the Medical Records Department as required for other medical records of patients assessed and/or treated in the hospital.

Based on review of the Rules and Regulations of the Medical Staff, record review, and interview, it was determined that all patient records were not authenticated by the person providing the service, when 3 of 3 outpatient records reviewed for authentication, did not have medical staff signatures (Patients #20, 21, and 22). The potential risk is to the health and safety of patients, who may not have been safe for discharge or transfer, without authentication from the medical staff that they were in agreement with the Qualified Medical Person's (QMP's) assessment of the patient.

Findings include:

The Rules and Regulations of the Medical Staff revealed: "...7.13 Completion of Medical Records-All discharge summaries and other medical record documentation shall be completed within thirty (30) days following the patient's discharge...."

Patient # 20

Patient #20 presented as a "Walk In" to the Intake (emergency unit) of the hospital on 04-05-16. A Medical Screening Examination (MSE) was conducted by a Qualified Medical Person (QMP), and a telephone consultation was documented with Medical Staff #4, a psychiatrist. Medical Staff
#4, did not sign the telephone consultation.

Patient # 21

Patient #21 presented to the emergency unit on 04-06-16 as a "Scheduled Assessment." A Medical Screening Examination (MSE) was conducted by a QMP, and a telephone consultation was documented with Medical Staff #15, a Psychiatric Nurse Practitioner (NP). Medical Staff #15, did not sign the telephone consultation.

Patient # 22

Patient #22 presented as a "Walk In" to the Intake (emergency unit) of the hospital on 04-10-16. A Medical Screening Examination (MSE) was conducted by a QMP, and a telephone consultation was documented with Medical Staff #4, a psychiatrist. Medical Staff # 4, did not sign the telephone consultation.

Medical Staff #15 acknowledged, during interview conducted on 05-10-16 at 12:30 P.M., that the medical staff should sign the telephone consultation, and that within the telephone consultation, the communication between the QMP and the Medical Staff member should be clearly documented.