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Based on staff interviews and facility records review, the facility failed to ensure that registered nurses evaluate the nursing care for 1 of 5 patients (Patient 4) when it failed to do the following:

1. Identify and recognize that the medication Dilaudid, ordered for pain relief, was ordered without accompanying parameters on when to administer the drug according to an established pain rating scale in which pain is evaluated by the patient as being mild, moderate or severe or with a numerical pain rating scale of 0 to 10, 10 being the most severe pain experienced to prevent unnecessary administration of the medication.

2. Reassess the efficacy and evaluate for any side effects after the administration of Dilaudid as per hospital policy.

3. Identify and recognize that the medication Norvasc, ordered to control high blood pressure, was ordered without clear instructions from the prescriber for specific parameters when to administer or withhold the medication when an assessment of the patients' blood pressure was performed in order to prevent unnecessary administration of the drug.

These deficient practices had the potential to result in affecting the physical health, safety and psychological well being of Patient 4.

Findings:

On 7/17/12, a review of Patient 4's medical record was conducted. The medical record revealed that Patient 4 was admitted to the facility emergently and underwent a surgical Laparoscopic Appendectomy on 7/2/12. Further review indicated that Patient 4 had developed post- operative complications and was readmitted to the facility on 7/9/12. Patient 4 was placed on continuous intravenous TPN (Total Parenteral Nutrition) therapy and had a naso-gastric tube (NGT) inserted due to a paralytic ileus (a post-operative complication- a non-functioning digestive tract.)

1. On 7/17/12, a review of Patient 4's Physician Orders Sheet, dated 7/9/12, and timed at 10:39 AM, revealed the following medication orders:

a. Dilaudid 0.25 milligrams IV (Intravenously) every 2 hours PRN (as necessary).

b. Pepcid 20 milligrams IV every 24 hours.

c. Ambien 5 milligrams taken by mouth every bedtime as necessary.

d. Flagyl 500 milligrams taken by mouth three times a day.

e. Norvasc 10 milligrams taken by mouth every 24 hours daily.

There was no documented evidence in the Physicians Orders Sheet, dated 7/17/12, that Patient 4's physician had ordered a clear, well-defined pain intensity rating scale, directing nursing staff with specific parameters on when to administer the drug according to an established pain rating scale in which pain is evaluated by the patient as being mild, moderate or severe or with a numerical pain rating scale of 0 to 10, 10 being the most severe pain experienced.

On 7/17/12, a review of Patient 4's Medication Administration Record (MAR), printed by the pharmacy department, from 7/9/12 through 7/17/12 was conducted. Documentation indicated Dilaudid was ordered to be given intravenous push, 0.25 milligrams every 2 hours as necessary.

There was no indication that the facility's pharmacist had identified or recognized that the Dilaudid order had any accompanying parameters instructions on when to administer the drug according to an established pain rating scale in which pain was evaluated by the patient as being mild, moderate or severe or with a numerical pain rating scale of 0 to 10, 10 being the most severe pain experienced.

On 7/17/12, a review of the facility's policy and procedure titled, "PHARMACY DEPARTMENT OPERATING POLICIES", dated 4/3/09, stipulated, " ...The hospital pharmacy department shall provide and/or identify all medications administered to patients at the facility. The pharmacy will provide a safe and efficient medication distribution system which shall include the evaluation and administration of pharmaceuticals and other chemicals ... "

There was no documented evidence that the nursing staff member signing off and noting the physicians' order, attesting that the order for Dilaudid was complete, accurate and final, and had identified or recognized the irregularity that the Dilaudid order did not have a clear, well defined pain intensity rating scale (parameters) on when to administer the drug according to the patient's perceived pain level.

On 7/17/12, a review of the facility's policy and procedure titled, "DECREASING MEDICATION ERRORS", dated 5/16/12, stipulated, " ...The facility shall be aware that errors can occur at any step on the process: prescribing, ordering or monitoring the effects of the medication. Nursing staff provides patient education on all medications ordered for and administered to the patient during their hospital admission. Training and monitoring nursing practice regarding this policy and procedure are the responsibilities of the Nurse Manager, Pharmacy, and Medication Safety Committee ... "

On 7/18/12, at approximately 9:30 AM, the Director of Quality confirmed the finding that the medication order for Dilaudid lacked clear parameters when to administer the drug for pain relief without following a defined pain intensity rating scale. He stated that the physician, pharmacist and nursing staff should have picked up on the medication irregularity order.

2. On 7/17/12, a review of Patient 4's Medication Administration Record (MAR) dated 7/9/12 through 7/17/12 was conducted. Documentation revealed on 7/14/12, at 3:13 AM, Patient 4 was administered Dilaudid 0.25 milligrams IVP for pain (no documentation of the intensity or level of pain reported). Further documentation revealed that Patient 4 was not reassessed for the efficacy or was monitored for any side effects of the medication until 5:37 AM.

In addition, documentation in Patient 4's MAR revealed that an additional dose of Dilaudid was administered at 5:39 AM for pain relief and was not reassessed for pain relief effectiveness until 10:30 AM, on 7/14/12.

On 7/17/12, a review of the facility's policy and procedure titled, " PAIN ASSESSMENT " dated 5/17/12, stipulated, " ...The patient and their families will be informed of the pain assessment tool/scale. The following pain assessment scales will be used to assess level of pain: Adjective rating scale in which pain is evaluated by the patient as mild, moderate or severe or the Numerical rating scale in which the patient should be advised that a score from 0 to 10 is used to describe the levels of pain. 10 being the most severe pain and 0 is without any pain symptoms. Pain should be assessed routinely at regular intervals. For post-operative patients every 4 hours while awake for 1 day after surgery. With each new report of pain and at suitable intervals after each analgesic intervention, 30 minutes after parental and 1 hour after oral ... "

On 7/17/12, at approximately 3:30 PM, RN 1 confirmed the finding that the nursing staff did not assess in a timely manner Patient 4's pain status after administering Dilaudid at 3:13 AM and at 5:39 AM as per facility policy.

3. On 7/17/12, a review of Patient 4's Physicians' Order Sheet dated 7/9/12 and timed at 10:39 AM was conducted. The Physicians' Order Sheet revealed an order for Norvasc 10 milligrams to be taken by mouth, administered every 24 hours.

On 7/17/12, a review of Patient 4's Medication Administration Record from 7/9/12 through 7/17/12 revealed documentation as printed by the pharmacy department that Norvasc (amlodipine) 10 milligrams was to be administered every 24 hours on a daily basis.

According to the Davis Drug Guide, dated 2011, it stated, "The patient's blood pressure and pulse should be monitored before therapy and should be contraindicated in a systolic blood pressure less than 90 mm Hg (millimeters of mercury). "

There was no indication in Patient 4's Physician's Order Sheet or from other facility sources that written instructions was ordered by the physician for monitoring the patient's blood pressure prior to administering Norvasc.

There was no documented evidence in Patient 4's Physicians' Order Sheet or from other facility sources that orders were written by the physician instructing the nursing staff to withhold the Norvasc if the systolic blood pressure was less than 90 mm Hg (millimeters of mercury).

There was no evidence that the facility's pharmacist had recognized the medication irregularity order written by the physician regarding Norvasc being withheld if the patient's systolic blood pressure was less than 90 mm Hg.

On 7/17/12, a review of the facility's policy and procedure titled, "PHARMACY DEPARTMENT OPERATING POLICIES ", dated 4/3/09, stipulated, " ...The hospital pharmacy department shall provide and/or identify all medications administered to patients at the facility. The pharmacy will provide a safe and efficient medication distribution system which shall include the evaluation and administration of pharmaceuticals and other chemicals ... "

On 7/17/12, at approximately 9:45 AM, the Director of Pharmacy confirmed the finding that Patient 4' physician should have ordered specific parameters when to withhold the medication especially if the systolic blood pressure was less than 90 mm Hg.

Based on staff interviews and facility records review, the facility failed to ensure that all drugs, biological, and intravenous medications must be administered under accepted standards of practice for 1 of 5 patients (Patient 4) when the facility's pharmacist failed to ensure the following:

1. Identify and recognize that the medication Dilaudid, ordered for pain relief, was ordered without accompanying parameters on when to administer the drug according to an established pain rating scale in which pain is evaluated by the patient as being mild, moderate or severe or with a numerical pain rating scale of 0 to 10, 10 being the most severe pain experienced to prevent unnecessary administration of the medication.

2. Identify and recognize that the medication Norvasc, ordered to control high blood pressure, was ordered without clear instructions from the prescriber for specific parameters when to administer or withhold the medication when an assessment of the patients' blood pressure was performed to prevent unnecessary administration of the medication.

3. Identify and recognize that a verbal/telephone order on 7/17/12 was not repeated back to the prescriber as per facility policy after receiving an order over the phone to administer potassium chloride.

These deficient practices had the potential to affect the physical health, safety and psychological well being of Patient 4.

Findings:

On 7/17/12, a review of Patient 4's medical record was conducted. The medical record revealed that Patient 4 was admitted to the facility emergently and underwent a surgical Laparoscopic Appendectomy on 7/2/12. Further review indicated that Patient 4 had developed post- operative complications and was readmitted to the facility on 7/9/12. Patient 4 was placed on continuous intravenous TPN (Total Parenteral Nutrition) therapy and had a naso-gastric tube (NGT) inserted after developing a paralytic ileus (a post-operative complication- a non-functioning digestive tract).

1. On 7/17/12, a review of Patient 4's Physicians' Order Sheet, dated 7/9/12 and timed at 10:39 AM, revealed the following medication orders:

a. Dilaudid 0.25 milligrams IV (Intravenously) every 2 hours PRN (as necessary).

b. Pepcid 20 milligrams IV every 24 hours.

c. Ambien 5 milligrams taken by mouth every bedtime as necessary.

d. Flagyl 500 milligrams taken by mouth three times a day.

e. Norvasc 10 milligrams taken by mouth every 24 hours daily.

There was no documented evidence in the Physicians' Orders Sheet, dated 7/17/12, that Patient 4's physician had ordered a clear, well-defined pain intensity rating scale, instructing the nursing staff with specific parameters on when to administer the drug according to an established pain rating scale in which pain is evaluated by the patient as being mild, moderate or severe or with a numerical pain rating scale of 0 to 10, 10 being the most severe pain experienced.

On 7/17/12, a review of Patient 4's Medication Administration Record (MAR), printed by the pharmacy department, from 7/9/12 through 7/17/12 was conducted. Documentation indicated Dilaudid was ordered to be given intravenous push, 0.25 milligrams every 2 hours as necessary.

There was no indication that the facility's pharmacist had identified or recognized that the Dilaudid order had any accompanying parameters on when to administer the drug according to an established pain rating scale in which pain was evaluated by the patient as being mild, moderate or severe or with a numerical pain rating scale of 0 to 10, 10 being the most severe pain experienced.

On 7/17/12, a review of the facility's policy and procedure titled, "PHARMACY DEPARTMENT OPERATING POLICIES" dated 4/3/09, stipulated, " ...The hospital pharmacy department shall provide and/or identify all medications administered to patients at the facility. The pharmacy will provide a safe and efficient medication distribution system which shall include the evaluation and administration of pharmaceuticals and other chemicals ... "

2. On 7/17/12, a review of Patient 4's Physicians' Orders Sheet dated 7/9/12 and timed at 10:39 AM was conducted. The Physicians' Orders Sheet revealed an order for Norvasc 10 milligrams to be taken by mouth, to be administered every 24 hours.

On 7/17/12, a review of Patient 4's Medication Administration Record from 7/9/12 through 7/17/12 revealed documentation, as printed by the pharmacy department, that Norvasc (amlodipine) 10 milligrams was to be administered every 24 hours.

According to the Davis Drug Guide, dated 2011, it stated, "The patient's blood pressure and pulse should be monitored before therapy and contraindicated if the systolic blood pressure is less than 90 mm Hg (millimeters of mercury). "

There was no indication in Patient 4's Physicians' Orders Sheet or from other facility sources that written instructions was ordered by the physician for monitoring the patient's blood pressure prior to administering Norvasc.

There was no evidence that the facility's pharmacist had recognized the medication irregularity order written by the physician regarding Norvasc being withheld if the patient's systolic blood pressure was less than 90 mm Hg.

On 7/17/12, a review of the facility's policy and procedure titled, "PHARMACY DEPARTMENT OPERATING POLICIES" dated 4/3/09, stipulated, " ...The hospital pharmacy department shall provide and/or identify all medications administered to patients at the facility. The pharmacy will provide a safe and efficient medication distribution system which shall include the evaluation and administration of pharmaceuticals and other chemicals ... "

On 7/17/12, at approximately 9:45 AM, the Director of Pharmacy confirmed the finding that Patient 4's physician should have ordered specific parameters when to withhold the medication especially if the systolic blood pressure was less than 90 mm Hg.

3. On 7/17/12, a review of Patient 4's Physicians' Orders Sheet dated 7/17/12 and timed at 12:50 AM, revealed a verbal order taken over the phone by the facility's pharmacist to administer "Potassium Chloride 40 milliequivalents in liquid form, to be taken by mouth, one time only. "

On 7/17/12, a review of the facility's policy and procedure titled, "VERBAL AND WRITTEN ORDERS" , dated 5/2009, stipulated, " ...Only verbal/telephone orders from an approved licensed independent practitioner will be taken. A "read back" process will be conducted by the individual receiving the order, whereby the individual will repeat the frequency and all instructions for use in the non-abbreviated format ..."

In addition, a review of the facility's policy and procedure titled, "DECREASING MEDICATION ERRORS" , dated 5/16/12, stated, " ...All verbal orders received (orally or via telephone) will include the 'read back' verification process by the individual receiving the order ... "

There was no documented evidence in Patient 4's Physicians' Orders Sheet, dated 7/17/12 indicating that Pharmacist 1 "read back" or "repeated back" the potassium chloride order received over the phone to the prescriber as per facility policy.

On 7/18/12, at approximately 9:45 AM, an interview with Pharmacist 1 was conducted. Pharmacist 1 confirmed the finding and stated, "I did not repeat back to the physician the order to administer potassium 40 meq. In liquid form one time only. It was my fault, I did not follow policy."











28020

Based on interview and record review, the facility failed to ensure that a care plan for 3 of 5 sampled patients (Patients 3, 4 and 5) were kept current and individualized to reflect the care needs of the patients. These failures contributed to the potential for Patients' 3, 4, and 5 to not have their needs met.

Findings:

1. A record review, on 7/17/12, at 1:30 PM, indicated that Patient 3 was admitted to the intensive care unit (ICU) on 7/17/12, with the diagnosis of diabetic ketoacidosis (DKA- a potentially life threatening complication in patients with diabetes). Patient 3 had a blood glucose level of 837 (critically high).

A record review, on 7/17/12, at 1:30 PM, of Patient 3's physician history and plan of care for Patient 3, dated 7/17/12, indicated that Patient 3 would be placed on a continuous intravenous insulin drip to decrease the blood glucose level and would be continuously monitored.

An interview and a concurrent record review of Patient 3's care plans were conducted with RN 1 (Patient 3 ' s nurse). RN 1 stated that the care plans which were developed for Patient 3 were generic and had not been modified or individualized to reflect Patient 3's care needs or treatment plan. Further review of Patient 3's care plan showed no documented evidence that a care plan was developed to address the continuous insulin drip that the physician ordered.

2. A record review, on 7/17/12, at 2 PM, indicated that Patient 5 was admitted on 7/12/12, with a diagnosis which included a left femur (thigh bone) fracture. On 7/13/1/2, Patient 5 had surgery to repair the fractured femur.

An interview and a concurrent record review, on 7/17/12, at 2 PM, of Patient 3's physician orders dated 7/13/12, was conducted with RN 2. The physician orders included, a foley catheter (a catheter inserted into the bladder to drain the patients bladder), compression boots (helps prevent blood clots) to both lower extremities, narcotics (pain medications which can contribute to constipation or respiratory depression), ice therapy (to the fractured extremity), lovenox (a medication used to help prevent blood clots but can also contribute to bleeding) among others.

An interview and a concurrent record review, on 7/17/12, at 2 PM, of Patient 3's care plans were conducted with RN 2. RN 2 indicated that the care plans which were developed for Patient 3 had not been individualized for the patient and that the care plans were generic. Further review showed no care plans to reflect the foley catheter, compression boots, narcotics, ice therapy or the lovenox which the physician ordered.

A record review, on 7/17/12, at 3 PM, of the facility policy for "Nursing Care Plan, effective and reviewed on 4/18/12, was conducted. The policy indicated, " A nursing care plan is a current, written, personalized plan for the individual patient that indicates the kind of nursing care s/he needs, how it can best be accomplished, and the goals which nursing personnel hope to attain with the patient... " The policy also indicated that the care plan was to be updated per " Lippincott Procedure and documented in the patient's medical record... "

A record review, on 7/17/12, at 3 PM, of "Lippincott Procedure, for Care Plan Preparation, revised on March 31, 2012, " revealed the following: " ...Nurses update and revise the plan throughout the patient ' s stay and the document becomes part of the permanent patient record...A nursing care plan serves as a database for planning assignments, giving change-of-shift reports, conferring with the Doctor or other members of the health care team, planning patient discharge and documenting patient care. In addition, the care plan can be used as a management tool to determine staffing needs and assignments...Customize a standardized care plan to avoid standardizing your patient ' s care and to allow you to address your patient ' s individual concerns...Documentation of the patients ' progress (or lack of it) is required by The Joint Commission and other regulatory agencies that monitor health care quality. Document all pertinent nursing diagnoses, expected outcomes, nursing interventions, and evaluations of expected outcomes. "



26502

3. On 7/17/12, a review of Patient 4's medical record was conducted. The medical record revealed that Patient 4 was admitted to the facility emergently and underwent a surgical Laparoscopic Appendectomy on 7/2/12. Further review indicated that Patient 4 had developed post- operative complications and was readmitted to the facility on 7/9/12. Patient 4 was placed on continuous intravenous TPN (Total Parenteral Nutrition) therapy and had a naso-gastric tube (NGT) inserted due to a paralytic ileus (a post-operative complication- a non-functioning digestive tract).

On 7/17/12, a review of Patient 4's nursing care plans from 7/9/12 through 7/17/12 revealed one (1) care plan for" Nausea and Vomiting"; no other care plan was developed during that time period.

There was no documented evidence in Patient 4's medical record or from other facility sources that other care plans were developed addressing Patient 4's post operative nursing and medical needs during her recovery period. There was no documented evidence that other care plans were developed addressing Patient 4's postoperative assessment needs, such as postoperative pain management, nutritional status and management of continuous intravenous TPN infusion, Intake and Output and electrolyte monitoring, surgical wound management, gastrointestinal status, alteration in comfort levels and discharge planning requirements.

Therefore, there was no documented evidence that nursing services developed a comprehensive and individualized plan of care addressing Patient 4's post operative assessed needs from 7/9/12 through 7/17/12.

A record review, on 7/17/12, at 3 PM, of the facility policy for "Nursing Care Plan, effective and reviewed on 4/18/12, was conducted. The policy indicated, "A nursing care plan is a current, written, personalized plan for the individual patient that indicates the kind of nursing care s/he needs, how it can best be accomplished, and the goals which nursing personnel hope to attain with the patient... " The policy also indicated that the care plan was to be updated per " Lippincott Procedure and documented in the patient ' s medical record... "

A record review, on 7/17/12, at 3 PM, of " Lippincott Procedure, for Care Plan Preparation, revised on March 31, 2012, " revealed the following: " ...Nurses update and revise the plan throughout the patient ' s stay and the document becomes part of the permanent patient record...A nursing care plan serves as a database for planning assignments, giving change-of-shift reports, conferring with the Doctor or other members of the health care team, planning patient discharge and documenting patient care. In addition, the care plan can be used as a management tool to determine staffing needs and assignments...Customize a standardized care plan to avoid standardizing your patient ' s care and to allow you to address your patient ' s individual concerns...Documentation of the patients ' progress (or lack of it) is required by The Joint Commission and other regulatory agencies that monitor health care quality. Document all pertinent nursing diagnoses, expected outcomes, nursing interventions, and evaluations of expected outcomes. "

On 7/17/12, at approximately 2:30 PM, an interview with RN 1 was conducted. When asked if Patient 4's plan of care was comprehensive and individualized material to the patient's condition and diagnosis, she stated, "No, it looks like we only developed one nursing care plan and it only addressed her nausea and vomiting symptoms. "