HospitalInspections.org

Based on review of clinical records, physician's orders, nursing policies and interview, it was determined a Registered Nurse failed to supervise the care for patients in that care was not rendered per physician's orders and Facility nursing policies for 7 (#1-#4, #7, #9-10) of 10 (#1-10) patients. Failure to provide care per physician's orders and Facility policies did not ensure patients received the highest quality of care to facilitate wellness and timely discharge. The failed practice affected Patients #1-#4, #7, #9-10. Findings follow:

A. Review of the following Policies and Procedures received from the Executive Director of Nursing at 1000 on 07/16/15 revealed the following:
Intravenous Therapy, Peripheral, under I.D.: 1. Peripheral lines that are continuously infusing should be assessed for signs and symptoms of phlebitis or infiltration every 2 hours, except in the NICU where they are assessed hourly.

Pain Management and Assessment, under II. Assessment, Intervention and Reassessment D., I Pain Assessment Frequency: 1. Pain is assessed upon admission 2. Pain is assessed at least every 4 hours and on an "as needed" basis...

Indwelling Urinary Catheter, Placement and Care, V. Maintenance - ...J. Catheter should be assessed each shift for signs and symptoms of infection/obstruction, etc. as noted above...

B. Review of Patient #1's clinical record revealed she was admitted on 07/14/15. Review of orders authored by Physician #2 at 0950 on 07/14/15 revealed orders to flush the Cecostomy tube with 50 mls (milliliters) of NS (normal saline) every shift. Review of the clinical record revealed no documentation the Cecostomy tube was flushed.

Review of orders authored by Physician #2 at 0950 on 07/14/15 revealed IV fluids to run at 85 ml per hour for 11.8 hours. Review of orders authored by Physician #2 at 2125 on 07/15/15 revealed IV fluids to run at 100 ml per hour for 10 hours. Review of the clinical record for both the above time periods revealed the IV site was not assessed every two hours per policy. During an interview with the Clinical Informatics Educator at 1105 on 07/15/15 she verified the above findings.

C. Review of Patient #2's clinical record revealed she was admitted on 07/14/15. Review of orders authored by Physician #3 at 2321 on 07/14/15 revealed orders to obtain vital signs Q (every) 4 hours. Review of the clinical record revealed vital signs were not obtained every 4 hours as ordered from 2318 on 07/14/15 through 07/15/15 at 2059.

Review of orders authored by Physician #3 at 2321 on 07/14/15 revealed IV fluids to run at 150 ml per hours for 6.7 hours. Review of the clinical record for the above time period revealed the IV site was not assessed every two hours per policy. During an interview with the Clinical Informatics Educator at 1130 on 07/16/15 she verified the above findings.

D. Review of Patient #3's clinical record revealed he was admitted on 07/06/15. Review of the clinical record revealed no pain assessments documented from 1100 to 1900 on 07/07/15, 1900 07/07/15 to 0700 on 07/08/15, 0700 to 1900 on 07/08/15, 2300 on 07/08/15 to 0700 on 07/09/15, 0700 to 1900 on 07/10/15, 0800 to 1900 on 07/11/15, 0700 to 1515 on 07/13/15, 0700 to 2000 on 07/15/15, 2000 on 07/15/15 to 0600 on 07/16/15. As per policy in A., pain assessments should have been performed every four hours. During an interview with the Clinical Informatics Educator at 1230 on 07/16/15 she verified the above findings.

E. Review of Patient #4's clinical record revealed he was admitted on 07/13/15. Review of the clinical record revealed the urinary catheter was not assessed every shift from admission at 1733 until time of clinical record review at 1315 on 07/16/15. As per policy in A., the urinary catheter should have been assessed every shift until removal. During an interview with the Clinical Informatics Educator at 1315 on 07/16/15 she verified the above findings.

F. Review of Patient #7's clinical record revealed he was admitted on 05/11/15 for surgery. Review of the clinical record revealed orders authored by Physician #4 at 1630 on 05/11/15 for neurological checks of the lower extremities Q 8 hours beginning POD #1 (post-operative day). Review of the clinical record revealed neurological checks were not performed Q 8 hours on 05/12/15 and 05/13/15. During an interview with the Clinical Informatics Educator at 1510 on 07/16/15 she verified the above findings.

G. Review of Patient #9's clinical record revealed she was admitted on 04/29/15. Review of the clinical record revealed orders authored by Physician #7 at 1101 on 04/29/15 for neurological checks every four hours. Review of the clinical record revealed neurological checks were not performed every four hours from 2300 on 04/29/15 to 2000 on 04/20/15, from 0400 to 2000 on 05/01/15, and from 0400 until discharge at 1815 on 05/02/15. Review of the orders authored by Physician #1 at 2129 on 04/29/15 revealed orders for I & O (intake and output) every 2 hours.
Review of the clinical record revealed I & O was not documented every two hours as ordered.

Review of the orders authored by Physician #1 at 0329 on 04/30/15 revealed orders for vital signs to be obtained every two hours. Review of the clinical record revealed vital signs were not obtained every two hours on 04/30/15 until 05/02/15 at 0900. During an interview with the Interim Director of Clinical Informatics at 1020 on 07/17/15 she verified the above findings.

Review of the orders authored by Physician #1 at 2126 on 04/29/15 revealed orders for IV fluids to infuse at 20 ml per hour for 50 hours. As per policy in A. above, Patient #9's IV site should have been assessed every two hours. Review of the clinical record revealed Patient #9's IV site was not assessed every two hours on 04/30/15, 05/01/15 and 05/02/15 until its removal at 1428 on 05/02/15. During an interview with the Interim Director of Clinical Informatics at 1020 on 07/17/15 she verified the above findings.

H. Review of Patient #10's clinical record revealed he was admitted on 06/08/15. Review of orders authored by Physician #7 at 1137 on 06/8/15 revealed orders to obtain vital signs every 2 hours and Level of Consciousness and Orientation assessments (LOC) every 15 minutes. Review of the clinical record revealed vital signs were not obtained every two hours on 06/06/15, 06/11/15 and 06/12/15. Review of the clinical record revealed LOC checks were not performed every 15 minutes as ordered. Review of the orders authored by Physician #6 at 2006 on 06/08/15 and 1928 on 06/10/15 revealed orders for IV fluids at 125 ml per hour over 8 hours and 20 ml per hour over 50 hours respectively. Review of the clinical record revealed Patient #9's IV site was not assessed every two hours during the above time frames. As per policy in A. above, Patient #9's IV site should have been assessed every two hours. During an interview with the Interim Director of Clinical Informatics at 1042 on 07/17/15 she verified the above findings.