HospitalInspections.org

Based on interview and record review the facility failed to provide 1 of 1 discharged patients who became unresponsive at the facility (patient #1) with medications and monitoring as ordered by the patient's physician, resulting in increased risk of poor health outcomes for all patients served by the facility. Findings include:

On 2/20/15 at 1430 patient #1's clinical record was reviewed with staff A. Record review revealed that on 11/19/14 Nurse G documented patient #1's pulse as 70-125 and BP (Blood Pressure) as 78/60. On 11/18/14 at 2220 physician E ordered "Change Lisinopril to 10 mg. by mouth daily. Hold if BP (Blood Pressure) under 120/80." On 11/19/14 physician E ordered "change Lisinopril to 20 mg PO (by mouth) once/day." The parameters for holding Lisinopril were not discontinued. On 11/21/14 at 0900 patient #1 received 20 mg. of Lisinopril despite having a Blood Pressure of 109/63. At 1400 on 11/21/14 patient #1's Blood Pressure was 105/67. Staff A confirmed that these findings during record review.

On 2/20/15 at 1440 patient #1's clinical record was reviewed with staff A. Record review revealed that on 11/18/14 the Registered Dietitian (staff F) documented that patient #1 should have a daily fluid intake of 2250-2625 ml fluid/day. A physician's order for "I and O" (Intake and Output) was noted on 11/19/14. I & O documentation forms in patient #1's clinical record contained no information of output on 11/19/14, 11/20/14 or 11/21/14. Fluid intake documentation for the last three days of the patient's life (11/19/14-11-21/14) ranged from 800-1200 ml daily. On 11/21/14 abnormal lab values for patient #1 related to kidney function included: a BUN (Blood Urea Nitrogen) of 56.0 mg/dl, (Reference Range 6.0-20.0), Creatinine of 2.8 mg/dl, (Reference Range 0.5-0.9) and a GFR (Glomerular Filtration Rate African American) of 21 (Reference Range of 60 or above). On 11/22/14 patient #1 became unresponsive and was transferred to an acute care hospital where the patient was pronounced dead. These findings were confirmed by staff A on 2/20/15 during the records review.

Based on record review and interview the facility failed to ensure that staff maintained an updated nursing plan of care for 1 of 1 patients with failure to record Intake and Output deficits (patient #1), resulting in increased risk of poor health outcomes for all patients. Findings include:

On 2/20/15 at 1440 patient #1's clinical record was reviewed with staff A. Record review revealed that a physician's order for "I and O" (Intake and Output) was noted on 11/19/14. Patient #1's Care Plan was not updated to include the intervention of documenting input and output and output was not documented on 11/19/14, 11/20/14 or 11/21/14. These findings were confirmed by staff A on 2/20/15 during record review.