HospitalInspections.org

Based on staff interviews, clinical record review, and facility documentation review, it was determined the facility staff failed to notify the parent or guardian of a change in patient's condition which required the addition of medication for one (1) of seven (7) patients (Patient #5) in the survey sample.

The findings include:

Patient #5 was admitted to the facility on 5/6/21 with diagnoses that included, but not limited to, eating disorder (restriction, possible purging, and possible binging), major depressive disorder, generalized anxiety disorder, rule out PTSD and obsessive-compulsive disorder. Patient #5 was discharged home on 5/21/21 therefore a closed record review was conducted.

On 7/6/21 at 1:30 p.m. Patient #5's clinical record was reviewed. The review revealed the following Medical Progress Notes:

Date of service: 5/11/2021 read in part: "... [Patient] did complain of a sore throat earlier today to the nurse. On exam, the back of her throat appears quite red, however, there is no visible drainage seen and no swelling of the tonsils. [Patient] reports some increased sneezing and sniffling, but no coughing, no headache, and no overall flu symptoms...The patient says [Patient] may have allergies sometimes, but is not quite sure about the details. A rapid strep test was performed and was negative this morning. We will start the patient on some Claritin for possible seasonal allergies. We will also add some p.r.n. Tylenol in case [Patient] should complain of another sore throat or other pain..."

Date of service: 5/14/2021 read in part: "...[Patient] had ear discomfort this morning, which [Patient] says resolved by lunch time. [Patient] appreciates occasional cough, stuffiness and itchy throat, but again attributes them to allergies. [Patient] is prescribed Claritin and Flonase to address these issues and [Patient] request no additional medical attention..."

Date of service: 5/20/2021 read in part: "...Nursing reports that patient complained of nausea early this morning and had vomiting x 1 in her bed this morning and has had 5 episodes of diarrhea since this morning. [Patient] was administered Zofran 4 mg oral..."

Date of service: 5/21/2021 read in part: "...Yesterday, [Patient] had numerous episodes of loose stool and one episode of emesis. Early this morning, [Patient] had 2 additional episodes of emesis..."

Review of physician orders and the medication administration record revealed loratadine (Claritin) 10 mg tablet was ordered daily and started on 5/12/21 and fluticasone (Flonase) nasal spray was ordered daily and started 5/14/21. And, ondansetron (Zofran) 4 mg on 5/20/21.

There was no documentation that Patient #5's parent was notified of the change of condition or medications ordered. The administrative team was notified of the finding on 7/6/21 at approximately 4:15 p.m.

On 7/7/21 at 10:45 a.m., an interview was conducted with the Director of Nursing, Staff #15 regarding parent or guardian notification when there is a change of condition. Patient #5's medical conditions were discussed. Staff #15 stated "I would expect the staff to notify the family especially if the patient was well and then was ill."

On 7/7/21 at 4:25 p.m. an end of day meeting was conducted with the administrative team. When asked if any information regarding Patient #5's family notification was found, Staff #2 stated "No, [Patient] wasn't here long so it would've been in the chart."

Policy titled "Nursing Services Policy on Change in Patient Condition and Rapid Response" with a revision date of 05/20 included "Family Education Outcome Standards...10. The family or guardian will be notified of any acute changes in the patient's condition and this notification will be documented in the record..."