HospitalInspections.org

Based on interview, record review, and policy review, it was determined the facility failed to ensure a patient's medical condition was assessed/reassessed per facility policy for one (1) of ten (10) sampled patients and one unsampled patient (Patient #1 and Unsampled Patient A). In addition, the facility failed to notify a patient's physician of a change in the condition for Patient #1.

The findings include:

Review of the facility policy titled "Assessment & Reassessment, Nursing," dated August 2013, revealed a registered nurse would assess each patient's need for nursing care in all settings in which nursing care is to be provided. Further review of the policy revealed patients would be reassessed every six hours on the Medical Surgical Unit, with any change of condition, and to evaluate the patient's response to care, treatment, and services.

Review of the facility policy titled "Notification of Physician of Change of Condition," dated 08/13/13, revealed the licensed nurse assigned to the patient is responsible for informing the physician about a change in the patient's condition.

Review of the facility policy titled "PRN Medications," dated October 2013, revealed all prescribed medication orders which indicate a frequency for administration of "PRN" (as needed) must state how often and for what indications the PRN medication can be administrated. PRN pain medications should specify the severity of pain as it relates to the hospital's pain scale.

1. Review of the medical record for Patient #1 revealed the facility admitted Patient #1 from a local nursing facility on 09/04/14 with a diagnosis of aspiration pneumonia. Review of the admission nursing assessment revealed the patient had "redness to the hip with bruising noted to the inner left leg and redness noted to the inner left heel." Review of the Medication Administration Record (MAR) revealed on 09/08/14 at 9:24 AM Norco 5/325 milligrams (a pain medication) was given to Patient #1. There was no documentation in the nursing record of the reason RN #1 gave the patient the medication or the patient's response to the medication. Further review of the MAR revealed on 09/08/14 at 9:59 PM Norco 5/325 milligrams was given to the patient by RN #2. There was no documentation in the record that indicated the reason the pain medication was given to the patient. Continued review of the record revealed the patient was discharged back to the nursing facility on 09/09/14 at 4:21 PM.

Interview with Certified Nursing Assistants #1, #2, and #3 on 09/23/14 between 12:34 PM and 1:20 PM revealed they all provided direct care to Patient #1 during the patient's first admission (09/04/14-09/09/14). CNAs #2 and #3 provided care for the patient on 09/07/14 and 09/08/14. All CNAs stated they turned and repositioned the patient every two hours. They also stated the patient was a total care patient and required two staff persons to clean and change the patient's brief. At no time did any of the CNAs recall being rough or hearing Patient #1's spouse complain about rough treatment or abuse of any kind.

Interview with RN #1 on 09/23/14 at 11:02 AM revealed she provided care for Patient #1 on 09/08/14 and 09/09/14. RN #1 stated she did not recall any bruising or injury to the patient's right knee, ankle, or foot. However, RN #1 could not give any explanation as to why she administered pain medication to the patient on 09/08/14 at 9:24 AM. RN #1 stated it was the policy of the facility to document why a PRN medication was given and patient's response to the medication. The RN offered no explanation as to why she did not document this in Patient #1's record.

Interview with Patient #1's spouse on 09/22/14 at 3:15 PM revealed he/she reported to the morning nursing staff on 09/08/14 that the patient's right ankle, foot, and knee were swollen and bruised. He/she stated the nursing staff did not assess the patient or contact the physician as far as he/she knew. Patient #1's spouse stated the patient was discharged on 09/09/14 to the nursing facility and then transferred back to the hospital on 09/09/14 and diagnosed with a fractured right hip.

Review of the nursing facility record for Patient #1 revealed the patient arrived at the nursing facility on 09/09/14 at 5:45 PM and was assessed to have a large amount of bruising noted to the right leg. The nursing facility contacted their on-call provider and when no explanation could be given by the transferring facility to the nursing facility for the bruising to the patient's leg, the provider ordered Patient #1 to be sent back to the hospital for further evaluation and treatment.

Review of the medical record for Patient #1 revealed the facility re-admitted Patient #1 on 09/09/14 at 6:56 PM to the Emergency Department for a right hip fracture. The nursing assessment dated 09/09/14 at 6:57 PM revealed upon arrival at the Emergency Department bruising was noted to the right knee, right thigh, and right hip. The bruising was described as "yellow" in color. Further review of the medical record revealed a consultation report from a radiologist stated the patient was assessed to have "intertrochanteric fracture which appears to be slightly displaced to the patient's right hip." Continued review of the record revealed on 09/10/14 at 11:43 AM RN #4 administered Demerol for pain to the patient but the record offered no documentation of the reason the medication was given or the effects of the medication.

Interview with RN #4 on 09/23/14 at 2:00 PM revealed PRN pain medications are supposed to be scored on a scale from 1 to 10 and the patient is supposed to be reassessed within one hour of administering the pain medication. When asked about the failure to document the reason and response related to Patient #1's pain medication, RN#4 stated she "just didn't."

Interview with the Nurse Manager on 09/23/14 at 2:15 PM revealed it was facility policy for nurses to document the reason a PRN medication was administered and to follow up with the patient's response to the medication. She could offer no explanation as to why RN #1 or RN #2 did not document in Patient #1's record the reason a PRN pain medication was administered or why no follow-up was documented.

Interview with the Director of Nursing on 09/22/14 at 1:29 PM revealed she was unaware of any incident or allegation of abuse and that she "kind of knew" the facility needed to improve on their documentation of PRN medication and it was in the plan to add that category to their annual re-education. She stated that it was facility policy for nurses to always notify physicians of a patient's change in condition. She stated the facility was investigating this case because of the re-admission of the patient not because of any allegation of abuse.

Interview with the Radiologist on 09/22/14 at 1:38 PM revealed she read Patient #1's x-ray and her impression of the patient's x-ray was an "acute displaced trauma fracture." She stated acute was defined as an injury three to five days old.

2. During a tour of the Medical Surgical Unit on 09/23/14 at 11:35 AM observation of a medication pass revealed RN #3 administered PRN Dilaudid (pain medication) 1 milligram IV (intravenously) to Patient A. Review of Patient A's medical record on 09/23/14 at 2:51 PM revealed no documentation by RN #3 of the reason she administered the pain medication to Patient A or the effectiveness of the pain medication.

Interview with RN #3 on 09/23/14 at 2:52 PM revealed the new computer charting system made it too difficult to document PRN medications. However, RN #3 stated she knew facility policy was to document the reason a PRN medication was given and to document the effects of the medication.