HospitalInspections.org

Based upon review of 4 of 5 (#s 5, 7, 8, 11), out of a total sample size of 15 medical records, Policy and Procedures, and staff interviews the Registered Nurse failed to develop and implement a nursing care plan which addressed the patient's medical diagnoses as related to: 1) patient #5's high blood pressure ; 2) patient #7's diabetes and high blood pressure; 3) patient# 8's self inflicted lacerations to her left wrist; and 4) patient # 11's severe eating disorder, anorexia . Findings:

Review of patient #5's medical record revealed a History and Physical (H&P) Examination, dated 10/02/09, documented by Family Practice physician S20. Review of the H&P revealed patient #5 had a history of a stroke in April 2008 and a heart defect (hole) that required surgical intervention in May 2008. Further review of the H&P revealed patient #5 was on medications for her stroke and heart (Plavix 75 milligrams and Aspirin 81 milligrams). Continued review of the H&P revealed a section titled "PLAN OF CARE: Based on today's medical evaluation she needs to be monitored and followed on a regular basis...".

Further review of patient #5's medical record revealed a form titled "Interdisciplinary Treatment Plan", dated 10/01/09. On this form, the sections "Admitting Diagnosis, Revised Diagnosis, Patient's Assets, Patient's Stressors, Discharge Criteria, Preliminary Discharge Plan, Long Term Goals" were blank, no documentation by the interdisciplinary team. Continued review of the medical record revealed another form titled "Problem List", dated 10/01/09. Under Problem List there were 2 items identified: #1. SI (suicidal ideation) and #2. depressed mood. RN S21 had documented "Med (medical) Hx (history) Hx of stroke in 4/08 and High blood pressure". Review of form titled "Treatment Plan-Problem List revealed "Problem #1 SI (suicidal ideation)" with documentation listed under short term goals; however, the patient's diagnoses of depression and high blood pressure was not listed as problems and there lacked documented evidence the patient's depression diagnosis had been addressed.

A review of patient #5's medical record revealed there failed to be documented evidence a nursing care plan had been formulated, implemented and kept current to monitor the patient's high blood pressure as recommended by physician S20.

Review of patient #7's medical record revealed a H&P, dated 11/03/09, documented by Family Practice physician S20. Patient #7 had diagnoses of diabetes and hypertension (high blood pressure). Review of the Initial Nursing Assessment, dated 11/02/09, revealed RN S22 documented under the section titled "Recommendations for Nursing Care", the patient would be assessed for safety, for the effectiveness of psychiatric medications and she would receive education on her disease process.

Continued review of patient #7's medical record revealed a form titled " Interdisciplinary Treatment Plan". Review of the treatment plan addressed her suicidal ideation and depression; however, there failed to be documentation relative to her diagnosed medical problems of diabetes and high blood pressure.

Review of patient #8's medical record revealed an H&P, dated 11/15/09, documented by Nurse Practitioner S23. The physical evaluation revealed patient #8 had self inflicted lacerations to her left wrist and was to have them cleaned twice a day and have an antibiotic ointment and light dressing applied. Continued review of patient #8's medical record revealed a form titled "Interdisciplinary Treatment Plan". Further review of the treatment plan revealed there failed to be documentation relative to the left wrist lacerations nor were there documented interventions associated with the care of the lacerations.

Review of patient #11's medical record revealed admission diagnoses of Suicidal Ideation and Depression. Continued review of patient #11's medical record revealed an H&P, dated 02/04/10, documented by Nurse Practitioner S23. The physical evaluation was significant for severe weight loss, greater than 38 pounds, in the past 3 months. Patient #11's diagnoses for admission were Suicidal Ideation, Depression and Anorexia. Review of the Interdisciplinary Treatment Plan revealed a documented care plan for suicidal ideation; however, there lacked documentation her depression and anorexia had been care planned by an RN.

Review of a policy titled "Nursing Assessment Policy Number: PE.029" revealed the following:
"I. POLICY
It is the policy of the Nursing Services to assess and evaluate all patients to determine priorities for determining initial nursing treatment approaches...as well as generating data for the multi-disciplinary treatment process.
II. PROCEDURE
1. ...the RN should begin formulating a nursing treatment plan utilizing the nursing process of goal setting, data collection, planning implementation, and nursing interventions aimed at providing quality patient care...
8. The Registered Nurse will review the obtained information, meet with the patient and develop conclusions and indications for treatment. The RN will also identify the priorities for nursing care".

Interview, on 03/01/10 at 10:00 AM, with Director of Nursing S1, confirmed the nursing staff had not formulated, implemented and kept current nursing care plans for patient #s 5, 7, 8, and 11 that addressed their individual medical problems as well as their psychiatric problems.

Based upon review of 1 of 15 medical records (#11), Policy and Procedures, and staff interview the hospital failed to ensure a nurse administered Prozac 20 milligrams by mouth every morning and Remeron 15 milligrams by mouth at bedtime to patient #11 as ordered by psychiatrist S4 as evidenced by a lack of documentation on the Medication Administration Record for patient #11. Findings:

Review of patient #11's medical record revealed a Physician Admission Order form, dated 02/03/10 and documented by psychiatrist S4, with an order for Prozac 20 milligrams (mg) PO (by mouth) Q (every) AM and Remeron 15 mg PO Q PM. Review of the Medication Administration Record (MAR) revealed Prozac 20 mg po q AM was documented to be administered at 7 AM and Remeron 15 mg po q PM was to be administered at 8 PM. Continued review of the MAR revealed there failed to be documentation the above 2 medications were administered as ordered; nor were nurses' signatures documented.

Review of a policy titled "Medication Administration" revealed nurses were to draw a line through the administration time and place their initials next to the time they administered the medication. The nurse was to place her signature and initials on the bottom of the MAR in order to identify the nurse who administered a medication.

Interview, on 03/01/10 at 2:55 PM, with Registered Nurse (RN) S8 confirmed the medications (as listed above) were not administered as evidenced by the lack of documentation by the medication nurse. Continued interview with RN S8 further confirmed that when the medication nurse administered a medication she would place her initials by the time the medication was administered along with a line drawn through the time that the medication was administered.

There failed to be documentation on the MAR or in the Nursing Progress Notes that the medication nurse (working on patient #11's unit) administered the Prozac and Remeron as ordered by psychiatrist S4.