HospitalInspections.org

Based on interview and record review, it was determined the hospital failed to ensure the Registered Nurse evaluated 2 of 20 patients [Patient #4 and #6]. The RN failed to evaluate an elevated blood pressure for [Patient #4] and for an upper respiratory infection for [Patient #6].

Findings Included:

1) Patient #4's History and Physical dated 01/19/11 reflected, "43 year old male who has been having homicidal ideations...wants to kill manager of his apartments...had recent back surgery...has chronic back pain, hypertension..."

The admission physician orders dated 01/19/11 timed at 01:00 AM reflected, "Catapress 0.2 mg [milligram] po [by mouth] bid [twice daily]..."

The nursing assessment dated 01/19/11 timed at 02:15 AM reflected, "43 year old male admitted...patient's blood pressure was elevated on admission catapress 0.2 milligrams given...blood pressure on admission 178/120...B/P rechecked after HS [hour of sleep] medications 160/102..." No further nursing documentation was found which addressed Patient #4's elevated blood pressure.

The patient activity record dated 01/19/11 reflected, "02:15 AM B/P [blood pressure] 178/120...at 03:00 AM blood pressure 160/102...at 06:00 blood pressure 114/101..." Patient #4's diastolic blood pressure remained elevated.

The daily nursing assessment/observation dated 01/19/11 reflected no nursing documentation indicating the nursing staff were monitoring Patient #4's elevated blood pressure.

On 01/25/11 at approximately 1:00 PM Staff #4 reviewed Patient #4's medical record. Staff #4 stated the nurse should have documented in the nurses notes Patient #4's status after his blood pressure was taken at 03:00 AM and it remained elevated.

2) Patient #6's history and physical dated 01/18/11 reflected, "asthma...chronic pain, depression, left knee surgery and legally blind..."

The physician's order sheet dated 01/21/11 reflected, "Z-Pak, albuterol two puffs every six hours prn [as needed]..."

The daily nursing assessment/observation records for 01/21/11 to 01/23/11 reflected no documentation indicating Patient #6's respiratory status and/or medical treatment for an upper respiratory infection was documented.

On 01/25/11 at approximately 3:30 PM Staff #4 was interviewed. Staff #4 reviewed the nursing documentation and verified no documentation was found by the nursing staff indicating monitoring of Patient #6's upper respiratory infection.

The policy and procedure entitled, "Charting in the Medical Record" with a review date of 05/10 reflected, "The clinical notes should describe each patient's behavior, attitude, symptoms, nursing intervention used,and reactions of the patients...daily flow sheets shall be completed each shift by designated staff member. Narrative charting is by exception only. These cases shall be: admission of patient, if there is a change in medical status, mental status, unusual occurrence..."

Based on interview and record review, it was determined the hospital failed to develop and keep current a care plan for 1 of 20 patients [Patient #4] treated for chronic back pain.

Findings Included:

Patient #4's History and Physical dated 01/19/11 reflected, "43 year old male who has been having homicidal ideations...wants to kill manager of his apartments...had recent back surgery...has chronic back pain, hypertension..."

The physician order sheet dated 01/19/11 timed at 9:00 AM reflected, "norco 10/325 po [by mouth] every six hours prn [as needed] for pain..."

The MAR [Medication Administration Record] reflected Patient #4 was medicated with Norco 10/325 po on 01/19/11 at 12:45 PM and 20:45 PM. On 01/20/11 at 09:30 AM and 21:00 PM. On 01/22/11 at 11:50 AM and at 21:10 PM. On 01/23/11 at 14:00 PM and 21:30 PM.

The Interdisciplinary Treatment Plan for chronic back pain problem #6 reflected no date initiated and no documentation for short/long goals, nor responsible staff and discipline responsible. The document was blank.

On 01/25/11 at approximately 1:00 PM Staff #4 was asked to review Patient #4's interdisciplinary treatment plan. Staff #4 stated the above document was incomplete and did not address Patient #4's chronic back pain and the treatment provided for the patient.

The policy and procedure entitled, "Master Treatment Plan" with a review date of 05/10 reflected, "The treatment team will in collaboration with the patient and identified family members, develop a individualized master treatment plan that addresses the problems identified...the initial treatment plan will be initiated by the admitting nurse in collaboration with the attending physician...initial problem list both psychiatric and medical...admitting nurse will complete appropriate nursing interventions for all problems that have been identified at admission..."

It was determined based on interview and record review, the hospital failed to ensure 1 of 20 patients [Patient #14's] social service/biopsychosocial evaluation was completed after Patient #14 was admitted to the hospital on 09/23/10.

Findings Included:

The physician discharge summary dated 10/01/10 reflected, Patient #14's medical diagnosis were "Bipolar Disorder, Post-traumatic Stress Disorder, Attention Deficit Hyperactivity, Mild Bronchitis and problem with primary support group, social, environmental, and educational...patient was admitted as she was angry, moody, and was thinking about hurting herself and others. She was very impulsive, hit walls and was in homebound school...allegedly gang raped by four people and does not remember who those people were..."

The social service assessment tool page 24 entitled, "Biopsychosocial/Clinical Formulation" reflected, no documentation which included, reason for admission, description of patient, current educational issues, legal, employment, environmental, family stressors,, chronic/acute suicidal problems, assets, liabilities, patient's perception of illness and goals for treatment...preliminary discharge plans or problems that might impact discharge..."

On 01/27/11 at 2:30 PM Staff #3 was asked to review Patient #14's social service assessment. Staff #3 stated the social service assessment had not been completed and was unable to identify who was responsible for the assessment as no one signed the document. Staff #3 stated the social worker should have completed the assessment within 72 hours.

The policy and procedure entitled, "Clinical Formulation" with a review date of 09/09 reflected, "This formulation is an evaluation and summary of the psychosocial stressors and treatment issues that need to be addressed...based upon the cumulative data contained in various assessment reviewed, the social service staff member will develop a clinical formulation [overall clinical picture] of the patient that describes their presenting problem, current functioning, clinical needs and issues to be addressed, and any discharge/aftercare needs patient may have..."