HospitalInspections.org

Based on record review, review of facility policies, and staff interview it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient and followed the physician ordered plan of care for 2 (#1 & #3) of 3 patients sampled.

Findings include:

1. Review of patient #1's medical record revealed the patient was admitted to the facility on 11/01/10 with complaints of chest pain. Review of the record revealed a hospitalist admitted the patient and consulted a cardiologist. The cardiologist examined the patient on 11/01/10 and reviewed the patient's history, EKG, and current laboratory tests. On 11/02/10 at 8:00 a.m., the patient underwent a cardiac catheterization. Review of the physicians orders for post cardiac care, dated 11/02/10 at 8:00 a.m., revealed an order to monitor vital signs every 15 minutes times four, then every 30 minutes times two, then every 1 hour times two. Review of the nursing documentation revealed the patient's vital signs were monitored every 15 minutes times four documented at 8:02, 8:17, 8:32, and 8:48 a.m. The next vital sign documentation occurred at 1:46 p.m. The patient's vital signs were not monitored as ordered by the physician every 30 minutes times two or every 1 hour times two. The facility failed to monitor the patient for changes in condition as ordered by the physician.

Review of patient #3's medical record revealed the patient was admitted to the facility on 11/06/10 with a diagnosis of chest pain. Review of the physician orders revealed an order, dated 11/06/10 at 10:05 a.m., for Dilaudid 2 mg IV every 4-6 hours as needed for pain. Review of the MAR revealed the patient received Dilaudid on 11/06/10 at 6:50 p.m. and on 11/07/10 at 6:35 a.m. There was no reassessment of the patient's pain level after the patient was medicated for pain. Review of the facility's policy, "Pain Management", last reviewed 7/01/10 states the nurse will evaluate effectiveness following administration of pain medication. The patient will be reassessed 30 minutes after IV medication and within 1 hour following mediation by other routes. The findings will be documented in the EMR (Electronic Medical Record).

Interview with the Director of Quality Management on 12/01/10 at 5:00 p.m. confirmed the above findings.