HospitalInspections.org

Based on interview and record review the hospital failed to ensure that patients admitted to the hospital received a written disclosure notice indicating that the hospital did not have a physician on-site at the hospital at all times. This failed practiced was evidenced by no documentation of a written disclosure notice that the hospital did not have a physician on-site at the hospital at all times in 4 of 4 (#1, #2, #4, #5) sampled current patient medical records and in 1 of 1 (#3) closed sampled patient medical records reviewed. The hospital had a total census of 11 patients out of a 22 patient capacity.

Findings:
A review of the hospital's Admission Packet given to all patients, and provided by S1ADM, revealed the hospital had no written disclosure notice in the Admissions Packet disclosing that the hospital did not have a physician on-site at the hospital at all times.

In a review of the sampled medical records for Patients #1- #5 there was no documented evidence in the EMR (electronic medical record) of a written disclosure notice given to patients that indicated that the patients were informed that the hospital did not have a physician on-site at al times.

In an interview on 12/20/17 at 12:45 p.m. with S9LPN, in a review of the sampled medical records for Patient #1- #5, she was unable to show documented evidence that patients had received and/or signed a disclosure notice form indicating that they were informed that the hospital did not have a physician on-site at all times.

In an interview on 12/20/17 at 3:15 p.m. with S3VP she indicated that patients were not provided a disclosure notice (verbally or in writing) upon admit indicating that the hospital did not have a physician on-site at all times. She indicated that a physician disclosure notice was not included in the Admission Packet given to patients and the physician disclosure notice was not posted anywhere. S3VP indicated that she was not aware that this was required under hospital regulations.

Based on record review and interview the hospital failed to ensure that the RN (Registered Nurse) supervised and evaluated the nursing care of each patient as evidenced by failing to assess and document blood pressure prior to administering blood pressure medications for 3 (#2, #3, #4) of 5 (#1-#5) sampled patient medical record reviewed for monitoring blood pressure prior to administrating blood pressure medications.

Findings:
A review of the hospital policy titled, "Medication Administration", as provided by S3VP as a current policy, revealed in part: the MAR (medication administration record) is used by the nurse to verify the medication selected is the correct medication based on medication order and medication product label and verifies that no contraindications exist for administering the medication. There was no documented evidence of any provisions in the policy that addressed assessment/monitoring parameters for blood pressure medication administration.

Patient #2
A review of the current medical record for the patient revealed he was a 62 year old male and was admitted on 12/11/17. A review of the patient's H&P (history and physical) revealed the admitting diagnosis was Suicidal Ideations and Major Depressive Disorder without psychosis, and substance abuse. The H&P further revealed he had a medical history of COPD (chronic obstructive pulmonary disease) and HTN (hypertension).

A review of the admit physician orders revealed an order for Metoprolol Succinate (Medication for High Blood Pressure) 50 mg. (milligrams) twice a day.

A review of the MAR revealed the above medication was administered daily at 9:00 a.m. and 9:00 p.m. A review of the vital sign sheet revealed the patient's blood pressure was documented at 7:00 a.m. and 7:00 p.m. each day. There was no documented evidence that the patient's blood pressure was assessed and documented prior to the administration of the blood pressure medication at 9:00 a.m. and 9:00 p.m. each day


Patient #3
A review of the closed medical record for the patient revealed she was a 88 year old female and was admitted on 02/14/17. A review of the patient's H&P revealed the admitting diagnosis was Major Depressive Disorder with recurrent, severe psychotic symptoms. The H&P further revealed she had a medical history of HTN, heart disease, left vascular stroke affecting left side with hemiplegia and hemiparesis, osteoarthritis, history of falls, anemia, and the patient had a UTI (urinary tract infection).

A review of the admit physician orders revealed orders for Metoprolol Succinate 50 mg. twice a day, Norvasc 5 mg at bedtime, and Diovan 12.5 mg twice a day (Medications for High Blood Pressure).

A review of the MAR revealed the Metoprolol Succinate and the Diovan were administered daily at 9:00 a.m. and 9:00 p.m. and the Norvasc was administered at 9:00 p.m. each night. A review of the vital sign sheet revealed the patient's blood pressure was documented at 7:00 a.m. and 7:00 p.m. each day. There was no documented evidence that the patient's blood pressure was assessed and documented prior to the administration of the blood pressure medications at 9:00 a.m. and 9:00 p.m. each day


Patient #4
A review of the medical record for the patient revealed he was a 70 year old male and was admitted on 12/12/17. A review of the patient's H&P revealed the admitting diagnosis was behavioral disturbances with violent behavior and Dementia. The H&P further revealed he had a medical history of Parkinson's disease, Diabetes, and HTN.

A review of the admit physician orders revealed an order for Metoprolol Succinate 50 mg. twice a day (Medications for High Blood Pressure).

A review of the MAR revealed the blood pressure was administered daily at 9:00 a.m. and 9:00 p.m. A review of the vital sign sheet revealed the patient's blood pressure was documented at 7:00 a.m. and 7:00 p.m. each day. There was no documented evidence that the patient's blood pressure was assessed and documented prior to the administration of the blood pressure medication at 9:00 a.m. and 9:00 p.m. each day


In an interview on 12/19/17 at 4:00 p.m. with S2DON she indicated that vital signs for blood pressure medicine administration should be done by the nurse prior to the administration of the blood pressure medication. She said that staff used the 7:00 a.m. and 7:00 p.m. vital signs taken by the MHT (mental health technicians) prior to administering a patient's blood pressure medicine at 9:00 a.m. and 9:00 p.m. She indicated that the time between when the vital signs were taken and when the blood pressure was administered could be a difference of 30 - 90 minutes. S2DON indicated it was probably good nursing practice to take blood pressures immediately before administering blood pressure medications.

Based on record review and interview the hospital failed to ensure the nursing staff developed and kept current an individualized, comprehensive nursing care plan for each patient for 4 (#1, #2, #3, #5) of 5 (#1- #5) sampled patient medical records reviewed for care plans.

Findings:
A review of the hospital policy titled, "Plan of Care", as provided by S3VP, as the most current policy, revealed in part: Every patient shall have an individualized comprehensive plan of care and shall be revised based on changes in the patient's condition, problems, needs and responses to care, treatment and services.


Patient #1
A review of the current patient's medical record revealed the patient was a 87 year old female and was admitted on 12/07/17 with an admit diagnosis of Major Depressive Disorder (single episode) and psychosis. A further review of the medical record revealed the patient had a history of Parkinson's disease, Alzheimer's, and HTN. The patient was admitted for a psychiatric evaluation and treatment. A Fall Risk Assessment was performed upon admit and the patient was placed on fall precautions due to a prior fall history, dementia, UTI, agitation, and taking more than 4 medications. On 12/09/17 the patient had a fall. A Post Fall Risk Assessment was not completed, according to hospital policy. There was no documented evidence that the care plan was revised or updated after the fall on 12/09/17.

In a medical record review on 12/20/17 with S9LPN of the patient care plan, she indicated that there was no documented evidence of a care plan revision after the patient's fall on 12/09/17 and no documentation of a completion of a Post Fall Risk Assessment.

Patient #2
A review of the current patient's medical record revealed the patient was a 62 year old male and was admitted on 12/11/17 with an admit diagnosis of Suicidal Ideations and Major Depressive Disorder without psychosis and substance abuse. A further review of the medical record revealed the patient had a history of COPD and HTN. The patient was admitted for a psychiatric evaluation and treatment. A Fall Risk Assessment was performed upon admit and the patient was placed on fall precautions due to a prior fall history, gait imbalances, weakness, and taking more than 4 medications. On 12/11/17 the patient had a fall. A Post Fall Risk Assessment was not completed, according to hospital policy. There was no documented evidence that the care plan was revised or updated after the fall on 12/11/17. A further review of the patient's care plan revealed no documented evidence that the patient was care planned for HTN and the patient had physician orders for blood pressure medication upon admit.

In a medical record review on 12/20/17 with S9LPN of the patient care plan, she indicated that there was no documented evidence of a care plan revision after the patient's fall on 12/11/17 and no documentation of a completion of a Post Fall Risk Assessment. She further indicated that there as no care plan for HTN.


Patient #3
A review of the closed patient's medical record revealed the patient was a 88 year old female and was admitted on 02/14/17 with an admit diagnosis of Major Depressive Disorder with recurrent, severe psychotic symptoms. A further review of the medical record revealed the patient had a history of HTN, heart disease, left vascular stroke affecting left side with hemiplegia and hemiparesis, osteoarthritis, history of falls, anemia, and the patient had a UTI. The patient was admitted for a psychiatric evaluation and treatment. A Fall Risk Assessment was performed upon admit and the patient was placed on fall precautions due to a prior fall history, seizure disorder, had left sided weakness, an unsteady balance, and taking more than 4 medications. On 02/15/17 and 02/21/17 the patient had a fall. A Post Fall Risk Assessment was completed, according to hospital policy. There was no documented evidence that the care plan was revised or updated after the falls on 02/15/17 and 02/21/17. A further review of the patient's care plan revealed no documented evidence that the patient was care planned for HTN and the patient had physician orders for blood pressure medication upon admit.

In a medical record review on 12/19/17 with S9LPN of the patient care plan, she indicated that there was no documented evidence of a care plan revision after the patient's falls on 02/15/17 and 02/21/17. She further indicated that there as no care plan for HTN.


Patient #5
A review of the current patient's medical record revealed the patient was a 74 year old female and was admitted on 12/14/17 with an admit diagnosis of Dementia with Behavioral Disturbances with violent behavior. A further review of the medical record revealed the patient had a history of COPD and HTN. The patient was admitted for a psychiatric evaluation and treatment. A Fall Risk Assessment was performed upon admit and the patient was placed on fall precautions due to a prior fall history, gait imbalances, weakness, and taking more than 4 medications. A review of the patient's care plan revealed no documented evidence that the patient was care planned for COPD and the patient had physician orders for nebulizer treatments twice a day upon admit.

In a medical record review on 12/20/17 with S9LPN of the patient care plan, she indicated that there was no care plan for COPD.

In an interview on 12/20/17 at 4:00 p.m. with S4RN and S5LPN they indicated that all patient's medical needs should be care planned, but S4RN indicated that she mostly just care plans for the main medical diagnoses.

In an interview on 12/19/17 at 4:00 p.m. with S2DON she indicated that nursing did not care plan for all of the patient's medical conditions, mostly just for the admitting diagnoses. She indicated that they are in the process of implementing a more specific comprehensive care plan documentation for all medical diagnoses, but they have no process developed yet for this at present.