HospitalInspections.org

Based on record review and staff interview it was determined that the facility failed to ensure a registered nurse supervised and evaluated care related to assessments for 1 (#1) of 3 sampled patients. This practice may result in failure to achieve patient goals.

Findings include:

1. Patient #1 had an insertion of an Inferior Vena Cava (IVC) Filter on 8/6/10. The interventional radiologist wrote a post procedure note dated 8/6/10 requiring that vital signs were to be recorded every 15 minutes times 4, then every 30 minutes times 2, then every 60 minutes times 2, then per routine.

Review of the documentation during the procedure revealed that vital signs were monitored every 15 minutes and discontinued at 6:06 p.m.

A document labeled Pre & Post -Procedure Flow Sheet revealed the first post procedure vital signs were recorded at 6:05 p.m. The vital signs were not recorded again until 7:00 p.m. which was 55 minutes later. Vital signs were then recorded at 7:15 p.m. and 7:30 p.m. The vital signs at that time were Blood Pressure- 123/61, pulse 111, respiratory rate 20. The next documentation of vital signs was at 8:00 p.m. The blood pressure had decreased to 108/55, the heart rate had increased to 146, the respiratory rate was not recorded. An order was obtained to transfer to the Intensive Care Unit (ICU) at 8:00 p.m.

Review of nursing documentation revealed no further assessment until the patient arrived at the ICU at 8:30 p.m. The ICU nurse documented that the patient was "tachycardic and diaphoretic. Vital signs at 8:45 p.m. were Blood pressure of 116/35, heart rate at 153 and respiratory rate of 35. There was no evidence that the patient was monitored by nurse after the order to transfer to the ICU was obtained at 8:00 p.m.

During interview on 2/2/11 at approximately 5:00 p.m., the Nursing Director confirmed the above findings.

2. Review of the Adult Clinical Flowsheet for patient # 1 revealed that vital signs were not recorded on the 7 a.m. to 7 p.m. shift for 8/6/10 until the pre-procedure vital signs at 5:00 p.m. Intake and output was not recorded for the Day shift on 8/6/10. Safety, hygiene, activity, skin were not addressed for the 7 a.m. to 7 p.m. shifts on 8/6/10. The every two hour interventions for patient rounds and toileting needs were not recorded after 6:00 a.m. on 8/6/10.

During interview on 2/2/11 at approximately 5:00 p.m. the Nursing Director confirmed that above findings.

Based on record review and staff interview, it was determined that the facility failed to initiate medication as ordered for 1 (#1) of 3 sampled patients. This practice may result in failure to achieve desired therapeutic results.

Findings include:

1. Review of the medical record of patient #1 revealed a physician order for a Heparin bolus and Heparin drip. The order was written on 8/6/10 at approximately 5:00 p.m. There was no documentation that the heparin was initiated. The patient had a Inferior Vena Cava filter inserted at 5:00 p.m.

During interview on 2/2/11 at approximately 5:00 p.m., the Nursing Director confirmed the heparin was not initiated as ordered.