HospitalInspections.org

Based on interview and a review of facility documentation, the facility failed to ensure the establishment of a process to provide complete information to each patient regarding whom to contact to file a grievance.

Findings:

A review of facility documentation did not uncover any process through which patients could be informed of the address of the State agency (Agency for Health Care Administration) where they may lodge a grievance. In addition, there was no evidence of a process through which patients could be informed that grievances filed with the State agency could be filed whether or not a grievance had already been filed with the facility.

During an interview of the Risk Manager on 1/15/12 at approximately 2 PM, he confirmed the preceding.

Based on interview and a review of facility documentation, the facility failed to ensure the establishment of a policy requiring a working knowledge by physicians and other licensed independent practitioners concerning the use of restraints or seclusion.

Findings:

During a review of facility documentation, no evidence of a policy requiring a working knowledge by physicians and other licensed independent practitioners concerning the use of restraints or seclusion was discovered.

During an interview of the Vice President of Quality on 1/16/13 at approximately 12:30 PM, she confirmed the preceding.

Based on observation, interview and record review, the facility failed to give 1 of 3 patients observed receiving medications in a timely manner and in accordance with hospital policy (#5).
Findings included:

Patient #5, age 67, was admitted on 12/17/2012 for abdominal pain, bloody stool, and newly diagnosed ulcerative colitis.

The medication pass observation on 1/14/2013 from 12:05 to 12:30 p.m. showed registered nurse (RN) #K gave the following medications: Aldactone 12.5 milligrams (mg.) tablet by mouth (po), Fish oil (vitamin supplement) 1000 mg. po, Vitamin D (vitamin supplement) 1000 mg. tablet, Metropolol (decreases blood pressure) 75 mg. tablet, Celexa (medication used for depression) 20 mg. tablet, and Amiodarone (medication used to control the heart rate) 200 mg. tablet. All these medications were crushed and mixed together in tap water and given by RN #K on 1/14/2013 at 12:05 p.m. by way of the patient's percutaneous feeding tube (tube placed in the abdomen for access into the stomach). The nurse checked the stomach for residue and flushed the tube after the medication pass.

On 1/14/2013 at 12:30 p.m., RN #K completed the medication pass by giving patient #5 Lasix (a diuretic medication) 40 mg. by intravenous push, Canasa (medication used for treatment of colitis) 1000 mg. rectal suppository, and Nitroglycerine patch (medication used for chest pain) 0.4 mg to right upper arm area.

Review of the physician's orders and the medication administration record showed all of the medications were due to be given to patient #5 at 10 a.m. and were given 2 hours late.

During an interview on 1/14/2014 at 12:45 p.m., RN #K was asked if the facility policy allows multiple medications to be mixed and then given through the percutaneous feeding tube and she responded at the last place she worked it was allowed, but she said she was not sure what facility policy was here. She was also asked why the 10 a.m. medications were being given at 12:05-12:30 p.m. and she said she has 5 patients today and patient # 5 was her last one, and with so many patients, this is when she can get to giving them. She said 5 patients is a big load for one nurse.

Quality Coordinator #F and Director Clinical Nursing #B were both present and confirmed the statements made by RN #K.

Review of the policy "Medication Administration" includes knowledge based medication administration, dated as reviewed 11/01/2012, "Medication Administration....should be administered within 60 minutes before or 60 minutes after the hour ordered.... Facility policy "Nasogastric, Orogastric and Percutaneous Feeding Tube placement and Maintenance", dated as reviewed 11/01/2012 read, "Medication Administration Guidelines....Administer medications separately. Mixing them may cause the tube to clog....Flush the tube after administering each medication to help prevent clogging the tube."