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Based on interview and record review, Hospital A failed to ensure that a physician who was present and on the unit when an order was given to the Registered Nurse (RN), entered the physician's order into the medical record, for 1 of 35 sampled patients (1), in accordance with a policy from the hospital's medical staff manual. Physician 1 did not enter an order for Patient 1's free water administration into the medical record.

Failure to enter physician's orders for the administration of free water, had the potential to cause free water administration errors which could negatively impact patients' medically fragile health status. Also, the lack of a physician's order made it difficult to determine whether or not the physician actually prescribed the documented medical treatment plan.

Findings:

On 4/1/14 beginning at 10:20 A.M., a tour of Hospital A's 6 North, medical-surgical unit was conducted with the Chief Nursing Officer (CNO), the Nursing Director of Telemetry (NDOT), Nursing Director of Critical Care (NDCC) and the charge nurse (RN 1).

A review of Patient 1's medical record was conducted on 4/1/14 at 10:53 A.M. Patient 1 was admitted to Hospital A on 3/28/14 with diagnoses which included cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth) and volvulus (an obstruction caused by twisting of the stomach or intestine) per the History and Physical (H&P), dated 3/29/14. Per the same H&P, Patient 1 had a G-tube (gastrostomy tube - an artificial external opening into the stomach for nutritional support).

According to RN 1, Patient 1 did not want to have visitors in his room. An observation and interview with Patient 1 could not be conducted.

A review of Patient 1's physician's orders was conducted. On 4/1/14 at 7:25 A.M., a physician's order indicated to administer Patient 1's tube feeding via gastrostomy tube, Isosource at 75 ml (milliliters) per hour and free water 200 ml every 6 hours. There was no physician's order for free water administration prior to this date.

Per Patient 1's Intake and Output (I&O) in the medical record, dated 3/30/14 to 3/31/14, registered nurses were administering free water through Patient 1's feeding tube without documented evidence that a physician's order had been obtained.

A joint interview and record review with RN 3 was conducted on 4/2/14 at 9:17 A.M. RN 3 stated that she took care of Patient 1 on 3/30/14. She stated that she had spoken to Physician 1 about Patient 1 receiving 200 ml of free water every 6 hours with his tube feeding. She stated that she was not aware that Physician 1 had not entered the order into Patient 1's medical record. However, she stated that it was her responsibility to ensure that a physician's order related to the administration of Patient 1's free water had been entered into the medical record.

A review of the hospital's policy titled "Physician Orders Giving, Receiving, Authenticating", last review date of 10/2013, was conducted. The policy stipulated that "To the extent possible, verbal orders will be reserved for instances when it is impossible or impractical to write an order or transmit an order electronically." Per the same policy, it indicated that "Verbal orders will not be routinely accepted when the physician is present except during emergent situations, a code, or when sterile technique may be compromised."

A review of the hospital's policy titled "Enteral Feeding Management", last review date of 3/2014, was conducted. The policy indicated that "Process order for enteral feeding into the order communication (OC) system. Order should include name or type of formula; total volume, or ml per hour if using a pump or ml per shift, and ml of water per shift; must include enteral access/route."

A joint interview and record review with the Nursing Director of Medical-Surgical Services (NDMS) was conducted on 4/3/14 at 4:15 P.M. The NDMS acknowledged that when physicians were present and not involved in some emergent situation, it was their responsibility to enter physician's orders that they have communicated to the nursing staff per the hospital's policy. She acknowledged that Physician 1 should have entered the free water administration order into Patient 1's medical record since the physician was present on the unit when the order was given to the RN.

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Based on interview and record review, Hospital A failed to ensure that the registered nurses (RNs) had adequate oversight of the nursing care for 1 of 35 sampled patients (1). RNs did not ensure that a complete physician's order related to tube feeding had been obtained prior to the tube feeding administration, in accordance with the hospital's policy and procedure. RN's proceeded to administer Patient 1's tube feeding without a complete physician's order. In addition, Hospital A's Registered Nurses (RNs) failed to ensure that a physician's order had been entered into Patient 1's medical record for the free water administration.

Failure to obtain and enter complete physician's orders for tube feeding and free water administration, had the potential to cause tube feeding and free water administration errors which could negatively impact patients' medically fragile health status. Also, the lack of a physician's order made it difficult to determine whether or not the physician actually prescribed the documented medical treatment plan.

Findings:

1. On 4/1/14 beginning at 10:20 A.M., a tour of Hospital A's 6 North, medical-surgical unit was conducted with the Chief Nursing Officer (CNO), the Nursing Director of Telemetry (NDOT), Nursing Director of Critical Care (NDCC) and the charge nurse (RN 1).

A review of Patient 1's medical record was conducted on 4/1/14 at 10:53 A.M. Patient 1 was admitted to Hospital A on 3/28/14 with diagnoses which included cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth) and volvulus (an obstruction caused by twisting of the stomach or intestine) per the History and Physical (H&P), dated 3/29/14. Per the same H&P, Patient 1 had a G-tube (gastrostomy tube - an artificial external opening into the stomach for nutritional support).

According to RN 1, Patient 1 did not want to have visitors in his room. An observation and interview with Patient 1 could not be conducted.

The following physician's orders were found in Patient 1's medical record:

On 3/29/14 at 12:30 P.M., the physician's order read "Restart TF's (tube feedings) as per home".

On 3/30/14, no time was documented, the physician's order read "Start TF's (tube feedings)". This was noted by the nursing staff on 3/30/14 at 12:25 P.M.

On 3/30/14 at 12:25 P.M., the physician's order indicated tube feeding which contained the route - gastrostomy tube and the formula name .

On 3/29/14 at 1:31 P.M., the physician's order read "Restart TF (tube feeding) as per home", tube feeding route indicated gastrostomy tube.

A clear and complete tube feeding physician's order was not found in the Patient 1's medical record.

According to Nurse's Notes dated 3/30/14 at 1:11 P.M., Patient 1's tube feeding was started at 35 ml (milliliters) on 3/30/14 at 1:10 P.M. Per the same note, Patient 1's tube feeding was to be increased by 10 ml every 8 hours, for a goal of 75 ml per hour.

Per Patient 1's Care Activity - Assessments in the medical record, dated 3/30/14 to 3/31/14, registered nurses continued to administer the patient's tube feeding.

An interview with RN 2 was conducted on 4/1/14 at 11:55 A.M. RN 2 stated that she was Patient 1's primary nurse for 4/1/14 from 7:00 A.M. to 7:30 P.M. (12 hour shift). She stated that during the handoff report, she was told that Patient 1's diet was Isosource (formula name) via tube feeding at 75 ml per hour. She stated that she was informed that Patient 1 had met his tube feeding goal. However, she stated upon her search for a physician's order to verify the administration of Patient 1's tube feeding, she was unable to find a physician's order. She stated that she called the physician on 4/1/14 at 7:25 A.M., clarified Patient 1's diet and tube feeding administration and obtained a physician's order for it. She stated that a complete tube feeding physician's order contained the following elements: name or type of formula, total volume or ml per hour, water flush instruction and route of tube feeding.

Patient 1's physician's order dated, 4/1/14 at 7:25 A.M., indicated to administer tube feedings via gastrostomy tube, Isosource at 75 ml per hour and free water 200 ml every 6 hours.

A review of the hospital's policy titled "Enteral Feeding Management", last review date of 3/2014, was conducted. The policy indicated that "Process order for enteral feeding into the order communication (OC) system. Order should include name or type of formula; total volume, or ml per hour if using a pump or ml per shift, and ml of water per shift; must include enteral access/route."

A review of the hospital's policy titled "Physician Orders Giving, Receiving, Authenticating", last review date of 10/2013, was conducted. The policy stipulated that "All written orders, including those on pre-printed forms or electronically transmitted orders, must be clear, legible and complete." Per the same policy, it indicated that "Orders that are illegible or improperly written will not be carried out until unwritten or clarified and understood by the licensed or certified professional."

A joint interview and record review with the Nursing Director of Medical-Surgical Services (NDMS) was conducted on 4/3/14 at 4:15 P.M. The NDMS acknowledged that Patient 1's medical record did not contain a complete tube feeding physician's order prior to the administration of the tube feeding, in accordance with the hospital's policy.

2. On 4/1/14 beginning at 10:20 A.M., a tour of Hospital A's 6 North, medical-surgical unit was conducted with the Chief Nursing Officer (CNO), the Nursing Director of Telemetry (NDOT), Nursing Director of Critical Care (NDCC) and the charge nurse (RN 1).

A review of Patient 1's medical record was conducted on 4/1/14 at 10:53 A.M. Patient 1 was admitted to Hospital A on 3/28/14 with diagnoses which included cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth) and volvulus (an obstruction caused by twisting of the stomach or intestine) per the History and Physical (H&P), dated 3/29/14. Per the same H&P, Patient 1 had a G-tube (gastrostomy tube - an artificial external opening into the stomach for nutritional support).

According to RN 1, Patient 1 did not want to have visitors in his room. An observation and interview with Patient 1 could not be conducted.

A review of Patient 1's physician's orders was conducted. On 4/1/14 at 7:25 A.M., a physician's order indicated to administer Patient 1's tube feeding via gastrostomy tube, Isosource at 75 ml (milliliters) per hour and free water 200 ml every 6 hours. There was no physician's order for free water administration prior to this date.

Per Patient 1's Intake and Output (I&O) in the medical record, dated 3/30/14 to 3/31/14, registered nurses were administering free water through Patient 1's feeding tube without documented evidence that a physician's order had been obtained.

A joint interview and record review with RN 3 was conducted on 4/2/14 at 9:17 A.M. RN 3 stated that she took care of Patient 1 on 3/30/14. She stated that she had spoken to Physician 1 about Patient 1 receiving 200 ml of free water every 6 hours with his tube feeding. She stated that she was not aware that Physician 1 had not entered the order into Patient 1's medical record. However, she stated that it was her responsibility to ensure that a physician's order related to the administration of Patient 1's free water had been entered into the medical record.

A review of the hospital's policy titled "Physician Orders Giving, Receiving, Authenticating", last review date of 10/2013, was conducted. The policy stipulated that "All written orders, including those on pre-printed forms or electronically transmitted orders, must be clear, legible and complete." Per the same policy, it indicated that "Orders that are illegible or improperly written will not be carried out until unwritten or clarified and understood by the licensed or certified professional."

A review of the hospital's policy titled "Enteral Feeding Management", last review date of 3/2014, was conducted. The policy indicated that "Process order for enteral feeding into the order communication (OC) system. Order should include name or type of formula; total volume, or ml per hour if using a pump or ml per shift, and ml of water per shift; must include enteral access/route."

A joint interview and record review with the Nursing Director of Medical-Surgical Services (NDMS) was conducted on 4/3/14 at 4:15 P.M. The NDMS acknowledged that Patient 1's medical record did not contain a physician's order for the administration of free water via the feeding tube, in accordance with the hospital's policy. She stated that the RNs should have had a written or electronic physician's order in Patient 1's medical record related to the administration of the free water.






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Based on observation, interview and record review, Hospital A failed to ensure that there was documented evidence in the medical record to demonstrate that ordered water flushes were consistently provided to 1 of 35 sampled patients (1). Patient 1's medical record did not contain documentation to accurately reflect or demonstrate the amount of free water administered versus the feeding tube flushes given throughout a shift by the nursing staff. The lack of documented evidence made it difficult to determine whether or not the ordered water flushes were being administered to the patient to ensure adequate hydration.

Findings:

On 4/1/14 beginning at 10:20 A.M., a tour of Hospital A's 6 North, medical-surgical unit was conducted with the Chief Nursing Officer (CNO), the Nursing Director of Telemetry (NDOT), Nursing Director of Critical Care (NDCC) and the charge nurse (RN 1).

A review of Patient 1's medical record was conducted on 4/1/14 at 10:53 A.M. Patient 1 was admitted to Hospital A on 3/28/14 with diagnoses which included cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth) and volvulus (an obstruction caused by twisting of the stomach or intestine) per the History and Physical (H&P), dated 3/29/14. Per the same H&P, Patient 1 had a G-tube (gastrostomy tube - an artificial external opening into the stomach for nutritional support).

A review of Patient 1's physician's orders was conducted. On 4/1/14 at 7:25 A.M., a physician's order indicated to administer Patient 1's tube feeding via gastrostomy tube, Isosource at 75 ml (milliliters) per hour and free water 200 ml every 6 hours. There was no physician's order for free water administration prior to this date.

Per Patient 1's Intake and Output (I&O) in the medical record, dated 3/30/14 to 3/31/14, registered nurses were administering free water through Patient 1's feeding tube. The documented free water administration indicated the following:

3/30/14 at 10:59 P.M. - Patient 1 received 300 ml of tube irrigant (free water and/or flushes).
3/31/14 at 6:59 A.M. - Patient 1 received 600 ml of tube irrigant.
3/31/14 at 10:59 P.M. - Patient 1 received 430 ml of tube irrigant.
4/1/14 at 6:59 A.M. - Patient 1 received 620 ml of tube irrigant.

There was no documented evidence found in Patient 1's medical record to accurately determine if the 200 ml free water and/or general feeding tube flushes were administered in accordance with the physician's order and/or the hospital's policy.

A joint interview and record review with RN 3 was conducted on 4/2/14 at 9:17 A.M. RN 3 stated that she took care of Patient 1 on 3/30/14. She stated that she had spoken to Physician 1 about Patient 1 receiving 200 ml of free water every 6 hours with his tube feeding. She stated that she was not aware that Physician 1 had not entered the order into Patient 1's medical record. However, she stated that it was her responsibility to ensure that a physician's order related to the administration of Patient 1's free water had been entered into the medical record. She stated that she started Patient 1's 200 ml free water every 6 hours administration on 3/30/14 and documented it in the patient's I&O record.

A review of the hospital's policy titled "Enteral Feeding Management", last review date of 3/2014, was conducted. The policy indicated that "Process order for enteral feeding into the order communication (OC) system. Order should include name or type of formula; total volume, or ml per hour if using a pump or ml per shift, and ml of water per shift; must include enteral access/route." Per the same policy, it stipulated under maintenance ... "1. Maintain and record formula and water on Intake and Output Record. 2. Flush the tube with a least 50 ml of water using sterile syringe, or per physician order, every eight (8) hours, at start of the feeding, when the container is changed, when the dose has been reached and the pump turned off. 3. Provide additional water at any time for adequate hydration."

A joint interview and record review with the Nursing Director of Medical-Surgical Services (NDMS) was conducted on 4/3/14 at 4:15 P.M. The NDMS acknowledged that Patient 1's medical record did not contain documented evidence to accurately reflect or demonstrate the amount of free water administered versus the feeding tube flushes given throughout a shift by the RNs.




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Based on observation, interview and document review, the hospital failed to ensure that the nurse call light system was maintained and operable to ensure an acceptable level of safety for 4 out of 4 patient tub rooms at Hospital B. Four patient tub rooms did not have functioning call light systems in an effort to ensure that an operable device was in place and was readily accessible to all patients who may require nursing or staff assistance in an emergency.

Findings:

1. During a tour of hospital B's 3 north locked behavioral unit on 4/3/14 at 8:00 A.M., the patient tub room was observed. The nursing call light button was pressed from inside the tub room and there was no audible or visual response.

An interview with the Director of Outpatient Services (DOS) was conducted on 4/3/14 at 8:20 A.M. She stated that the patients usually used the showers in the patient rooms and that the tub rooms are only occasionally used for patients that prefer to take a bath. She acknowledged that the nursing call light system was not functioning for the tub room.

A review of the Hospital's policy entitled "Utility Systems Management Plan" was conducted on 4/3/14 at 11:50 A.M. The policy indicated under section 4 critical components that "the Director of Plant Operations has overall responsibility for the proper maintenance and operation of the utility and mechanical systems at [Hospital Name]. These systems include, but are not limited to the following: Nurse Call System".

2. A tour of Hospital B's 3 south locked behavioral unit was conducted on 4/3/14 at 8:15 A.M. A patient tub room was observed to have a nursing call light system in place and when the button was pressed from inside the tub room and there was no audible or visual response.

An interview with the Director of Outpatient Services (DOS) was conducted on 4/3/14 at 8:20 A.M. She stated that the patients usually used the showers in the patient rooms and that the tub rooms are only occasionally used for patients that prefer to take a bath. She acknowledged that the nursing call light system was not functioning for the tub room.

A review of the Hospital's policy entitled "Utility Systems Management Plan" was conducted on 4/3/14 at 11:50 A.M. The policy indicated under section 4 critical components that "the Director of Plant Operations has overall responsibility for the proper maintenance and operation of the utility and mechanical systems at [Hospital Name]. These systems include, but are not limited to the following: Nurse Call System".



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3. On 4/3/14 beginning at 9:15 A.M., a tour of Hospital A's 2 floor behavioral unit was conducted with the Director of Behavioral Health (DBH) and the nursing supervisor (Registered Nurse - RN 4). The north side patient tub room was observed. A silver plate, very similar to an electrical outlet face plate, with two hollow holes was located on the wall behind the door. On the silver plate, the upper hole had an engraving that read "call placed". The lower hole on the silver plate had an engraving that read "push for help". There was nothing that could be pushed to determine that the call light system was operable and functioning. There was no audible and visual response.

An interview with the charge nurse (RN 5) was conducted on 4/3/14 at 9:20 A.M. RN 5 stated that the call light system was not working in the tub rooms. She stated that the nursing staff or mental health workers conducted frequent rounds and checked in on patients who were using the tub rooms.

An interview with the Chief Nursing Officer (CNO) was conducted on 4/3/14 at 9:30 A.M. Through observations and interviews, it was confirmed that Hospital B's tub rooms did not have functioning call light systems. The CNO acknowledged that the patients had showers in their patient bathrooms and that the tub rooms were only used by the patients that preferred to take a bath. She acknowledged that the nursing call light system in the tub rooms were not functioning.

A review of the Hospital's policy titled "Utility Systems Management Plan" was conducted on 4/3/14 at 11:50 A.M. The policy indicated under section 4 critical components that "the Director of Plant Operations has overall responsibility for the proper maintenance and operation of the utility and mechanical systems at [Hospital Name]. These systems include, but are not limited to the following: Nurse Call System". This policy was not implemented when the patient tub rooms did not have functioning nurse call light systems.

4. On 4/3/14 beginning at 9:15 A.M., a tour of Hospital A's 2 floor behavioral unit was conducted with the Director of Behavioral Health (DBH) and the nursing supervisor (Registered Nurse - RN 4). There was a patient using the the patient tub room located on the south side of the unit. A staff member was waiting outside the door. An observation of the patient tub room could not be conducted at this time.

An interview with the charge nurse (RN 5) was conducted on 4/3/14 at 9:20 A.M. RN 5 stated that the call light system was not working in the tub rooms. She stated that the nursing staff or mental health workers conducted frequent rounds and checked in on patients who were using the tub rooms.

An interview with the Chief Nursing Officer (CNO) was conducted on 4/3/14 at 9:30 A.M. Through observations and interviews, it was confirmed that Hospital B's tub rooms did not have functioning call light systems. The CNO acknowledged that the patients had showers in their patient bathrooms and that the tub rooms were only used by the patients that preferred to take a bath. She acknowledged that the nursing call light system in the tub rooms were not functioning.

A review of the Hospital's policy titled "Utility Systems Management Plan" was conducted on 4/3/14 at 11:50 A.M. The policy indicated under section 4 critical components that "the Director of Plant Operations has overall responsibility for the proper maintenance and operation of the utility and mechanical systems at [Hospital Name]. These systems include, but are not limited to the following: Nurse Call System". This policy was not implemented when the patient tub rooms did not have functioning nurse call light systems.