HospitalInspections.org

A. Based on document review and interview, it was determined that for 1 of 5 records reviewed (Pt. #12) for vital sign monitoring and assessments, the Hospital failed to ensure that a nurse supervised the care of a patient by monitoring vital signs post-procedure as ordered/required.

Findings include:

1. The Hospital's policy titled, "Care of Adult Surgical/Procedural Patients (Pre and Post Procedure)" (revised 10/11/2019), was reviewed on 1/24/2023 and required, "Post procedure Care: ... RN [Registered Nurse] assures that routine post-operative care guidelines post procedure are completed per surgery/procedure guidelines. Patient care guidelines may include, but are not limited to the following: Vital Sign Monitoring: Blood pressure, pulse, respiration every 15 minutes x 4; every 30 minutes x 2... then every 4 hours unless otherwise indicated or ordered..."

2. The clinical record of Pt. #12 was reviewed on 1/23/2023. Pt. #12 was admitted to the 6 North Medical/Surgical Unit on 1/9/2023 with diagnoses of sacral decubitis ulcer, end-stage renal disease, and altered mental status. Pt. #12 had an IR (interventional radiology) biopsy procedure on 1/12/2023, between approximately 9:17 AM and 9:48 AM. A physician's order, dated 1/12/2023 at 9:34 AM, included, "Vital Signs... Q15MIN (Every 15 minutes) x4; Q30MIN x2." The Vital Signs Flowsheet on 1/12/2023 was reviewed and indicated that the first vital signs post procedure were documented at approximately 10:43 AM. The next set of vital signs were not documented until 11:15 AM (15 minutes late) and did not include the patient's respirations. Vital signs at 11:25 AM did not include heart rate/pulse or respirations. Vital Sign records also lacked documentation that a complete set of vitals (pulse, respirations, temperature, blood pressure, and oxygen saturations) were obtained every 4 hours on 1/17/2023 between approximately 11:03 AM and 6:05 PM (7 hours and 3 minutes) and on 1/22/2023 between approximately 2:00 AM and 7:45 AM (5 hours and 45 minutes) and between 7:45 AM and 8:38 PM (over 12 hours later).

3. An interview was conducted with the 6 North/South Charge Nurse (E#2) on 1/23/2023 and 1/24/2023. E#2 stated that vital signs are obtained every 4 hours on this unit. E#2 stated that if a patient has surgery or a procedure, vitals signs are typically monitored more frequently following the procedure and based on policy will go back to every 4 hours, unless the physician places a new vital signs order following the procedure to indicate a different frequency for monitoring. E#2 stated that all vital signs should be recorded and includes the pulse, temperature, blood pressure, respirations, and oxygen saturations.


B. Based on document review and interview, it was determined that for 2 of 2 records reviewed (Pts. #9 and #10) for pain management, the Hospital failed to ensure that a nurse supervised the care for each patient by conducting a complete pain assessment and reassessing the patient's pain to evaluate the effectiveness of pain interventions.

Findings include:

1. The Hospital's policy titled, "Pain Management [Hospital System] (Hospitals)" (revised 10/4/2021) was reviewed on 1/23/2023 and required, "...Some components of a pain assessment include but are not limited to location, sedation score, quality, radiation, numeric pain score, patient's pain goal, onset, indication/etiology, pattern, and duration, aggravating and alleviating factors, associated symptoms, and interventions... Severe pain: 7-10... Pain reassessment is the evaluation after a pain intervention to assess its effectiveness. Pain reassessment occurs within one hour of that pain intervention..."

2. The clinical record of Pt. #9 was reviewed on 1/23/2023. Pt. #9 was admitted on 1/19/2023, with a diagnoses of chronic renal failure, hematuria (blood in the urine), and urinary tract infection. The Medication Administration Record (MAR) indicated that Pt. #9 received the following medications for pain:
- Percocet 5/325 mg (milligram) tablet by mouth for moderate pain on 1/19/2023 at 9:02 PM.
- Hydromorphone 0.2 mg IV (intravenously) for severe pain on 1/19/2023 at 8:18 PM and 10:35 PM, and again on 1/20/2023 at 6:31 AM.
- Hydromorphone IV 1 mg for severe pain on 1/21/2023 at 5:37 AM and 11:18 PM, and again on 1/22/2023 at 6:18 PM.
- Pain assessments conducted at the time of administrations only included the numerical score rating the level of pain; however, lacked documentation of the other components of the pain assessment such as location, quality, onset, pattern, duration, etc.
- The record lacked documentation of a pain reassessment following the administration of IV hydromorphone on 1/22/2023 at 6:18 PM.

3. The clinical record of Pt. #10 was reviewed on 1/23/2023. Pt. #10 was admitted on 1/21/2023, with a diagnoses/complaints of alcohol dependence, pneumonia, abdominal pain, and vomiting. The MAR indicated that Pt. #10 received morphine 1 mg IV for pain at the following dates/times: 1/21/2023 at 10:23 PM; 1/22/2023 at 5:40 AM; 1/22/2023 at 1:30 PM; 1/22/2023 at 5:55 PM; 1/22/2023 at 11:03 PM; and 1/23/2023 at 5:30 AM.
- Pain assessments conducted at the time of administrations only included the numerical score rating the level of pain; however, lacked documentation of the other components of the pain assessment such as location, quality, onset, pattern, duration, etc.
- The record lacked documentation of pain reassessments following the administrations of IV morphine on 1/21/2023 at 10:23 PM; 1/22/2023 at 5:40 AM, 5:55 PM, and 11:03 PM; and 1/23/2023 at 5:30 AM. On two occasions (1/21/2023 at 11:23 PM and 1/22/2023 at 6:40 AM), the medication response was documented as: "Not done: Not appropriate at this time"; however, the record lacked documentation as to why the assessment was not appropriate at the time and that a reassessment was attempted at a later time.

4. An interview was conducted with the Charge Nurse (E#2) on 1/23/2023, at approximately 12:00 PM. E#2 stated that the pain assessment should include details of the pain (i.e. location), so that staff can evaluate the source of the pain in order to manage it. E#2 stated that a pain reassessment must be conducted and documented within 15-30 minutes for IV medications and within 30 minutes-1 hour for PO (by mouth) medications. E#2 reviewed the electronic medical records for Pts. #9 and #10 and could not find documentation of pain reassessments as noted above. E#2 stated that if staff are unable to perform a pain reassessment, they should document the reason why it was not appropriate at the time and should attempt to reassess at a later time.


C. Based on document review and interview, it was determined that for 1 of 2 records reviewed (Pt. #12) for wound care, the Hospital failed to ensure that a nurse supervised the care for each patient by conducting wound care as ordered.

Findings include:

1. The Hospital's policy titled, "Standards of Care" (revised 4/1/2021), was reviewed on 1/24/2023 and required, "RN [Registered Nurse] will obtain wound management orders from provider per recommendations from the wound nurse... Documentation of all care delivered will be entered into EMR [electronic medical record."

2. The clinical record of Pt. #12 was reviewed on 1/23/2023. Pt. #12 was admitted to the 6 North Medical/Surgical Unit on 1/9/2023 with diagnoses of sacral decubitis ulcer, end-stage renal disease, and altered mental status. Pt. #12 had a pressure injury on the coccyx. A Physician's ordered, dated 1/14/2023, included "Negative Pressure Wound Therapy... TRSA (Tue, Thu, Sat)... Unit Staff to manage... 15-30 minutes prior to dressing change, turn off wound vac and instill Vashe (wound cleanser) to all wound site... Cleanse... Apply Mepitel Ag to the base of the wound of coccyx... then pack wound cavity with black GranuFoam.... Protect Sacral wound dressing with a Foam dressing...." A Wound Care Note, dated 1/19/2023, included, "Primary RN... & Charge RN... notified of next dressing change due on Saturday [1/21/2023] to be managed by the unit staff..." The Wound Management Flowsheets, from 1/19/2023-1/21/2023 were reviewed and lacked documentation that wound care was performed as ordered on 1/21/2023.

3. An interview was conducted with the Charge Nurse (E#2) on 1/23/2023, at approximately 12:00 PM. E#2 reviewed Pt. #12's EMR and could not find documentation that wound care had been performed as ordered. E#2 stated that the unit staff should have performed and documented that wound care was completed as scheduled on 1/21/2023.

A. Based on document review and interview, it was determined that for 3 of 5 records (Pts. #9, Pt. #10 and Pt. #12) reviewed, the Hospital failed to ensure that a nursing care plan was developed for each patient and that it was current and reflected the patient's goals and nursing care to be provided to meet the patient's needs.

Findings include:

1. The Hospital's policy titled, "Documentation in the Medical Record by Nursing Personnel" (revised 10/15/2019), was reviewed on 1/23/2023 and required, "Documentation in the medical record by nursing personnel: ... The plan of care, which includes identification of problems, interventions, and outcomes is reviewed and updated every shift..."

2. The clinical record of Pt. #9 was reviewed on 1/23/2023. Pt. #9 was admitted on 1/19/2023, with a diagnoses of chronic renal failure, hematuria (blood in the urine), and urinary tract infection. The History & Physical (H&P), dated 1/19/2023 included, "Sent here from dialysis clinic for hemoglobin of 6.3. "Suffering from radiation and bleeding..." The clinical record indicated that Pt. #9 was voiding with blood and received blood transfusions. The record also indicated that Pt. #9 was reporting pain. The iPOC (Nursing Plan of Care), initiated 1/20/2023, included only Discharge Planning as a problem area identified.

3. The clinical record of Pt. #10 was reviewed on 1/23/2023. Pt. #10 was admitted on 1/21/2023, with a diagnoses/complaints of alcohol dependence, pneumonia, abdominal pain, and vomiting. The H&P, dated 1/21/2023, included "[Pt. #10] with pmhx [past medical history]... chronic back pain... alcohol abuse/dependence w/ hx withdrawals... depression, anxiety... pt reports mild diarrhea..." The clinical record lacked documentation that a Nursing Plan of Care was initiated for Pt. #10.

4. The clinical record of Pt. #12 was reviewed on 1/23/2023. Pt. #12 was admitted to the 6 North Medical/Surgical Unit on 1/9/2023 with diagnoses of sacral decubitis ulcer, end-stage renal disease, and altered mental status. The record indicated that Pt. #12 had multiple pressure injuries upon admission; however, the nursing plan of care was not updated to include "Pressure Injury" until 1/17/2023 (nearly a week after admission).

5. An interview was conducted with the Charge Nurse (E#2) on 1/23/2023, at approximately 12:00 PM. E#2 stated that the Nursing Plan of Care or iPOC should be initiated within 24 hours of admission. E#2 stated that the nurses are expected to update the plan with the patient's current problems, goals, and interventions. E#2 stated that knowing these patients, Pt. #9 should have had other problems other than discharge planning, such as risk of bleeding, UTI, and/or pain management. E#2 stated that Pt. #10 should have had an iPOC initiated by 1/22/2023 which should have included alcohol withdrawal, anxiety, and pain management. E#2 stated that Pt. #12's pressure injury should have been added to the iPOC upon admission when the wounds were noted.

Based on document review and interview, it was determined that for 2 of 2 records (Pts. #9 and #12) reviewed for blood transfusions, the Hospital failed to ensure that blood was transfused in accordance with policy.

Findings include:

1. The Hospital's policy titled, "Blood Products Administration" (revised 2/25/2020), was reviewed on 1/23/2023 and required, "Obtain vital signs 15 minutes after start time... When transfusion is complete, obtain post transfusion vital signs... include: ... Date and time transfusion was started and stopped..."

2. The clinical record of Pt. #9 was reviewed on 1/23/2023. Pt. #9 was admitted on 1/19/2023, with a diagnoses of chronic renal failure, hematuria (blood in the urine), and urinary tract infection. Physician's orders, dated 1/19/2023 and 1/20/2023, included to transfuse a total of 4 units of red blood cells (RBCs). The Transfusion flowsheets indicated that Pt. #9 received one unit of RBCs on 1/20/2023 from 1:54 PM to 3:12 PM and another on 1/20/2023 from 3:18 PM to 4:52 PM. The 15 minute vitals signs taken at 2:15 PM and 3:30 PM lacked inclusion of the patient's temperature, respirations, and oxygen saturation.

3. The clinical record of Pt. #12 was reviewed on 1/23/2023. Pt. #12 was admitted to the 6 North Medical/Surgical Unit on 1/9/2023 with diagnoses of sacral decubitis ulcer, end-stage renal disease, and altered mental status. Pt. #12 received a blood transfusion of 1 unit of RBCs on 1/12/2023, starting at 1:24 PM per physician's orders. The Transfusion flowsheets lacked the patient's temperature, respirations, and oxygen saturation 15 minutes after the start of the transfusion. The record also lacked the end time of the transfusion.

4. An interview was conducted with the Charge Nurse (E#2) on 1/23/2023, at approximately 12:00 PM. E#2 stated that vital signs should be monitored pre-transfusion, after 15 minutes, and post-transfusion. E#2 stated vital signs should include the patient's heart rate, respirations, blood pressure, temperature, and oxygen saturation. E#2 stated that the end time of the transfusion should be documented.