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Based on observation, interview, and record review the hospital failed to ensure that a Physician's Order was obtained for the application of soft wrist restraints for 1 of 34 sampled patients (23), in accordance to the hospital's policy. Patient 23's soft wrist restraints were applied during the night shift in order to prevent pulling out medical devices. There was no evidence that a licensed practitioner was notified or evaluated the necessity when the restraints were applied. In addition, there was no written Physician's Order until 12 hours later.

The application of a restraint without the involvement from a licensed practitioner could lead to inappropriate use of physical restraints. 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:

Patient 23 was admitted to the hospital on 2/2/14 with the diagnoses that included altered level of consciousness (confusion) per the History and Physical, dated 2/2/14.

A joint observation of Patient 23 and interview with Registered Nurse (RN) 21, the Senior Director of Education (SDE), the Performance Improvement Quality Resource (PIQR), the Nursing Director (RN) 10, and the Intensive Care Clinical Manager (ICCM) was conducted on 2/3/14 at 1:50 P.M. Patient 23 rested in the bed with both eyes closed, was connected to a ventilator (machine designed to mechanically move breathable air into and out of the lungs), and had a soft padded device around both wrist with a strap tied to each side of the bed. RN 21 stated that Patient 23 wore bilateral soft wrist restraints to prevent pulling out medical devices.
A joint review of the Nursing Notes and Physician's Orders with the ICCM, RN 10, the SDE, and the PIQR was conducted on 2/4/14 at 8:50 A.M. An RN documented on 2/2/14 on the morning shift, "no need for restraints at this time." On 2/2/14 at 10:00 P.M., the night shift RN documented on the Restraint Observation Record, "Day #1... impulsive, restraints applied." There was no indication that the physician had been notified and had evaluated Patient 23 prior to or shortly after the application of the restraints.
The Medical/Protective Restraint Care Record indicated, "Restraint Day: #1: 2/2/14." The form was signed by the physician on 2/3/14 at 9:00 A.M. and by RN 22 on 2/3/14 at 10:00 A.M. The ICCM stated, she was unable to provide an indication for the time delay in obtaining a Physician's order for the restraint. The ICCM confirmed and acknowledged that the Physician's order for Patient 23's wrist restraints was not written until 12 hours later.
The night shift RN was unavailable for an interview.
A joint review of the hospital's policy titled "Use of Restraints" with the ICCM and RN 10 was conducted on 2/5/14 at 1:50 P.M. The policy indicated, "Initiation of Restraint Orders for use in Medical Surgical Care: If a Licensed Independent Practitioner is not available to issue such an order, a trained RN initiates restraint based on an appropriate assessment of the patient. In that case, a Licensed Independent Practitioner is notified immediately and a verbal or written order is obtained from that practitioner and entered into the patient's medical record. The verbal order shall be read back to the physician." The DICU stated according to the hospital's policy, the physician's order should have been obtained as soon as possible. Both RN 10 and the ICCM stated they were unable to locate the physician's order for the restraint application on 2/2/14 at 10:00 P.M. Both acknowledged that either a telephone or verbal order should have been written or obtained in accordance with the hospital's policy.
A joint interview and review of the hospital's Restraint Policy with the Senior Director of Quality and Risk Management (DQRM) was conducted on 2/6/14 at 10:45 A.M. The DQRM stated a physician's order should be obtained as soon as possible when applying a restraint. The DQRM further stated although the hospital's Restraint Policy referenced Medical Surgical Care Unit, the policy also applied to the ICU.

Based on observation, interview and record review, the hospital failed to ensure that the registered nurses (RNs) had adequate oversight of the nursing care provided for 4 of 34 sampled patients (1, 15, 26, 28) when the RNs did not follow physician's orders and hospital's policy and procedures related to tube feeding and water flush administration. The nursing staff's failure to document the administration of tube feedings and water flushes made it difficult to determine if the patients received their tube feedings and water flushes, in accordance with the physician's orders and the hospital's policy. Lack of documentation pertaining to tube feedings and water flushes made it difficult to assess a patient's nutrition and hydration status.

The hospital failed to ensure that RNs performed blood pressure monitoring, for 1 of 34 sampled patients (2) who was on a Levophed drip, a vasopressor (also known as norepinephrine, a drug that raises blood pressures). The lack of documented blood pressure monitoring made it difficult to determine if the goal listed on the physician's orders was achieved, in an effort to evaluate the effectiveness of the medication administered, and that the physician's orders were implemented as written.

In addition, the hospital failed to clarify medication administration orders for 2 of 34 sampled patients (12, 28). Patient 12's pain medication order was incomplete when there was no clear instruction as to when to start the medication and an indication for use. Patient 28's medications were ordered to be administered by mouth for a patient who was to receive nothing by mouth (NPO) due to swallowing difficulties and had a feeding tube.

Failure to clarify the medication orders and the route of medication administration could cause a medication error or negatively impact the patients medically fragile health status when prescribed medications were unclear and incomplete.

Findings:

1. On 2/3/14 beginning at 4:07 P.M., a tour of the medical-surgical unit in the north wing was conducted with the Chief Operating Officer (COO), the clinical educator (RN 1) and the Nursing Director (RN 10).

On 2/4/14 at 4:00 P.M., Patient 1 was observed sleeping in bed with his tube feeding running at 50 ml/hr (milliters per hour) via a nasogastric tube (NGT - medical process involving the insertion of a plastic tube through the nose, down into the stomach). The bottle of tube feeding had a label that read "Jevity (tube feeding formula) 1.2 cal (calorie)".

A review of Patient 1's medical record was conducted on 2/4/14 at 4:07 P.M. Patient 1 was admitted to the hospital on 1/18/14 with diagnoses that included altered level of consciousness (confusion) and acute hypernatremia (a high level of sodium in the blood possibly due to dehydration or decrease in total body water; normal adult value for sodium 136 - 145 mEq/L [milliequivalent per liter]) per the History and Physical, dated 1/19/14. Per the same H&P, Patient 1's sodium level was 149.

A Physician's order, dated 1/31/14 at 1:23 P.M., indicated that Patient 1 was to be given Jevity 1.2 (fiber) at 30 ml per hour via the feeding tube to a goal rate of 50 ml per hour, hold feedings for residuals greater than 100 mls. Per the same order, it instructed to increase the tube feeding as tolerated by 10 ml every 4 hours.

A review of the hospital's policy titled "Feeding; Via Enteric Tube", dated 3/18/13, was conducted on 2/4/14. The policy indicated to "10. Check the order for correct feeding times, amount, and liquid nourishment. 32. ...Check gastric residual volume (GRV) every four hours. 37. ...If administering a continuous feeding, flush the feeding tube with at least 30 ml of water before and after every medication administration and periodically to prevent tube occlusion. 56. Record procedure, type and amount of formula, intake and output."

A review of Patient 1's Intake and Output (I&O's), dated 1/31/14 - 2/1/14 from 7:00 P.M. to 7:00 A.M., indicated that the total enteral feeding was 470 mls.

A telephone interview with RN 4 was conducted on 2/5/14 at 9:30 P.M. RN 4 stated she recalled caring for Patient 1 on 1/31/14 from 7:00 P.M. to 7:30 A.M. (night shift). She stated that she performed gastric residual checks every 4 hours per hospital policy, and increased Patient 1's tube feedings by 10 ml every 4 hours in accordance with the physician's orders. However, she stated that she reviewed her documentation and acknowledged that there was no documented evidence to demonstrate that she performed the above nursing care and tasks (i.e.. the residual checks and the feeding increases).

An interview with RN 10 was conducted on 2/6/14 at 7:17 A.M. RN 10 confirmed that there was no documented evidence in Patient 1's medical record to demonstrate that RN 1 had performed the gastric residual checks, administered the tube feeding and increased it every 4 hours as tolerated by the patient, in accordance with the physician's orders and hospital policy. RN 10 stated that it was the nursing staff's responsibility to ensure that the documentation in Patient 1's medical record clearly reflected the nursing care rendered, implementation of physician's orders and tasks performed.

2. On 2/3/14 beginning at 4:07 P.M., a tour of the medical-surgical unit in the north wing was conducted with the Chief Operating Officer (COO), the clinical educator (RN 1) and the Nursing Director (RN 10).

On 2/4/14 at 4:00 P.M., Patient 1 was observed sleeping in bed with his tube feeding running at 50 ml/hr (milliters per hour) via a nasogastric tube (NGT - medical process involving the insertion of a plastic tube through the nose, down into the stomach). The bottle of tube feeding had a label that read "Jevity (tube feeding formula) 1.2 cal (calorie)".

A Physician's order, dated 1/31/14 at 1:23 P.M., indicated that Patient 1 was to be given Jevity 1.2 (fiber) at 30 ml per hour via the feeding tube to a goal rate of 50 ml per hour, hold feedings for residuals greater than 100 mls. Per the same order, it instructed to increase the tube feeding as tolerated by 10 ml every 4 hours, and to administer a water flush of 150 ml every 6 hours.

On 2/1/14 at 6:00 P.M., there was a new physician's order that read "Free water 250 ml via NG tube every 6 hours".

A review of Patient 1's Intake and Output (I&O's), dated 1/31/14 - 2/1/14 from 7:00 P.M. to 7:00 A.M., indicated that the NG (nasogastric tube) flush total was 300 mls. Per the I&O's, dated 2/1/14 - 2/2/14 from 7:00 P.M. to 7:00 A.M., it indicated that the NG flush total was 200 mls. The totals did not reflect water flushes that were administered via the feeding tube before and after medication administration and periodically to prevent tube occlusion.

A review of the hospital's policy titled "Feeding; Via Enteric Tube", dated 3/18/13, was conducted on 2/4/14. The policy indicated to "10. Check the order for correct feeding times, amount, and liquid nourishment. 37. ...If administering a continuous feeding, flush the feeding tube with at least 30 ml of water before and after every medication administration and periodically to prevent tube occlusion. 56. Record procedure, type and amount of formula, intake and output."

A telephone interview with RN 4 was conducted on 2/5/14 at 9:30 P.M. RN 4 stated she recalled caring for Patient 1 on 1/31/14 from 7:00 P.M. to 7:30 A.M. (night shift). RN 4 stated that she administered water flushes before and after medication administration and periodically to ensure that Patient 1's feeding tube was patent. However, RN 4 stated that she reviewed her documentation and acknowledged that there was no documented evidence to demonstrate the nursing care and tasks performed. She also confirmed that Patient 1's I&O record did not reflect the water flush administration and the patient's actual water intake for the shift per hospital policy.

An interview with RN 10 was conducted on 2/6/14 at 7:17 A.M. RN 10 confirmed that there was no documented evidence in Patient 1's medical record to demonstrate that the nursing staff had administered the water flushes in accordance with the physician's orders and hospital policy. RN 10 stated that it was the nursing staff's responsibility to ensure that the documentation in Patient 1's medical record clearly reflected the NG flush intake values and calculation per shift.

3. On 2/3/14 beginning at 4:07 P.M., a tour of the medical-surgical unit in the north wing was conducted with the Chief Operating Officer (COO), the clinical educator (RN 1) and the Nursing Director (RN 10).

A review of Patient 2's medical record was conducted on 2/4/14 at 2:11 P.M. Patient 2 was admitted to the hospital's Emergency Department (ED) on 2/2/14 with diagnoses that included fever and respiratory distress per the History and Physical, dated 2/2/14. According to Nurse's Notes, dated 2/2/14 at 7:46 P.M., Patient 2's blood pressure readings were hypotensive (abnormally low blood pressures), the physician was notified and the nursing staff continued to monitor blood pressures until an intervention was ordered by the physician.

A telephone Physician's Order, dated 2/2/14 at 8:00 P.M., indicated to start a Levophed drip and titrate to keep systolic blood pressure above 100.

A review of the hospital's protocol form titled "IV Drip Critical Care Medication Titration Orders - Vasopressors" was conducted on 2/4/14. There was a section for Norepinephrine Drip (Levophed) with a clinical response goal that read systolic blood pressure greater than or equal to 90 mmHg (millimeters of mercury - a unit of pressure measurement) or other with a blank (to list other specifications). Per the same form, the Standardized Titration Order indicated that a Levophed drip was to start at 1 mcg/min (micrograms per minute); titrate 1 mcg/min every 10 minutes until the clinical response was achieved. The maximum dose was 30 mcg/min, and to notify the physician if clinical response was not achieved for further orders.

According to Patient 2's electronic medical record, dated 2/2/14 at 9:20 P.M., indicated that the patient continued to be on a Levophed drip, administered at 8:15 P.M. Per the same record, Patient 2's blood pressure was 99/56 and the Levophed drip was running at 2 mcg/min. There was no documented evidence in the medical record to demonstrate that RNs performed blood pressure monitoring on Patient 2 when the patient was placed on a Levophed drip and titrations had been made, in accordance with the physician's orders and hospital's protocol.

An interview with RN 3 was conducted on 2/6/14 at 7:39 A.M. RN 3 stated that she recalled caring for Patient 2 on 2/2/14 and initiating the administration of the patient's Levophed drip as ordered. She stated that she had acknowledged the physician's order related to the initiation of the drip, obtained the hospital's IV drip protocol, started Patient 2's Levophed drip at 1 mcg/min as indicated in the hospital's protocol, and continued to monitor the patient's blood pressures every 5-10 minutes. She did confirm that at some point, she increased Patient 2's Levophed drip up to 2 mcg/min for not achieving the desired systolic blood pressure however, her documentation did not demonstrate the blood pressure monitoring that was performed on Patient 2 during the Levophed drip administration.

A review of the hospital's policy titled "Titrating Medications", dated 8/22/12, was conducted on 2/6/14. The policy indicated that "Orders for medications that require titration must include the desired state the prescriber desires for the patient ...." Per the same policy, "Useful dosage adjustment increments must be known before titrating medication to allow clinical staff to determine how much to increase or decrease the medication as attempts are made to achieve the [ordered state] for the patient."

An interview with the Nursing Director of Emergency Services (NDES) was conducted on 2/6/14 at 8:08 A.M. The NDES stated that the nurses were expected to obtain the hospital's IV drip protocol when a physician's order was obtained to start a Levophed drip and systolic blood pressure parameters were listed. He stated that Patient 2's medical record should have contained documented evidence to demonstrate that the nursing staff were monitoring the patient's blood pressures during the administration of the Levophed drip, and during the required titrations based on blood pressure readings every 10 minutes per hospital protocol and physician's orders.





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4. A review of patient 12's medical record was conducted on 2/3/14 at 3:10 P.M. Patient 12 was admitted to the hospital on 2/3/14 with a diagnosis of osteoarthrosis (arthritis) right knee and underwent a right knee surgical procedure on 2/4/14.

A review of the Recovery Room (PACU - Post Anesthesia Care Unit) Post-OP Orders, dated 2/3/14, indicated that an order for Dilaudid (narcotic pain medication) 0.5 milligrams (mg) intravenous (IV) every 15 minutes total of 2.0 mg. Patient 12's pain medication order was incomplete when there was no clear instruction as to when to start the medication and an indication for use.

A review of Patient 12's pain assessment documentation was conducted on 2/3/14 at 4:00 P.M. The pain assessment documentation indicated that on 2/3/14 at 3:10 P.M., Patient 12's right knee pain level was a 4 (moderate pain). There was no indication that the patient declined a pharmacological intervention, or that an intervention or pain medication was administered. On 2/3/14 at 3:25 P.M., 3:40 P.M., and 3:55 P.M., Patient 12's right knee pain level was a 4. Under the comment section, Patient 12 had declined pain medications offered at 3:25 P.M., 3:40 P.M., and 3:55 P.M.

An interview with registered nurse (RN 11) was conducted on 2/3/14 at 4:20 P.M. She stated that she had not administered any pain mediation, and that if the pain level was a 4 at the next assessment, she would administer the Dilaudid. She acknowledged that she had not contacted the physician to clarify the medication order.

A review of the hospital's policy entitled "Medication Orders, Resolving Questionable Physician" was conducted on 2/3/14. The policy indicated that "clarification of orders with the physician occurs when there may legibility, dosing or an incomplete order issue".

An interview with the charge nurse (RN 12) was conducted on 2/3/14 at 4:22 P.M. He stated that the Dilaudid medication order was unclear and did not specify an indication for use. He stated the RN should have clarified the order with the physician.

5. A review of Patient 15's medical record was conducted on 2/4/14 at 8:49 A.M. Patient 15 was admitted to the hospital on 1/30/14 with a diagnosis of altered mental status (confusion) per the Facesheet.

A Physician's order, dated 2/2/14 at 3:27 A.M., indicated tube feeding of Jevity (tube feeding formula) 1.2 (fiber) with a start rate of 30 ml/hr (milliliters per hour) and to increase by 10 mls every 4 hours. The max rate of the tube feeding was 50 ml/hr. Per the same order, it instructed to administer 200 mls of water flush every 6 hours.

A review of Patient 15's Intake and Output Detail Report indicated that only 80 ml of free water was documented on 2/3/14 at 10:00 P.M. There was no further documentation to demonstrate that water flush administration had been performed.

A review of the hospital's policy entitled "Feeding, Via enteric Tube" was conducted on 2/4/14. The policy indicated "check order for correct feeding times, amount and liquid nourishment."

An concurrent interview with the Nursing Director (RN 10) and ICU clinical manager (ICCM) was conducted on 2/4/14 at 9:00 A.M. They both acknowledged that the free water (flush) documented on the intake and output report was not consistent with the written physician's order and that the free water (flush) should have been documented as given per the written order in accordance with the hospital's policy.











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6a. Patient 26 was admitted to the hospital on 1/29/14 with the diagnoses that included congested heart failure (when the heart is unable to provide sufficient pump action to maintain blood flow to meet the needs of the body) per the History and Physical, dated 1/27/14.

A joint observation of Patient 26 and interview with Registered Nurse (RN) 23, the Senior Director of Education (SDE), the Performance Improvement Quality Resource (PIQR), and the Medical Surgical Clinical Manager (MSCM) was conducted on 2/4/14 at 10:40 A.M. Patient 26 rested in the bed with the head of the bed elevated, a tube feeding Jevity 1.2 infused at 50 milliliters (ml) per hour (hr). Patient 26 stated everything was good. RN 23 stated that Patient 28 was disoriented and received nothing by mouth (NPO) because of the tube feeding administration thru the G-tube (gastrostomy tube - surgically inserted feeding tube into the stomach).

A joint review of the Physician's Progress Notes, Physician's order, and Intake and Output Detail Report with the MSCM, SDE, and PIQR was conducted on 2/4/14 at 11:20 A.M. According to the Physician's Progress Notes, Patient 26's G-tube was inserted on 1/31/14. The Physician's order, dated 1/31/14, indicated that on 2/1/14 start Jevity 1.2 infuse at 20 ml/hr, increase 10 ml every four hours to reach the goal rate of 50 ml/hr with a water flush of 200 ml every six hours.

The following was documented on the Intake and Output Detail Report:
2/1/14 from 7:00 A.M. - 7:00 P.M.: 200 ml tube feeding, water flush blank
2/1/14 from 7:00 P.M. - 7:00 A.M.: Nothing by mouth (NPO); no documentation of tube feeding or water flush
2/2/14 from 7:00 A.M. - 7:00 P.M.: 600 ml tube feeding, water flush blank
2/2/14 from 7:00 P.M. - 7:00 A.M.: 600 ml tube feeding, 360 cubic centimeter (cc) water
2/3/14 from 7:00 A.M. - 7:00 P.M.: 1200 ml tube feeding, water flush blank
2/3/14 from 7:00 P.M. - 7:00 A.M.: tube feeding 0, water flush blank

The MSCM confirmed that the calculated intake contained inconsistent data. The MSCM acknowledged that the inconsistent data made it difficult to ascertain the actual nutritional and hydration status of the tube feeding administration.

An interview and joint review of the Intake and Output (I&O) Detail Report with RN 24, the MSCM, the SDE, and the PIQR was conducted on 2/4/14 at 11:25 A.M. RN 24 confirmed the inconsistent total volume documented for Patient 26. RN 24 stated he had documented the incorrect total amount for Patient 26's intake volume on 2/3/14. RN 24 stated documentation should be correct in order to track fluid balance. RN 24 acknowledged that the calculated total intake volume was inconsistent with the physician's order.

The hospital policy titled "Feeding; Via Enteric Tube" indicated to "10. Check the order for correct feeding times, amount, and liquid nourishment. 37. ...If administering a continuous feeding, flush the feeding tube with at least 30 ml of water before and after every medication administration and periodically to prevent tube occlusion. 56. Record procedure, type and amount of formula, intake and output."

A joint meeting with the Quality Assessment and Performance Improvement (QAPI) committee was conducted on 2/6/14 at 10:00 A.M. The Senior Director of Quality and Risk Management (DQRM) acknowledged that the hospital was aware of the nursing staff's inconsistent I&O documentation. The DQRM stated that the hospital was currently working on a process in order to streamline the documentation for the intake and output.

6b. Patient 28 was admitted to the hospital on 1/26/14 with the diagnoses that included dysphagia (difficult to swallow) post G-tube (gastrostomy tube - surgically inserted feeding tube into the stomach) placement per the History and Physical, dated 1/26/14.

A joint observation of Patient 28 and interview with Registered Nurse (RN) 23, the Senior Director of Education (SDE), the Performance Improvement Quality Resource (PIQR), and the Medical Surgical Clinical Manager (MSCM) was conducted on 2/4/14 at 10:30 A.M. Patient 28 rested in the bed with the head of the bed elevated, a tube feeding Glucerna 1.2 infused at 50 milliliters (ml) per hour (hr). RN 23 stated that Patient 28 received nothing by mouth (NPO) because of the tube feeding administration thru the G-tube.

A joint review of the Physician's Progress Note, the Physician's order, and the Intake and Output (I&O) Detail Report with the MSCM, SDE, and PIQR was conducted on 2/4/14 at 2:30 P.M. According to the Physician's Progress Notes, Patient 28's G-tube was inserted on 1/31/14.

The Physician's order, dated 2/2/14, indicated Glucerna 1.2 infused at 50 ml/hr, with a free water (flush) of 200 ml every six hours per the G-tube.

The following was the documented on the Intake and Output Detail Report:
2/1/14 from 7:00 A.M. - 7:00 P.M.: 165 ml tube feeding, 400 cubic centimeter (cc) water flush
2/1/14 from 7:00 P.M. - 7:00 A.M.: Blank
2/2/14 from 7:00 A.M. - 7:00 P.M.: 550 ml tube feeding, 1200 cc water flush
2/2/14 from 7:00 P.M. - 7:00 A.M.: 500 ml tube feeding, 400 cubic centimeter (cc) water
2/3/14 from 7:00 A.M. - 7:00 P.M.: Blank
2/3/14 from 7:00 P.M. - 7:00 A.M.: Blank
2/4/14 from 7:00 A.M. - 12:00 P.M.: Flush 380 cc
2/4/14 from 7:00 P.M. - 7:00 A.M.: Blank

The MSCM confirmed that the calculated intake contained inconsistent data. The MSCM acknowledged that the inconsistent data made it difficult to ascertain the actual nutritional and hydration status of the tube feeding administration.

An interview and joint review of the Intake and Output Detail Report with RN 25, the MSCM, the SDE, and the PIQR was conducted on 2/6/14 at 8:20 A.M. RN 25 stated that on 2/2/14 she believed that Patient 28's tube feeding had been on hold due to complications. She stated that the water flush order was 200 ml every six hours. According to the 1200 ml calculation documented in the I&O on 2/2/14 from 7:00 A.M. to 7:00 P.M., the total included 30cc water flushes with medications, and a 60 cc flush because the tube was bloody. RN 25 stated accurate intake was important for cardiac patients. RN 25 acknowledged that the calculated total intake volume was inconsistent with the physician's order.

The hospital policy titled "Feeding; Via Enteric Tube" indicated to "10. Check the order for correct feeding times, amount, and liquid nourishment. 37. ...If administering a continuous feeding, flush the feeding tube with at least 30 ml of water before and after every medication administration and periodically to prevent tube occlusion. 56. Record procedure, type and amount of formula, intake and output."

A joint meeting with the Quality Assessment and Performance Improvement (QAPI) committee was conducted on 2/6/14 at 10:00 A.M. The Senior Director of Quality and Risk Management (DQRM) acknowledged that the hospital was aware of the nursing staff's inconsistent I&O documentation. The DQRM stated that the hospital was currently working on a process in order to streamline the documentation for the intake and output.

7. Patient 28 was admitted to the hospital on 1/26/14 with the diagnoses that included dysphagia (difficult to swallow) post G-tube (gastrostomy tube - surgically inserted feeding tube into the stomach) placement per the History and Physical, dated 1/26/14. Per the same H&P, Patient 28 will be fed through the feeding tube.

A joint observation of Patient 28 and interview with Registered Nurse (RN) 23, the Senior Director of Education (SDE), the Performance Improvement Quality Resource (PIQR), and the Medical Surgical Clinical Manager (MSCM) was conducted on 2/4/14 at 10:30 A.M. Patient 28 rested in the bed with the head of the bed elevated, a tube feeding Glucerna 1.2 infuse at 50 milliliters (ml) per hour (hr). RN 23 stated that Patient 28 received nothing by mouth (NPO) because of the tube feeding administration thru the G-tube.

A joint review of the Physician's Progress Note with the MSCM, SDE, and PIQR was conducted on 2/4/14 at 2:30 P.M. According to the Physician's Progress Notes, Patient 28's G-tube was inserted on 1/31/14.

A joint review of the Physician's orders with the MSCM, SDE, and PIQR was conducted on 2/6/14 at 8:05 A.M. The Physician's orders, dated 1/27/14, indicated Colace (stool softener) liquid 10 milliliter (ml) oral twice a day; Flomax (improve urination) .04 milligram (mg) 1 capsule oral at bedtime; Avodart (improve urinary flow) 0.5 mg 1 capsule oral at bedtime; Lasix (water pill) 40 mg 1 tablet orally every morning; and Reglan (treat heartburn) 5 ml orally every six hours. There was no specifications documented to administer the medications via the G-tube.

The MSCM stated it was the expectation that the RN's clarify the physician's orders to have the exact designated route for medication administration. The MSCM acknowledged that the incorrect route for the medication administration could lead to a medication error or cause a medical complication.

The hospital policy titled "Feeding; Via Enteric Tube" indicated to "10. Check the order for correct feeding times, amount, and liquid nourishment. 37. ...If administering a continuous feeding, flush the feeding tube with at least 30 ml of water before and after every medication administration and periodically to prevent tube occlusion. 56. Record procedure, type and amount of formula, intake and output."

An interview with the Senior Director of Quality and Risk Management (DQRM) was conducted on 2/6/14 at 10:45 A.M. The DQRM stated there should be a clarification for the designated route of medication administration if the ordered route was by mouth when a patient was on a NPO status and had a feeding tube, to prevent complications related to dysphagia or a medication error.

Based on observation, interview and document review, the hospital did not ensure that emergency battery lighting was provided in 2 out of 2 labor and delivery (L&D) operating rooms (OR's) to ensure uninterrupted lighting during surgical procedures in the event of a power loss and a delay in the initiation of generator power. In addition, the hospital did not ensure that testing of the emergency battery lighting was conducted in accordance with manufacturer's specification in 5 out of 5 OR's.

Findings:

1. A tour of the two L&D operating rooms was conducted on 2/4/14 at 1:05 P.M., there were no battery operated lighting units observed in either of the two OR's. Functioning flashlights were produced by the OR staff for each L&D OR.

An interview with L&D OR technician was conducted on 2/4/14 at 8:55 A.M. She stated that when the power had gone out in the past that there was a brief period of darkness before the generator power came on.

An interview with the Director of Maternal Child Services was conducted on 2/4/14 at 1:10 P.M. She acknowledged that the L&D OR's did not have battery operated lighting units installed.

2. A tour of operating room 1, 2, 4 and 5 was conducted on 2/4/14 at 2:30 P.M. The emergency battery lighting was tested by pressing the test buttons in each OR which indicated that the battery lighting failed testing in OR's 1, 2, 4 and 5. OR 3's battery lighting test button was tested on 2/4/14 at 5:45 P.M. which also failed testing.

A review of the hospital's life safety code inspection form was conducted on 2/4/14 at 3:51 P.M. The form indicated that the emergency battery lighting had been tested and passed every month for the past year.

A review of the manufacture's specifications for the fluorescent emergency lighting system was conducted on 2/4/14 at 6 P.M. The specifications indicated that "test switch provides manual activation of 30 second diagnostic testing for on demand usual inspection".

An interview was conducted with the Director of Facilities on 2/5/14 at 8:30 A.M. He stated that upon inspection of the emergency lighting that the test buttons had not been "wired" and that is why they failed to illuminate the battery lighting when tested. He stated that facilities staff had tested the emergency battery lighting by turning off the lights and not by using the test buttons. He further stated that was why the life safety log indicated that the emergency lighting passed testing each month. He acknowledged that the lighting should be tested using the test buttons as indicated by the manufacturer.

Based on observation, interview and record review, the hospital failed to ensure that the registered nurses (RNs) had adequate oversight of the nursing care provided for 4 of 34 sampled patients (1, 15, 26, 28) when the RNs did not follow physician's orders and hospital's policy and procedures related to tube feeding and water flush administration. The nursing staff's failure to document the administration of tube feedings and water flushes made it difficult to determine if the patients received their tube feedings and water flushes, in accordance with the physician's orders and the hospital's policy. Lack of documentation pertaining to tube feedings and water flushes made it difficult to assess a patient's nutrition and hydration status.

The hospital failed to ensure that RNs performed blood pressure monitoring, for 1 of 34 sampled patients (2) who was on a Levophed drip, a vasopressor (also known as norepinephrine, a drug that raises blood pressures). The lack of documented blood pressure monitoring made it difficult to determine if the goal listed on the physician's orders was achieved, in an effort to evaluate the effectiveness of the medication administered, and that the physician's orders were implemented as written.

In addition, the hospital failed to clarify medication administration orders for 2 of 34 sampled patients (12, 28). Patient 12's pain medication order was incomplete when there was no clear instruction as to when to start the medication and an indication for use. Patient 28's medications were ordered to be administered by mouth for a patient who was to receive nothing by mouth (NPO) due to swallowing difficulties and had a feeding tube.

Failure to clarify the medication orders and the route of medication administration could cause a medication error or negatively impact the patients medically fragile health status when prescribed medications were unclear and incomplete.

Findings:

1. On 2/3/14 beginning at 4:07 P.M., a tour of the medical-surgical unit in the north wing was conducted with the Chief Operating Officer (COO), the clinical educator (RN 1) and the Nursing Director (RN 10).

On 2/4/14 at 4:00 P.M., Patient 1 was observed sleeping in bed with his tube feeding running at 50 ml/hr (milliters per hour) via a nasogastric tube (NGT - medical process involving the insertion of a plastic tube through the nose, down into the stomach). The bottle of tube feeding had a label that read "Jevity (tube feeding formula) 1.2 cal (calorie)".

A review of Patient 1's medical record was conducted on 2/4/14 at 4:07 P.M. Patient 1 was admitted to the hospital on 1/18/14 with diagnoses that included altered level of consciousness (confusion) and acute hypernatremia (a high level of sodium in the blood possibly due to dehydration or decrease in total body water; normal adult value for sodium 136 - 145 mEq/L [milliequivalent per liter]) per the History and Physical, dated 1/19/14. Per the same H&P, Patient 1's sodium level was 149.

A Physician's order, dated 1/31/14 at 1:23 P.M., indicated that Patient 1 was to be given Jevity 1.2 (fiber) at 30 ml per hour via the feeding tube to a goal rate of 50 ml per hour, hold feedings for residuals greater than 100 mls. Per the same order, it instructed to increase the tube feeding as tolerated by 10 ml every 4 hours.

A review of the hospital's policy titled "Feeding; Via Enteric Tube", dated 3/18/13, was conducted on 2/4/14. The policy indicated to "10. Check the order for correct feeding times, amount, and liquid nourishment. 32. ...Check gastric residual volume (GRV) every four hours. 37. ...If administering a continuous feeding, flush the feeding tube with at least 30 ml of water before and after every medication administration and periodically to prevent tube occlusion. 56. Record procedure, type and amount of formula, intake and output."

A review of Patient 1's Intake and Output (I&O's), dated 1/31/14 - 2/1/14 from 7:00 P.M. to 7:00 A.M., indicated that the total enteral feeding was 470 mls.

A telephone interview with RN 4 was conducted on 2/5/14 at 9:30 P.M. RN 4 stated she recalled caring for Patient 1 on 1/31/14 from 7:00 P.M. to 7:30 A.M. (night shift). She stated that she performed gastric residual checks every 4 hours per hospital policy, and increased Patient 1's tube feedings by 10 ml every 4 hours in accordance with the physician's orders. However, she stated that she reviewed her documentation and acknowledged that there was no documented evidence to demonstrate that she performed the above nursing care and tasks (i.e.. the residual checks and the feeding increases).

An interview with RN 10 was conducted on 2/6/14 at 7:17 A.M. RN 10 confirmed that there was no documented evidence in Patient 1's medical record to demonstrate that RN 1 had performed the gastric residual checks, administered the tube feeding and increased it every 4 hours as tolerated by the patient, in accordance with the physician's orders and hospital policy. RN 10 stated that it was the nursing staff's responsibility to ensure that the documentation in Patient 1's medical record clearly reflected the nursing care rendered, implementation of physician's orders and tasks performed.

2. On 2/3/14 beginning at 4:07 P.M., a tour of the medical-surgical unit in the north wing was conducted with the Chief Operating Officer (COO), the clinical educator (RN 1) and the Nursing Director (RN 10).

On 2/4/14 at 4:00 P.M., Patient 1 was observed sleeping in bed with his tube feeding running at 50 ml/hr (milliters per hour) via a nasogastric tube (NGT - medical process involving the insertion of a plastic tube through the nose, down into the stomach). The bottle of tube feeding had a label that read "Jevity (tube feeding formula) 1.2 cal (calorie)".

A Physician's order, dated 1/31/14 at 1:23 P.M., indicated that Patient 1 was to be given Jevity 1.2 (fiber) at 30 ml per hour via the feeding tube to a goal rate of 50 ml per hour, hold feedings for residuals greater than 100 mls. Per the same order, it instructed to increase the tube feeding as tolerated by 10 ml every 4 hours, and to administer a water flush of 150 ml every 6 hours.

On 2/1/14 at 6:00 P.M., there was a new physician's order that read "Free water 250 ml via NG tube every 6 hours".

A review of Patient 1's Intake and Output (I&O's), dated 1/31/14 - 2/1/14 from 7:00 P.M. to 7:00 A.M., indicated that the NG (nasogastric tube) flush total was 300 mls. Per the I&O's, dated 2/1/14 - 2/2/14 from 7:00 P.M. to 7:00 A.M., it indicated that the NG flush total was 200 mls. The totals did not reflect water flushes that were administered via the feeding tube before and after medication administration and periodically to prevent tube occlusion.

A review of the hospital's policy titled "Feeding; Via Enteric Tube", dated 3/18/13, was conducted on 2/4/14. The policy indicated to "10. Check the order for correct feeding times, amount, and liquid nourishment. 37. ...If administering a continuous feeding, flush the feeding tube with at least 30 ml of water before and after every medication administration and periodically to prevent tube occlusion. 56. Record procedure, type and amount of formula, intake and output."

A telephone interview with RN 4 was conducted on 2/5/14 at 9:30 P.M. RN 4 stated she recalled caring for Patient 1 on 1/31/14 from 7:00 P.M. to 7:30 A.M. (night shift). RN 4 stated that she administered water flushes before and after medication administration and periodically to ensure that Patient 1's feeding tube was patent. However, RN 4 stated that she reviewed her documentation and acknowledged that there was no documented evidence to demonstrate the nursing care and tasks performed. She also confirmed that Patient 1's I&O record did not reflect the water flush administration and the patient's actual water intake for the shift per hospital policy.

An interview with RN 10 was conducted on 2/6/14 at 7:17 A.M. RN 10 confirmed that there was no documented evidence in Patient 1's medical record to demonstrate that the nursing staff had administered the water flushes in accordance with the physician