HospitalInspections.org

Based on interview and record review, the facility failed to ensure that nursing staff administered medication according to the facility policy for 1 out of 10 sampled patients (Patient #8).

Findings include:

TX00206793

Review of complaint intake TX# 00206793 revealed that Patient #8 was admitted to the facility on 09/29/14 for "left hip replacement." Allegations included Registered Nurse (RN) #11 "refused to tell the patient what medications she was giving ...after the patient inquired ... RN #11 gave...the wrong medications...[the] patient was supposed to take Seroquel XR 50mg at night, not during the day."

Review of Patient #8's clinical record showed a 51-year-old female admitted to the facility on 09/29/14 for left hip replacement secondary to avascular necrosis. Further review of the clinical record revealed two main issues related to medication administration:

1. No documentation of medication dose twice.

Record review of the Patient #8's Medication Administration Record (MAR) revealed the following:

? On 09/30/14 at 8:34AM, "Seroquel 25mg not given ...Patient took home meds."
? On 10/01/14 at 8:49PM, "Seroquel not given ...Patient takes home meds against advice."

Interview on 01/02/15 at 2:30PM with Registered Pharmacist (RPh) #8, she stated she was unable to identify the dosage of Seroquel taken by Patient #8 on 09/30/15 and 10/01/14 based on her review of the MAR documentation. She also stated she was unable to tell if the Seroquel was administered by the staff or self-administered by the patient.

Record review of facility policy titled, "Medication: Administration, General," dated 10/2012, read:

? "The authorized personnel will ...observe the 'Five Rights' of medication administration: ...Right dose."
? "All documentation should be completed in the electronic medication administration record."
? "Self-administered drugs shall be supervised and documented by authorized personnel."


2. Failure to obtain timely physician's order for home meds.

Record review of Patient #8's Medication Administration Record (MAR) revealed:

? On 09/30/14 at 8:34AM, "Seroquel 25mg not given ...Patient took home meds".
? On 10/01/14 at 8:49PM, "Seroquel not given ...Patient takes home meds against advice."

Interview on 01/02/15 at 10:15AM with Nursing Director RN #3, she stated "a physician's order is needed prior to the administration of a patient's home meds. The meds are then reviewed by pharmacy and stored by the nursing staff with the patient's other medications." Based on the MAR documentation on 09/30/14 and 10/01/14, she also stated she was unable to tell if the Seroquel was administered by the staff or self-administered by the patient.

Record review of Physician Order, undated, revealed, "Patient Own Medication. Ordering Physician: MD #13 ...Seroquel XR 50mg tabs every 12 hours ...start 10/02/14 [at] 09:00 ...take 25mg (? tablet) by mouth at bedtime."

Record review of facility policy titled, "Medications: Patient's Personal," dated 09/2013, read:

? "Patient's personal drugs shall not be administered unless specifically authorized by the responsible prescribing practitioner."
? "Drugs brought into the facility by patients shall not be administered unless the drugs have been absolutely identified ...by a pharmacist. [U]nless directed otherwise by the responsible practitioner, personal drugs to be administered shall be stored with drugs supplied by the facility."

Review of facility policy titled, "Medication: Administration, General," dated 10/2012, read:
"A medication must not be left at the bedside or self-administered unless specifically ordered by the physician. Self-administered drugs shall be supervised and documented by authorized personnel."

Based on interview and record review, the facility failed to implement an effective system to provide and document respiratory services to 2 of 2 sampled patients with orders for Incentive Spirometry [IS] (Patient # 5 and 8).

There was a delay in implementing Incentive Spirometry for Patient # 8; and inconsistent/inadequate documentation of IS for both Patient # 8 and Patient # 5.

Findings include:

TX # 00206793

Patient # 8

Record review of complaint intake TX # 00206793 revealed: "...no incentive spirometer was given to the patient until 36 hours after surgery...by that time the patient's oxygen saturation was 86 %..."

Record review of Patient # 8's clinical record revealed she was 51 years old and admitted to the facility on 09-29-14. Her admission diagnosis was left hip replacement with avascular necrosis.

Further review of Patient # 8's clinical record revealed a physician order dated 09-29-14 (9:37 A.M.) : "incentive spirometry."

Interview on 01-02-15 at 3:20 p.m. with Respiratory Therapy (RT) Supervisor # 7 he said it was the responsibility of the Respiratory Therapy department to initiate IS when it was ordered and also educate the patient on its use. Nursing staff collaborated by reinforcing the use of IS. RT Supervisor # 7 stated his expectation was that respiratory staff initiate incentive spirometry during the same shift in which it was ordered.

At the same time of interview, RT Supervisory # 7 reviewed Patient # 8's electronic medical record. RT Supervisor # 7 said the documentation showed there was a delay in initiating the IS for this patient. It was ordered on 09-29-15 at 9:37 a.m. but not implemented until 09-30 at 11:30 p.m., approximately 36 hours later.

RT Supervisor # 7 went on to say the RTs should document IS every shift; more frequently if the patient was not meeting the established goal. If this was the case; he would expect documentation every 4 hours.

Record review of Patient # 8's documentation of incentive spirometry revealed only 4 entries related to IS being implemented. These were: 09-30-14; 10-01-14 ( twice); and 10-02-14. All four (4) entries related to IS were made by nursing.

RT Supervisor # 7 was unable to locate any documentation of IS for Patient # 8 by the Respiratory Therapy staff during her entire admission of 09-29-14 through 10-02-14.

Continued interview with RT Supervisor # 7, he said that according to the documented inspiratory volumes recorded by nursing (750, 750, 1000) ; Patient # 8 was not meeting her post-operative goals for inspiratory volume (greater than 1.0 milliliters).

Patient # 5

Record review of Patient # 5's clinical record revealed she was 83 years old and admitted to the facility on 12-23-14. Her admission diagnosis was right hip fracture.

Interview on 01-02-15 at 2:50 p.m. with staff RT # 14, she stated when a patient had an order for Incentive Spirometry(IS), the RT should document the IS use once per shift. This would be recorded on the daily "RT Multi Therapy Record" and would include documentation of the patient's inspiratory volume.

Record review of Patient # 5's electronic medical record with RT # 14 revealed a physician order for IS dated 12-25-14. RT # 14 was unable to locate any documentation by respiratory therapy of IS use or recording of inspiratory volumes. [Later on 01-02-15, RT Supervisor # 7 located four (4) IS entries for this patient; all documented by nursing staff].

Record review of facility Cardioplulmonary policy titled " Incentive Spirometry," dated 10/2013, read: "...Procedure: 1. Check Physician Order Sheet...2. explain therapy to patient...10. Record data on patients electronic medical record..."