HospitalInspections.org

Based on medical record review, policy review and staff interview, it was determined that for 1 of 5 (20%) patients (Patient #1) in the sample, nursing staff failed to administer medications in accordance with physician orders. Findings include:

The hospital policy entitled "Medication Ordering, Dispensing and Administration" stated, "...Each dose of medication administered must be properly recorded in the patient's medical record..."

Review of Patient #1's medical record revealed physician orders for Singulair 5 mg (milligrams) by mouth at bedtime dated 12/15/10, Flovent 110 mcg (micrograms) 2 puffs BID (twice a day) dated 12/16/10 and Risperdal liquid 0.25 mg PO (by mouth) at bedtime dated 12/17/10.

Review of the hospital documents entitled "Medication Administration Record" and "Nursing Documentation" revealed no evidence that the following medication doses were administered according to the physician's order:

1. Singulair 5 mg 12/20/10 at bedtime
2. Flovent 110 mcg 2 puffs 12/19 and 12/20/10 at bedtime
3. Risperdal liquid 0.25 mg 12/20/10 at bedtime

These findings were confirmed with the Chief Nursing Officer during a review of Patient #1's medical record on 2/3/11 at 3:10 PM.

Based on policy review, medical record review and staff interview, it was determined that for 1 of 5 (20%) patients in the sample (Patient #3), the medical record was not promptly completed. Findings include:

The hospital policy entitled, "Medical Record Department Standards and Functions" stated, "...ensure that all clinical information...in the form of a medical record or in electronic data is...current, completed in its entirety...the documentation contained in the medical record is timely; accurate..."

The hospital policy entitled "Hospital Plan for Provision of Nursing Care" stated, "...Nurses engage in an infinite number of activities...Activities critical to the provision of patient care activities include...Medical records auditing maintenance...Implementation and management of physician's orders..."

The hospital policy entitled, "Culture Collection and Preservation" stated, "...Cultures are obtained with a physician's order...document collection of the specimen in the progress notes..."

Review of Patient #3's medical record revealed:

1. The physician's orders dated 1/15/11 contained orders for the following medications to be administered as needed (PRN): Tylenol, Maalox, Phenergan, Milk of Magnesia and Vistaril.

Nursing staff failed to note the orders and transcribe onto the "Medication Administration Record" until 1/17/11 (2 days later).

2. On 1/28/11 the physician ordered urine laboratory tests (routine and cultures). No evidence was found to indicate that urine specimens were obtained and sent to the lab for testing.

This finding was confirmed with the Chief Nursing Officer on 2/3/11 at 4:30 PM.

Based on medical record review, policy review and staff interview, it was determined that for 4 of 5 (80%) patients (Patient #'s 1, 2, 3 and 5) in the sample, the medical record contained entries which were either illegible, not completed, not timed, or not authenticated by the authorized staff member making the entry. Findings include:
The hospital policy entitled "Medical Record Departmental Standards and Functions" stated, "...ensure that all clinical information maintained either in the form of a medical record or in electronic data is...current, legible, completed in its entirety, and has been authenticated...Quality of the documentation...is timely, accurate...and legible..."

The hospital policy entitled "Chart Documentation Requirements" stated, "...documentation is to be concise, legible, and accurate...Each entry is to be dated and timed...All documentation must be...timely...No other patient names are identified in the patient's record...Orders are dated and signed within 24 hours..."

The hospital policy entitled "Hospital Plan for Provision of Nursing Care" stated, "...Nurses engage in an infinite number of activities...Activities critical to the provision of patient care activities include...Medical records auditing maintenance...Implementation and management of physician's orders..."

Medical record review revealed the following:

I. Illegible entries

A. Patient #1

1. The "Consultation Form" dated 12/19/10 was illegible.

This finding was confirmed with the Chief Nursing Officer on 2/3/11 at 2:58 PM.

B. Patient #2

1. The "Internal Medicine Admission Note" dated 2/2/11 contained physician entries which were illegible.

This finding was confirmed with the Chief Nursing Officer on 2/3/11 at 1:50 PM.

C. Patient #3

1. The "Internal Medicine Admission Note" dated 1/16/11 contained physician entries which were illegible.

2. The "Consultation Form" dated 1/22/11 contained physician entries which were illegible.

These findings were confirmed with the Chief Nursing Officer on 2/3/11 at 4:30 PM.

II. Entries not dated and/or timed

A. Patient #2

1. The "Internal Medicine Admission Note" dated 2/2/11 was not timed.

This finding was confirmed with the Chief Nursing Officer on 2/3/11 at 1:50 PM.

B. Patient #3

1. The "Admission Note" dated 1/15/11 lacked the time of the entry.

2. The "Progress Record" dated 1/23/11 contained 1 entry which was not timed.

3. The "Patient Self Inventory/Adolescent Form" was not dated.

These findings were confirmed with the Chief Nursing Officer on 2/3/11 at 4:30 PM.

C. Patient #5

1. The "Internal Medicine Admission Note" dated 1/5/11 was not timed.

2. The "Progress Note" dated 1/8/11 was not timed.

3. The physician order dated 1/5/11 lacked the time the order was written.

4. The nurse who noted the 1/5/11 physician order failed to enter a time.

5. The nurse who noted the 1/6/11 physician order failed to enter a time.

6. The nurse who noted the three physician orders dated 1/7/11 failed to enter the time of the notation.

7. The physician failed to date and time when the verbal order for Senna (medication) was authenticated.

These findings were confirmed with the Chief Nursing Officer on 2/4/11 at 9:00 AM.

III. Documents lacked patient identifiers

A. Patient #3

1. The "Internal Medicine Admission Note" dated 1/16/11 lacked any patient identifier.

2. The "Initial Interdisciplinary Assessment -Nursing Assessment" form dated 1/15/11 lacked any patient identifier.

3. The "Patient Self Inventory/Adolescent Form" contained only the patient's first name, no other patient identifier.

These findings were confirmed with the Chief Nursing Officer on 2/3/11 at 4:30 PM.

IV. Entries lacked staff signatures

A. Patient #3

1. The "Medication Administration Record" lacked the signature of the nurses who administered the medications on the following dates and times:

Vistaril - 2/2/11 at 10:20 AM
Zoloft - 1/16, 1/18, 1/19 and 1/21/11 at 9:00 AM
Depakote - 1/16, 1/18, 1/19 and 1/21/11 at 9:00 AM
Depakote - 1/16, 1/18 and 1/21/11 at 1:00 PM
Abilify - 1/20/11 at 9:00 PM

2. The "Progress Record" dated 1/23/11 contained 3 entries which lacked the signature of the Mental Health Worker who initialed the entry.

These findings were confirmed with the Chief Nursing Officer on 2/3/11 at 4:30 PM.

B. Patient #5

1. The "Progress Note" dated 1/14/11 lacked the signature of the Mental Health Worker who initialed the entry.

2. The "Precautions Record" dated 1/14/11 lacked the signatures of two staff members who recorded 15 minute patient observations, which they initialed.

3. The nurse who noted the 1/5/11 physician order failed to enter a signature.

4. The nurse who noted the 1/6/11 physician order failed to enter a signature.

5. The nurse who noted the three physician orders dated 1/7/11 failed to enter a signature.

V. Medical Record Contained Multiple Patient's Information

A. Patient #3

1. The medical record for Patient #3 contained another patient's "Multidisciplinary Daily Group Note" dated 2/2/11.

This finding was confirmed with the Chief Nursing Officer on 2/3/11 at 4:30 PM.

Based on medical record review, policy review and staff interview, it was determined that for 3 of 5 (60%) patients (Patient #'s 1, 3 and 5) in the sample, the medical record failed to contain information necessary to monitor each patients' condition. Findings include:

The hospital policy entitled "Vital Signs" stated, "All patients admitted...will have vital signs taken on admission, daily and more frequently as ordered by the physician..."

The hospital policy entitled "Hospital Plan for Provision of Nursing Care" stated, "...Nurses engage in an infinite number of activities...Activities critical to the provision of patient care activities include...Medical records auditing maintenance...Implementation and management of physician's orders..."

I. The medical record failed to contain vital sign documentation.

A. Patient #1

"Physician's Admission Orders" dated 12/15/10 at 3:56 PM, included orders for vital signs two times daily for three days then daily thereafter.

Review of the "Vital Signs Log Sheet" revealed no vital sign documentation for the following dates/times:

12/17/10 - 4:00 PM
12/18/10 - 4:00 PM

During a review of Patient #1's medical record with the Chief Nursing Officer on 2/3/11 at 3:06 PM, it was confirmed that vital signs were not documented as completed per physician's orders.

B. Patient #3

Review of the "Vital Signs Log Sheet" revealed no vital sign documentation for the following dates: 1/21, 1/22, 1/23, 1/24 and 1/25/11.

This finding was confirmed during a review of Patient #3's medical record with the Chief Nursing Officer on 2/3/11 at 4:30 PM.

C. Patient #5

Review of the "Vital Signs Log Sheet" revealed no vital sign documentation for the following date: 1/5/11.

This finding was confirmed during a review of Patient #5's medical record with the Chief Nursing Officer on 2/4/11 at 9:00 AM.

II. The medical record failed to contain results of laboratory testing.

A. Patient #3

1. On 1/28/11 the physician ordered urine laboratory tests (routine and cultures). No evidence was found to indicate that urine specimens were obtained and sent to the lab for testing.

This finding was confirmed with the Chief Nursing Officer on 2/3/11 at 4:30 PM.