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Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the care of each patient as evidenced by:
1) failing to follow physicians orders for sliding scale insulin for 1 (#13) of 14 (#14, #15, #16, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30) medical records reviewed from a total sample of 30;
2) failing to notify the physician of medication error of insulin for 1 (#13) of 14 (#14, #15, #16, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30) medical records reviewed from a total sample of 30.


Findings:

Review of the hospital policy titled Reporting of Medication Errors, Number OAGH.PCARE.OS.032, revised 02/2020 revealed in part: V. Procedure- A. All medication errors identified will be reported immediately upon detection to the attending physician.

Patient #13

1) failing to follow physician's orders for sliding scale insulin.

Review of the medical record for patient #13 revealed an admit date of 10/25/2022 with physician admission orders for s/s insulin:
151-200- 2 units, after 10:00 p.m.- 1unit
201-250- 4 units, after 10:00 p.m.- 2 units
251-300- 6 units, after 10:00 p.m.- 3 units
301-350- 8 units, after 10:00 p.m.- 4 units
> 350- 10 units, after 10:00 p.m.- 5 units.
Further review of the medical record revealed CBG on 11/04/2022 at 05:34 a.m. of 181 with no documentation of s/s insulin given.

2) failing to notify the physician of medication error of insulin.

Review of the medical record for patient #13 revealed no documentation of physician notification of medication error for missed insulin dose on 11/04/2022 at 05:34 a.m.

Interview on 11/07/2022 at 2:25 p.m. with S7RN confirmed missed dose of s/s insulin on 11/04/2022 and no documentation physician was notified.

Based on record review, interview, and policy review, the hospital failed to ensure the nursing staff developed and kept current individualized and comprehensive nursing care plans. This deficient practice was evidenced by failure of the nursing staff to include all identified medical diagnoses and failure to include nursing interventions for 8 (#22, #23, #24, #25, #26, #27, #29, #30) of 14 (#14, #15, #16, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30) sampled patients reviewed for care plans from a total sample of 30.

Findings:

Review of the hospital policy titled Documentation of Outcomes and the Nursing Plan of Care, Number OHS.NURS.OS.044, dated 02/07/2022 revealed in part: B. Each patient's care plan should address their specific needs. Monitoring the patient's progress toward projected goals/expected outcomes is an interdisciplinary, collaborative effort that occurs throughout the patient's stay and culminates at discharge.

Patient #22

Review of the medical record for patient #22 revealed an admit date of 11/06/2022 with a diagnosis of Nausea and Vomiting. Further review of the care plan revealed no goal or intervention for fluid volume deficit.

Interview on 11/09/2022 at 10:15 a.m. with S6RN confirmed there was no care plan addressing fluid volume deficit for the patient.

Patient #23

Review of the medical record for patient #23 revealed an admit date of 11/01/2022 with a diagnosis of HTN. Further review of the care plan revealed no goal or intervention for HTN.

Interview on 11/09/2022 at 10:15 a.m. with S6RN confirmed there was no care plan addressing HTN for the patient.


Patient #24

Review of the medical record for patient #24 revealed an admit date of 10/31/2022 with a diagnosis of Anemia, DM, HTN, COPD, and Hypothyroidism. Further review of the care plan revealed no goal or intervention for HTN, DM, and Respiratory.

Interview on 11/09/2022 at 10:30 a.m. with S6RN confirmed there was no care plan addressing HTN, DM, and Respiratory for the patient.

Patient #25
Review of the medical record for patient #25 revealed an admit date of 11/01/2022 with a diagnosis of Pneumonia, HTN, CAD, Hypothyroidism, CHF, and PVD. Physician's orders dated 11/01/2022 for Telemetry and Oxygen. Further review of the care plan revealed no goal or intervention for Telemetry and Oxygen.

Interview on 11/09/2022 at 10:40 a.m. with S6RN confirmed there was no care plan addressing Telemetry and Oxygen for the patient.

Patient #26

Review of the medical record for patient #26 revealed an admit date of 11/05/2022 with a diagnosis of COPD, HTN, CAD, Hypothyroidism, DM, and GERD. Physician's orders dated 11/05/2022 for Oxygen. Further review of the care plan revealed no goal or intervention for Oxygen.

Interview on 11/09/2022 at 10:50 a.m. with S6RN confirmed there was no care plan addressing Oxygen for the patient.

Patient #27

Review of the medical record for patient #27 revealed an admit date of 10/24/2022 with a diagnosis of Pneumonia, HTN, and COPD. Physician's orders dated 10/24/2022 for Telemetry and Oxygen. Further review of the care plan revealed no goal or intervention for Telemetry and Oxygen.

Interview on 11/09/2022 at 11:00 a.m. with S6RN confirmed there was no care plan addressing Telemetry and Oxygen for the patient.

Patient #29

Review of the medical record for patient #29 revealed an admit date of 11/05/2022 with a diagnosis of Bronchitis, CHF, COPD, and HTN. Physician's orders dated 11/06/2022 for Telemetry and Oxygen. Further review of the care plan revealed no goal or intervention for Telemetry and Oxygen.

Interview on 11/09/2022 at 11:10 a.m. with S6RN confirmed there was no care plan addressing Telemetry and Oxygen for the patient.

Patient #30

Review of the medical record for patient #30 revealed an admit date of 10/30/2022 with a diagnosis of SOB, CHF, COPD, and HTN. Physician's orders dated 10/30/2022 for Telemetry and Oxygen. Further review of the care plan revealed no goal or intervention for Telemetry and Oxygen.

Interview on 11/09/2022 at 11:15 a.m. with S6RN confirmed there was no care plan addressing Telemetry and Oxygen for the patient.

Based on record review and interview, the hospital failed to ensure each patient had a medical H&P examination completed and documented no more than 30 days before or 24 hours after admission as evidenced by failing to have a documented H&P for 1 (#26) of 14 (#14, #15, #16, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30) medical records reviewed for H&P's from a total sample of 30.

Findings:

Review of the Medical Staff By-Laws, Fair Hearing Plan, Rules, Regulations & Credentialing Policies and Procedures, 4.1 Medical Records (b) revealed a history and physical examination report shall in all cases be recorded no more than thirty days before or twenty four hours following the patient's admission to the hospital.

Patient #26

Review of the medical record revealed the patient was admitted on 11/05/2022 for Fall. Further review revealed no documented H&P.

Interview on 11/09/2022 at 11:10 a.m. with S6RN confirmed there was no H&P in the medical record.

Based on interview and record review the hospital failed to ensure patient medical records had an updated H&P within 24 hours after admission for 1 (#16) of 14 (#14, #15, #16, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30) medical records reviewed for H&P's from a total sample of 30.

Findings:

Review of the Medical Staff By-Laws, Fair Hearing Plan, Rules, Regulations & Credentialing Policies and Procedures, 4.1 Medical Records (b) revealed a history and physical examination report shall in all cases be recorded no more than thirty days before or twenty four hours following the patient's admission to the hospital.

Patient #16

Review of the medical record for patient #16 revealed a 96 year old female admitted on 11/02/2022. The H&P dated 11/02/2022 did not contain the patient's past medical history and had not been updated.

Interview on 11/09/2022 at 11:15 a.m. with S6RN confirmed there was no addendum or update to reflect the patient's current medical history.