HospitalInspections.org

Based on document review and review of the North Dakota Administrative Code, the Critical Access Hospital (CAH) failed to completely record medications removed from pharmacy in the absence of the pharmacist for 1 of 1 hospital pharmacy. This failure limited the CAH's ability to ensure provision of pharmaceutical services in accordance with accepted professional principles.

Findings include:

The North Dakota Administrative Code, Chapter 61-07-01 "Hospital Pharmacy" stated, ". . . 61-07-01-05. Absence of pharmacist. 1. General. During such times a hospital pharmacy may be unattended by a pharmacist, arrangements must be made in advance . . . for the provision of drugs . . . by use of night cabinets or floor stock, or both, and in emergency circumstances, by access to the pharmacy. . . . 3. Access to pharmacy. Whenever any drug is not available from floor supplies or night cabinets, and such drug is required to treat the immediate needs of a patient whose health would otherwise be jeopardized, such drug may be obtained from the pharmacy in accordance with the requirements of this section in accordance with the requirements of this section. . . . a. Removal of any drug from the pharmacy by an authorized nurse must be recorded on a suitable form showing patient name, room number, name of drug, strength, amount, date, time, and signature of nurse. . . ."

Review of the current medication sign out sheet for nurses to document medications removed from the pharmacy after hours occurred on 10/16/18 at 2:30 p.m. The form failed to include the patient name, room number, strength, amount, and time.

Based on record review, review of professional literature, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff revised and individualized nursing care plans for 4 of 20 (Patients #4, #7, #8, and #18) records reviewed. Failure to revise and individualize care plans limited the CAH's ability to communicate treatment approaches, assist the patient to attain/maintain their highest physical, mental, and psychosocial well-being, and ensure continuity of care.

Findings include:

Berman, Snyder, and Frandsen's, "Kozier & Erb's Fundamentals of Nursing, Concepts, Process, and Practice" 2016 10th ed., pages 190-195, stated, ". . . A formal nursing care plan is a written or computerized guide that organizes information about the client's care. The most obvious benefit of a formal written care plan is that it provides for continuity of care. . . . Care plans include the actions nurses must take to address the client's nursing diagnoses and produce the desired outcomes. The nurse begins the plan when the client is admitted to the agency and constantly updates it throughout the client's stay in response to changes in the client's condition and evaluations of goal achievement. . . . care must be individualized to fit the unique needs of each client. The nurse should use the following guidelines when writing nursing care plans: . . . 4. Be specific . . . 6. Tailor the plan to the unique characteristics of the client . . . In the process of developing client care plans, the nurse engages in the following activities: . . . writing individualized nursing interventions . . ."

- Review of Patient #4's active medical record occurred on 10/16/18. The record identified the patient had a diagnosis of gastroenteritis and partial small bowel obstruction. Observation on 10/15/18 at 4:00 p.m., identified Patient #4 with a nasogastric tube in place to wall suction. Patient #4's care plan lacked individualized interventions specific to the nasogastric tube and monitoring of the bowel obstruction.

- Review of Patient #7's closed medical record occurred on 10/16/18. The record identified the CAH admitted the patient in August 2018 with an upper arm infection and diabetes. Patient #7 received intravenous antibiotics and dressing changes during hospitalization and experienced elevated blood glucose levels. Patient #7's care plan lacked individualized interventions specific to the patient's infection and elevated blood glucose levels.

- Review of Patient #8's closed medical record occurred on 10/16/18. The record identified the CAH admitted the patient in July 2018 with elevated blood glucose levels, nausea and vomiting, and acute renal failure. Patient #8's care plan lacked individualized interventions specific to the patient's blood glucose levels and nausea/vomiting.

- Review of Patient #18's closed medical record occurred on 10/16/18. The record identified hospitalization in May 2018 for abdominal pain, nausea and vomiting. Surgical procedures included an open appendectomy and four days later an exploratory laparotomy with lysis of adhesion bands. The record lacked a care plan specific to the surgical procedures and recovery.

During interview on the afternoon of 10/16/18, an administrative nurse (#8) confirmed the care plans lacked specific individualized interventions.


32641











37620