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Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure 3 of 8 patients (#12, #14, and #17), whose records were reviewed for allergies, were involved in planning their care and had the opportunity to refuse treatment. This interfered with patients' ability to make informed decisions. Findings include:

1. Patient #14's medical record documented a 53 year old female who was hospitalized from 4/03/13 to 4/05/13 for abdominal surgery. Her "HISTORY AND PHYSICAL," dated 3/21/13, stated "ALLERGIES: VICODIN CAUSING NAUSEA AND PRURITUS." Vicodin contains hydrocodone and acetaminophen. Untimed orders dated 4/04/13, called for Patient #14 to receive "Lortab elixir (Hydrocodone 7.5 mg/acetaminophen 500 mg per 15 ml) give 10-15 ml q 4 hrs prn pain."

Patient #14's medical record documented she received the Lortab on 4/04/13 at 3:49 PM and 11:20 PM. She also received Lortab at 6:37 AM on 4/05/13. An order, dated 4/05/13 at 7:20 AM, called for Patient #14 to receive Benadryl 50 mg "now." The progress note by the PA that was written with the order stated "Benadryl for likely allergic [reaction] to Hydrocodone."

No documentation was present in the medical record that Patient #14 was informed of the order for Lortab and told it was the same medication she had reported she was allergic to. No documentation was present in the medical record that Patient #14 was afforded the opportunity to refuse the medication.

The Department Director for the telemetry unit was interviewed on 10/21/13 beginning at 2:15 PM. She confirmed Patient #14 received medication that was listed as an allergen. She confirmed there was no documentation stating Patient #14 was informed about the medication and given an opportunity to refuse it.

Patient #14 was not informed medication had been ordered that she believed she was allergic to.

2. Patient #12's medical record documented a 68 year old male who was hospitalized from 5/05/13 to 5/20/13 for sepsis. His "HISTORY AND PHYSICAL," dated 5/05/13, stated he was allergic to Morphine.

The form "St. Lukes Admission and Discharge Medication Reconciliation Orders," dated 5/05/13 at 3:20 PM, stated Patient #12 was allergic to Morphine which caused "Mental Changes." The form "ADULT CRITICAL CARE INTENSIVIST PATIENT ADMIT ORDERS," dated 5/05/13 at 4:20 AM, stated he was allergic to Morphine. An order, dated 5/06/13 at 9:50 AM, stated Patient #12 was to receive Morphine IV every 4 hours as needed for pain. Patient #12's medical record documented he received the Morphine on 5/06/13 at 10:45 AM. An order dated 5/06/13 at 11:40 AM discontinued the Morphine.

No documentation was present in the medical record that Patient #12 was informed of the order for Morphine and told it was a medication he had reported he was allergic to. No documentation was present in the medical record that Patient #12 was afforded the opportunity to refuse medication.

The Medication Safety Coordinator, a pharmacist, was interviewed on 10/18/13 beginning at 8:05 AM. She stated the hospital had a system for pharmacists to evaluate reported allergies to determine whether they were true allergies prior to administration of the medication. She stated Patient #12 did not have a true allergy to Morphine.

The Department Director for the telemetry unit was interviewed on 10/21/13 beginning at 2:15 PM. She confirmed Patient #12 received medication that was listed as an allergen. She confirmed there was no documentation stating Patient #12 was informed about the medication and given an opportunity to refuse it.

Patient #12 was not informed medication had been ordered that he believed he was allergic to.

3. Patient #17's medical record documented an 80 year old female who was hospitalized from 5/13/13 to 5/23/13 for leg ulcers. Her "HISTORY AND PHYSICAL," dated 5/13/13, stated she was allergic to Morphine which caused gastrointestinal disturbances.

An order dated 5/18/13 at 6:00 PM called for Patient #17 to receive oral Morphine every 12 hours. No documentation was present that the medication was administered to Patient #17. The Morphine order was discontinued on 5/19/13 at 11:45 AM. A physician progress note, written at the same time, stated "Treating [Patient #17's] pain adequately with opioids will [increase] her risk of falls, constipation, and anorexia."

An addendum to the "DISCHARGE SUMMARY," dated 5/24/13, stated Patient #17 was discharged to a rehabilitation facility on 5/23/13. A "DISCHARGE PRESCRIPTION" form, dated 5/21/13 at 2:45 PM, stated Patient #17 was to receive oral Morphine 2 times a day for pain after she was discharged. No explanation was documented why the medication was ordered. No documentation was present in the medical record that Patient #17 was informed of the order for Morphine prior to discharge and given the opportunity to refuse the medication and request that another be ordered.

Patient #17 was readmitted to the hospital from 5/28/13 to 6/05/13, after a fall. Her history and physical, dated 5/28/13, again listed she was allergic to Morphine which it stated caused nausea and vomiting. Morphine was ordered 2 times a day on admission on 5/28/13 at 10:15 AM. The medical record stated she received the Morphine on 5/28/13, 5/29/13, and 5/30/13.

The Department Director for the telemetry unit was interviewed on 10/21/13 beginning at 2:15 PM. She confirmed the Morphine was ordered twice for Patient #17. She confirmed there was no documentation stating Patient #17 was informed about the medication and given an opportunity to refuse it.

Patient #17 was not informed a medication had been ordered that she believed she was allergic to.

4. The policy "Allergy, Intolerance, and Side Effect Assessment," revised 10/01/13, outlined a procedure to determine whether reported allergies were true allergies or side effects. The policy stated "If the patient identifies that they have an allergy, sensitivity or intolerance, the clinician is responsible for acknowledging the patient's concern, seek clarification and determine if true allergy, provide education and determine if an alternative is required."

The Clinical Nurse Specialist for the Medical/Surgical units and the Director of Accreditation and Patient Relations were interviewed together on 10/24/13 beginning at 9:55 AM. They stated the term clinician was broadly defined at the hospital. They confirmed the policy did not specify which staff should inform the patient that a medication was being ordered for which the patient had reported a prior problem to allow the patient to refuse the medication and discuss alternatives.

The policy did not promote informing patients about treatment options for medications to which they had known reactions.

Based on review of facility policies, medical record review and staff interview, it was determined the hospital failed to ensure a plan of care was developed and updated for 1 of 10 patients (#5) whose records were reviewed. This resulted in a lack of direction to interdisciplinary staff in the delivery of care to the patient and had the potential to interfere with coordination of patient care. Findings include:

Patient #5 was a 91 year old female with dementia admitted to the hospital on 2/24/13, after a fall at the assisted living facility she resided in. She was noted to have right sided weakness, facial droop and slurred speech, in addition to bruising and pain in her right arm. She was admitted with diagnoses of CVA and fracture of the right arm. Patient #5 was placed on "Comfort Care" status on 3/01/13, and discharged to a Skilled Nursing Facility with Hospice on 3/05/13. Patient #5's plan of care was not sufficiently developed and kept current as follows:

1. A form in Patient #5's medical record titled, "Interdisciplinary Care Management Plan," (ICMP) dated 2/24/13 to 3/01/13, included interventions of ice and elevation for her right arm fracture. The record did not contain documentation ice had been utilized as an intervention. The ICMP dated 3/02/13 to 3/06/13, did not include ice or elevation for the fracture.

During an interview on 10/21/13 beginning at 2:10 PM, Nurse B reviewed Patient #5's medical record and confirmed nursing staff had not updated and maintained the ICMP to include non-medication interventions such as ice for pain management.

2. Patient #5's ICMP was not individualized to include frequency of position changes, as well as, her hygiene, mobility and activity level requirements. The nursing documentation of position changes in Patient #5's medical record were inconsistent as follows:

2/24/13 (night shift) - turned 1 time in 12 hours
2/25/13 (night shift) - turned 1 time in 12 hours
2/26/13 (night shift) - turned 4 times in 12 hours
2/28/13 (night shift) - turned 2 times in 12 hours
3/01/13 (night shift) - turned 4 times in 12 hours
3/02/13 (day shift) - turned 4 times in 12 hours
3/02/13 (night shift) - turned 1 time in 12 hours
3/04/13 (day shift) - turned 4 times in 12 hours
3/04/13 (night shift) - turned 3 times in 12 hours

During an interview on 10/21/13 beginning at 1:45 PM, Nurse A, who had been assigned to care for Patient #5 on 3/05/13, reviewed the medical record. She confirmed the ICMP did not include frequency of position changes or mobility needs specific to Patient #5's needs. She stated the standard of care on her nursing unit was to ensure patients who had mobility deficits were repositioned every 2 hours around the clock. She stated a patient or family member may refuse repositioning, but usually that would be documented. Nurse A stated when a patient was placed on "Comfort Care," many patient care activities such as vital signs, monitoring blood sugars and labs would be discontinued. She stated the goal would be to keep the patient comfortable and the family would usually decide what and when patient care activities would be done, which included repositioning. She stated if the family member was not present, she would decide if the patient needed to be repositioned, but it was not on the every 2 hour schedule as the routine for the other patients.

3. Patient #5 had a SLP evaluation on the day of her admission, with additional assessments and dietary modifications on 2/25/13, 2/26/13, and 2/27/13 as noted:

- 2/24/13 at 1400 a "Dysphagia Evaluation" was completed by a Speech Language Pathologist (SLP). Physician's orders were written as pre-approved diet texture protocol orders and signed by a physician on 3/14/13. The diet orders included a general diet texture with any liquid and 1:1 assistance during meals because of Patient #5's fractured right arm.

- 2/25/13 at 11:05 AM, a SLP follow up visit progress note documented a decline in Patient #5's swallow function. Orders per "Swallow Protocol" were written for a Dysphagia 2 mechanically altered diet with liquids thickened to nectar consistency and signed by a physician on 2/25/13 at 1:45 PM.

- 2/26/13 at 10:30 AM, a SLP follow up visit progress note documented Patient #5 did not tolerate thin liquids, and her diet orders were changed. Orders per "Swallow Protocol" were written for a Dysphagia 2 mechanically altered diet with liquids thickened to honey consistency. The 1:1 assistance was continued to ensure oral clearing between bites. The order was authenticated by a physician on 2/26/13 at 10:43 AM.

- 2/27/13 at 12:20 PM, a SLP progress note documented Patient #5 had no difficulty with any viscosity of liquids. Orders were written for ADA (American Diabetic Association) dysphagia 2 mech-soft (mechanical soft), with any liquids. The order was authenticated by a physician on 2/27/13 at 2:00 PM.

- 2/28/13 at 9:15 AM, a SLP progress note recommended Patient #5 continue with the dysphagia 2 diet.

The dietary modifications were not continued when Patient #5 was placed on Comfort Care on 3/01/13, at which time all her previous orders were discontinued and a "General Diet" was ordered. The ICMP dated 3/02/13 to 3/06/13 documented Patient #5 was to have a general diet and did not include dysphagia precautions and mechanical soft texture.

During an interview on 10/21/13 beginning at 2:10 PM, Nurse B, who had been assigned to care for Patient #5 on 3/04/13, stated the ICMP indicated a "General Diet." Nurse B stated a general diet included foods without restrictions such as low sodium, no concentrated sweets, etc. She was not aware of the texture requirements that Patient #5 had prior to being placed on "Comfort Care" and stated she was unaware she had been on a dysphagia 2 diet and 1:1 assistance with meals was required. She stated multiple family members were with Patient #5 throughout that day and she had assumed they had fed their mother lunch and dinner. Nurse B stated when a family member told her the food was not appropriate, she thought they had meant Patient #5 did not want to eat and had refused the meal.

The hospital did not ensure Patient #5's plan of care was individualized and revised according to her needs.

Based on review of facility policies, medical record review and staff interview, it was determined the hospital failed to ensure a plan of care was developed and updated for 1 of 10 patients (#5) whose records were reviewed. This resulted in a lack of direction to interdisciplinary staff in the delivery of care to the patient and had the potential to interfere with coordination of patient care. Findings include:

Patient #5 was a 91 year old female with dementia admitted to the hospital on 2/24/13, after a fall at the assisted living facility she resided in. She was noted to have right sided weakness, facial droop and slurred speech, in addition to bruising and pain in her right arm. She was admitted with diagnoses of CVA and fracture of the right arm. Patient #5 was placed on "Comfort Care" status on 3/01/13, and discharged to a Skilled Nursing Facility with Hospice on 3/05/13. Patient #5's plan of care was not sufficiently developed and kept current as follows:

1. A form in Patient #5's medical record titled, "Interdisciplinary Care Management Plan," (ICMP) dated 2/24/13 to 3/01/13, included interventions of ice and elevation for her right arm fracture. The record did not contain documentation ice had been utilized as an intervention. The ICMP dated 3/02/13 to 3/06/13, did not include ice or elevation for the fracture.

During an interview on 10/21/13 beginning at 2:10 PM, Nurse B reviewed Patient #5's medical record and confirmed nursing staff had not updated and maintained the ICMP to include non-medication interventions such as ice for pain management.

2. Patient #5's ICMP was not individualized to include frequency of position changes, as well as, her hygiene, mobility and activity level requirements. The nursing documentation of position changes in Patient #5's medical record were inconsistent as follows:

2/24/13 (night shift) - turned 1 time in 12 hours
2/25/13 (night shift) - turned 1 time in 12 hours
2/26/13 (night shift) - turned 4 times in 12 hours
2/28/13 (night shift) - turned 2 times in 12 hours
3/01/13 (night shift) - turned 4 times in 12 hours
3/02/13 (day shift) - turned 4 times in 12 hours
3/02/13 (night shift) - turned 1 time in 12 hours
3/04/13 (day shift) - turned 4 times in 12 hours
3/04/13 (night shift) - turned 3 times in 12 hours

During an interview on 10/21/13 beginning at 1:45 PM, Nurse A, who had been assigned to care for Patient #5 on 3/05/13, reviewed the medical record. She confirmed the ICMP did not include frequency of position changes or mobility needs specific to Patient #5's needs. She stated the standard of care on her nursing unit was to ensure patients who had mobility deficits were repositioned every 2 hours around the clock. She stated a patient or family member may refuse repositioning, but usually that would be documented. Nurse A stated when a patient was placed on "Comfort Care," many patient care activities such as vital signs, monitoring blood sugars and labs would be discontinued. She stated the goal would be to keep the patient comfortable and the family would usually decide what and when patient care activities would be done, which included repositioning. She stated if the family member was not present, she would decide if the patient needed to be repositioned, but it was not on the every 2 hour schedule as the routine for the other patients.

3. Patient #5 had a SLP evaluation on the day of her admission, with additional assessments and dietary modifications on 2/25/13, 2/26/13, and 2/27/13 as noted:

- 2/24/13 at 1400 a "Dysphagia Evaluation" was completed by a Speech Language Pathologist (SLP). Physician's orders were written as pre-approved diet texture protocol orders and signed by a physician on 3/14/13. The diet orders included a general diet texture with any liquid and 1:1 assistance during meals because of Patient #5's fractured right arm.

- 2/25/13 at 11:05 AM, a SLP follow up visit progress note documented a decline in Patient #5's swallow function. Orders per "Swallow Protocol" were written for a Dysphagia 2 mechanically altered diet with li