HospitalInspections.org

Based on record review and interview, the facility failed to ensure care in a safe setting as shown by three days delay in documentation of physician orders for three of three patients (Patient #'s 1, 2, and #3).

Findings included:

TX00386907, TX00387786

Record review of policy titled "Transcription of Physician orders", policy # 760.500.22 dated 5/20 stated that the policy was to assure the transcription of physician orders are completed by a licensed nurse and followed hospital guidelines. All telephone orders, after entering, are to be repeated back to doctor. Also, the nurse transcribing the order is to verify completion of transcription prior to signing off.

Record review of occurrence report which involved sexually acting out allegations reported by Patient #2 and #3 against Patient #1, reported to RN-Staff #E on the evening of 6/17/21, showed that the physician, MD-Staff #D, was notified of the sexual allegations made. All three patients were roommates. Occurrence report showed that the doctor ordered that all three patients be put on sexual acting out (SAO) precautions and to separate the patients by changing room assignments immediately. This was ordered by doctor on 6/18/21 after learning of the sexual allegations made.

Record review of physician orders from MD-Staff #D showed that the orders given on 6/18/21 were not transcribed by the RN-Staff #E until 6/21/21.

In an interview on 7/23/21 at 10:00 am with Assistant Administrator-Staff #A, they way staff can tell which precautions a patient was on, besides the doctor's orders, was to look at daily bedboard, daily bedlog and Observation Rounds sheets. Staff #A then added it was not possible to reproduce the daily bedboard log because it was not historical and something that was done daily. When questioned how the patient precautions were initially communicated, he stated by doctors orders.
In addition to RN-Staff #E not transcribing the orders received on 6/18/21 until 6/21/21, a nursing progress note concerning the alleged incident was not entered until 6/25/21.


Record review of close observation rounds sheets, which communicates which precautions a patient was on, failed to capture at least 2 days for 2 of the patients for SAO precautions; 6/20/21 and 6/21/21 for Patient# 1 and Patient #2 (Note; Patient #3 was still residing in the facility so his close observation sheets were not available, as they had to be scanned and uploaded, which occurs when a patient discharges).