HospitalInspections.org

Based on document review and interview, a registered nurse failed to ensure policies/standards were followed for completing patient assessments for 1 of 10 patients (patient #1), failed to ensure orders were obtained for oxygen (O2) administration for 3 of 10 patients (patients #1, 2 and 6), failed to ensure nurses followed physician orders for 8 of 10 patients (patients #1, 2, 3, 4, 6, 7, 9 and 10) and failed to ensure nursing notified the physician of a change in condition (decreased oxygen saturation level) for 1 of 10 patients (patient #1).

Findings include:

1. Facility policy titled "RESPIRATORY CARE OXYGEN THERAPY ASSESSMENT PROGRAM" last reviewed/revised 5/30/15 states on page 1 of 4: "E. If there is no order at initiation, one must be obtained;......" (Unchanged from previous revision/review).

2. Facility policy titled "DOCUMENTATION STANDARDS: INPATIENT" last reviewed/revised 10/31/12 states on page 9 of 21 under "Physical Assessment": Document a physical assessment of all systems (cardiovascular, EENT, gastrointestinal, genitourinary, integumentary, musculoskeletal, neurological, respiratory), as well as psychosocial assessment as ordered, per unit standard or a minimum of:.......b. Progressive care: every 4 hours". Page 18 of 21 states: "Narrative Notes A narrative note is used whenever the electronic or paperforms do not support the level documentation required to accurately and adequately capture a patient event, situation or care episode......Examples of events which may trigger a narrative note include: Significant Events:.....Respiratory changes: O2 desaturation......."

3. Review of patient #1 (Progressive Care Patient) medical record indicated the following:
(A) An order was written at 6:20 p.m. on 1/6/15 to call if diastolic blood pressure was < 60 or systolic blood pressure > 180.
(B) The record indicated the patients blood pressure was 114/55 at 5:00 p.m. on 1/7/15, 185/75 at 11:00 a.m. on 1/7/15, and 128/59 at midnight on 1/8/15 with no documentation that the physician was notified per order.
(C) The record indicated oxygen (O2) was placed on the patient at 4:00 a.m. on 1/8/15 with no indication in the medical record as to why it was applied. The record lacked an order for the oxygen. The O2 saturation was documented as 93% at the time the oxygen was applied. Additionally, the patients blood pressure was 133/54 at 4:00 a.m. on 1/8/15 with no documentation that the physician was notified per order.
(D) The record indicated that oxygen was placed on the patient at 10:00 a.m. on 1/8/15 with no indication as to why it was used. There was no order for the oxygen. The O2 saturation was documented as 94% at the time the oxygen was placed.
(E) The record indicated the patient's blood pressure was 106/52 and the O2 saturation was 84% at 3:31 p.m. on 1/8/15 with no documentation that the physician was notified of either the decreased blood pressure or the low O2 saturation. The record indicated that the patient had no oxygen on and was documented as being on "room air".
(F) The record lacked documentation that nursing physical assessments were completed between 8:45 a.m. and 2:26 p.m. on 1/8/15.

4. Review of patient #2 medical record indicated the following:
(A) An order was written on 1/9/15 at 2:19 p.m. to call if the diastolic blood pressure was < 60.
(B) The record indicated the patient's blood pressure was 115/55 at 7:34 a.m. on 1/11/15 and 127/51 at 11:29 a.m. on 1/11/15 with no documentation that the physician was notified per order.
(C) The record indicated that oxygen was placed on the patient at 7:34 a.m. on 1/11/15 and was placed on again at 11:29 a.m. on 1/11/15 with no indication as to why the oxygen was placed. There was no order for the patient to have oxygen during this time. His/her oxygen order was discontinued at 1:08 a.m. on 1/11/15. His/her O2 saturation levels were documented as 96% at 7:34 and 95% at 11:29. He/she was documented as being on "room air" between the 2 events of oxygen placement.

5. Review of patient #3 medical record indicated the following:
(A) An order was written on on 1/8/15 at 7:51 p.m. to call if diastolic blood pressure was < 60.
(B) The medical record indicated the patient's blood pressure was 117/46 at 12:05 a.m. on 1/9/15, 115/45 at 3:30 a.m. on 1/9/15, 119/44 at 7:21 a.m. on 1/9/15, 119/47 at 11:37 a.m. on 1/9/15 and 138/57 at 3:23 p.m. on 1/9/15 with no documentation that the physician was notified per order.

6. Review of patient #4 medical record indicated the following:
(A) He/she was admitted on 1/15/15 and underwent an Ileal loop with drain placement.
(B) An order was written at 3:09 p.m. on 1/15/15 to call physician if diastolic blood pressure was < 60.
(C) The record indicated the patient's blood pressure was 126/46 at 3:50 a.m. on 1/24/15, 117/58 at 8:25 a.m. on 1/24/15 and 146/50 at 4:30 p.m. on 1/25/15 with no documentation that the physician was notified per order.

7. Review of patient #6 medical record indicated the following:
(A) An order was written at 11:52 a.m. on 4/18/16 to call if the diastolic blood pressure was < 60.
(B) The record indicated the patient's blood pressure was 122/50 at 12:50 a.m. on 4/19/16 and 124/54 at 4:00 a.m. on 4/19/16 with no documentation that the physician was notified per order. The record indicated that oxygen was placed on the patient at 12:50 a.m. on 4/19/16 with no indication as to why the oxygen was applied and no order for oxygen. The O2 saturation level was documented as 94% at the time of the placement.

8. Review of patient #7 medical record indicated the following:
(A) An order was written at 11:44 a.m. on 4/11/16 to call physician if diastolic blood pressure was < 60.
(B) The record indicated the patient's blood pressure was 103/59 at 9:55 p.m. on 4/11/16, 114/58 at 10:00 p.m. on 4/11/16, 100/50 at midnight on 4/12/16, 108/54 at 3:30 a.m. on 4/12/16, 110/54 at 11:00 a.m. on 4/12/16, 106/56 at 3:54 p.m. on 4/12/16, 117/58 at 7:40 p.m. on 4/12/16, 114/58 at 8:05 p.m. on 4/13/16, 130/55 at 11:00 a.m. on 4/14/16 and 128/58 at 11:16 p.m. on 4/14/16 with no documentation that the physician was notified per order.

9. Review of patient #9 medical record indicated the following:
(A) He/she had an order written at 11:18 a.m. on 4/14/16 to call if diastolic blood pressure was < 60.
(B) The record indicated the patient diastolic blood pressure was low including, but not limited to, blood pressure of 105/59 at 8:00 p.m. on 4/14/16, 94/54 at 9:00 p.m. on 4/14/16, 97/51 at 10:00 p.m. on 4/14/16, 100/48 at 3:00 a.m. on 4/15/16 and 96/51 at 5:00 a.m. on 4/15/16 with no documentation that the physician was notified per order.

10. Review of patient #10 medical record indicated the following:
(A) An order was written at 5:10 p.m. on 4/15/16 to call if diastolic blood pressure was < 60.
(B) The medical record indicated the patient had low diastolic blood pressures including, but not limited to, a blood pressure of 97/48 at 5:15 p.m. on 4/15/16, 106/51 2:39 a.m. on 4/16/16 and 123/54 at 3:04 p.m. on 4/16/16 with no documentation that the physician was notified per order.

11. Staff member #2 (Manager of Clinical Informatics) verified the medical record information beginning at 11:15 a.m. on 4/19/16.

12. Staff member #1 (Accreditation/Regulatory Specialist) indicated in interviews beginning at 2:05 p.m. that oxygen placement would require an order. He/she verified this information with Respiratory Therapy (RT).

Based on document review and interview, the facility failed to ensure the medical records contained complete information for 4 of 10 patients (patients #1, 2, 3 and 6).

Findings include:

1. Review of patient #1 medical record indicated the following:
(A) The record indicted oxygen (O2) was placed on the patient at 4:00 a.m. on 1/8/15 with no indication in the medical record as to why it was applied. The O2 saturation was documented as 93% at the time the oxygen was applied.
(B) The record indicated that oxygen was placed on the patient at 10:00 a.m. on 1/8/15 with no indication as to why it was used. The O2 saturation was documented as 94% at the time the oxygen was placed.

2. Review of patient #2 medical record indicated the following:
(A) The record indicated that oxygen was placed on the patient at 7:34 a.m. on 1/11/15 and was placed on again at 11:29 a.m. on 1//11/15 with no indication as to why the oxygen was placed. His/her O2 saturation levels were documented as 96% at 7:34 and 95% at 11:29. He/she was documented as being on "room air" in between the 2 events of oxygen placement.

3. Review of patient #3 medical record indicated the following:
(A) An order was written at 4:45 p.m. on 1/8/15 for oxygen titration to keep O2 saturation of 92% or greater.
(B) The record indicated that the patient was on "room air" at 8:38 p.m. on 1/8/15 with an O2 saturation level of 95%. The record indicated that oxygen was placed on the patient at 12:05 a.m. on 1/9/15 with no reason documented as to why the oxygen was placed. The patient's O2 saturation level was documented as 98%.

4. Review of patient #6 medical record indicated the following:
(A) The record indicated that oxygen was placed on the patient at 12:50 a.m. on 4/19/16 with no indication as to why the oxygen was applied. The O2 saturation level was documented as 94% at the time of the placement.

5. Staff member #2 (Manager of Clinical Informatics) verified the medical record information beginning at 11:15 a.m. on 4/19/16.