HospitalInspections.org

Based on clinical record review, and staff interviews, the facility failed to provide nursing services in order to ensure that all physician orders were noted and followed in order to prevent any delay in patient care for 1 (Patient #1) of 10 patients reviewed.

The findings include:

A review of Patient #1's clinical record revealed that the patient was admitted on 12/15/2010 with complaints of shortness of breath and dizziness which was documented in the physicians history and physical. A physician's order was entered into the electronic system for a CBC with differential that read STAT, 12/15/2010 9:43:00 EST, AM (Every morning) 1 day, 12/16/2010 9:42:00 EST.

Interview with the clinical informatcs person on 12/21/10 revealed that the lab orders automatically go to the lab for processing, however, with the new system, STAT and routine orders need to be separated which was not done with this one. Nursing also receives a copy of the order, however, did not note that there should have been a STAT collection in order to determine if the patient would need any blood products.

The order history stated that the collection time and date should have been 12/15/2010 at 09:43 EST and done as a STAT (immediate) order, but the test was not completed until 12/16/2010 at 04:55 EST. The results of the CBC with differential revealed the patient had a critical hemoglobin result of 5.7 ( normal range is 13.8-17.2). As a result, there was a delay in the patient receiving blood products to treat his condition.