HospitalInspections.org

Based on review of medical records and staff interviews, the facility failed to ensure that a registered nurse evaluated the nursing care for each patient incorporating past medical history and all current problems.

This failure created the potential for negative patient outcome.

Findings

1. The facility failed to follow up on Patient #8's medical history of deep vein thrombosis (DVT) and blood thinner medication in a timely manner.

a) On 06/18/13 Patient #8's medical record was reviewed. The admission document, "Health Assessment", dated 03/07/13, revealed that the patient was currently not taking any medications. However, the health care practitioner documented that the patient had been on blood thinners for a DVT at an acute care hospital in another city in January of the same year.

b) The medical record included a faxed cover letter from the mother of the patient and power of attorney documentation dated 03/08/13. The mother requested that she be allowed to assist with the care of her disabled son and wanted a phone call in return.

c) A review of the patient's Problem List dated 03/14/13 noted an inactive status for blood thinners for a DVT of the left lower extremity.

d) A review of the facility document, "Progress Notes", dated 03/15/13 revealed a note written by a Social Worker (SW) at 12:45 p.m. documenting a telephone conversation with the patient's mother. The mother informed the SW that the patient takes medication for blood clots, and to her knowledge, he had not received the medication since being admitted to this facility. The SW documented that s/he would speak to the physician about this matter.

e) A review of the facility document, "Physician's Orders", dated 03/22/13 one week after the above conversation and 15 days after admission, revealed that a Nurse Practitioner wrote an order at 11:00 a.m. to obtain the patient's medical records from the acute care hospital at which the patient was allegedly treated with blood thinners for a DVT. On this date another health care provider ordered aspirin 325 mg to be administered daily.

f) On 06/17/13 at 3:30 p.m. an interview with the lead nurse on the patient's ward was conducted. S/he stated that when a new patient is admitted, s/he relied on the information regarding the patient's past medical and psychiatric history from the sending facility. S/he was not aware of any occasions when a patient had not received the medical treatment they needed due to incomplete information.

g) On 06/19/13 at 9:50 a.m. an interview with the Chief of Medical Staff was conducted. S/he stated that there is an expectation for health care providers to work together and obtain all necessary information about patients, especially when those patients are unstable pyschologically and may not provide accurate information at the time of their admission. S/he further stated that the multi-disciplinary team, which includes registered nurses, medical and psychiatric physicians, and social workers, should have read the information regarding the patient's history of DVT and blood thinners in the health assessment and referred the patient to the medical clinic for additional follow up. Although the medical record noted that the patient was initially combative and aggressive on admission, the team should have recognized sooner the need for a referral to the medical clinic for further evaluation. Medical records from other treatment facilities should have been requested in a more timely manner as well.