HospitalInspections.org

.
Based on record review, interview, and review of hospital policies and procedures, the hospital failed to ensure that staff completed required specialized assessments for 3 of 4 patient records reviewed (Patient #301, #302, and #303).

Failure to assess and reassess a patient's sedation level risks patients not receiving medical treatment appropriate to their care needs.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Pain and Sedation Management for Adult Ventilated Patients," no policy number, approved 03/18, showed that a Richmond Agitation Sedation Scale (RASS) assessment is performed a minimum of every 2 hours or every 4 hours and as needed for a change in the patient's condition.

Document review of the hospital's policy and procedure titled, "Nursing Minimum Documentation Reference," no policy number, approved 06/19, showed that in the intensive care or intermediate care unit environment, all patients within one hour of admission and with assumption of care, or a change in the patient's condition will have a RASS score obtained. Patients on sedatives will have a RASS score documented every 2 hours and with each drip titration.

2. On 01/13/20 at 9:10 AM, Investigator #3 and the Neuroscience Clinical Nurse Specialist (Staff #301) reviewed the records of four patients who were receiving intravenous sedation medication while their breathing was controlled by a mechanical breathing machine (mechanical ventilation). The review showed the following:

a. Patient #301 was a 56-year old admitted on 01/09/20 for progressive weakness and was intubated and placed on mechanical ventilation. The patient was receiving a continuous intravenous infusion of dexmedetomidine for sedation. The investigator found no documentation that a RASS assessment was completed from 01/09/20 at 8:00 PM until 01/10/20 at 8:00 AM, a period of 12 hours. The investigator found similar findings that a RASS assessment was not completed from 01/11/20 at 8:00 AM until 01/11/20 at 8:00 PM, a period of 12 hours.

b. Patient #302 was a 30-year old who suffered a cardiac arrest on 01/05/20 and was placed on mechanical ventilation. The patient was receiving multiple continuous intravenous sedating medications including dexmedetomidine, ketamine, and midazolam. The investigator found no documentation that a RASS assessment was completed on 01/11/20 at 7:00 AM until 01/11/20 at 8:00 PM, a period of 13 hours. Similar findings that a RASS assessment was not completed on 01/12/20 at 10:02 AM until 01/12/20 at 8:00 PM, a period of 9 hours and 58 minutes.

c. Patient #303 was a 63-year old who suffered a seizure on 01/07/20 and was placed on mechanical ventilation. The patient was receiving a continuous intravenous infusion of dexmedetomidine for sedation. The investigator found no documentation that a RASS assessment was completed on 01/11/20 at 4:00 PM until 01/12/20 at 8:00 AM, a period of 18 hours. Similar findings that a RASS assessment was not completed on 01/12/20 at 2:00 PM until 01/13/20 at 8:00 AM, a period of 18 hours.

3. At the time of the review, Investigator #3 interviewed the Neuroscience Clinical Nurse Specialist (Staff #301) about the findings described above. Staff #301 confirmed the findings and stated that the issue appears to be confined to a few individual staff members.

.

.
Based on interview and record review, the hospital failed to ensure nursing staff performed blood transfusion procedures according to hospital policy, for 2 of 3 patient records reviewed (Patients #1201 and #1202).

Failure to administer blood or blood products according to acceptable standards of practice risks transfusion reactions and potential patient harm.

Findings included:

1. Document review of the hospital policy and procedure titled, "Blood Management: Blood Administration (Adult)," approved 09/18, showed that vital signs, including a temperature, heart rate, respiratory rate, and blood pressure, were to be documented at minimum, within 30 minutes prior to initiation of the transfusion, within 15 minutes after the start of the transfusion, and within 30 minutes upon completion of the transfusion.

2. On 01/10/20 at 10:30 AM, Investigator #12 reviewed the records of three patients who received blood transfusions during their hospital stay. This review showed the following:

a. Document review of medical record for Patient #1201 showed that the patient received two units of blood on 01/10/20. The nursing staff did not document the temperature or respiratory rate upon completion of the first transfusion, within 30 minutes of the start of the second transfusion, and within 15 minutes after the start of the second transfusion as required by hospital policy.

b. Document review of medical record for Patient #1202 showed that on 01/09/20, the nurse did not document the patient's temperature within 15 minutes after the start of the blood transfusion or within 30 minutes of completion of the transfusion as required by hospital policy.

3. An interview with the Nursing Supervisor (Staff #1201), at the time of the record review confirmed the missing documentation.

.