HospitalInspections.org

Based on hospital policy and procedure review, medical record review and staff interview, the nursing staff failed to document a response to medication interventions per hospital policy for 7 of 10 sampled medical records reviewed. (Patient #7, #2, #3, #10, #5 and #4)

Findings included:

Review on 11/01/2018 of the hospital policy and procedure titled "PLAN FOR ASSESMENT, CARE PLANNING AND EDUCATION" revised 12/2015 revealed "Model for patient assessment and reasessment flowsheet: Implement Interventions, Evaluate Effectiveness of Interventions & Achievement of Desired Goals/Outcomes and Reassessment. A. Nursing ...2. Registered Nurse...d. 4. Evaluating a patient, family, and significant other's response to nursing interventions. ...Assessment/Reassessment Criteria ...patient's desire for treatment and response to treatment all serve to direct the process of assessment and reassessment...Reassessment includes, but not limited to...Measures a patient's response to care..."

Review on 10/31/2017 of the hospital policy and procedure titled "PAIN ASSESSMENT/REASSESSMENT" revised 12/2015 revealed "Pain Reassessment...reassessed within 60 minutes following any pain intervention."

1. Review on 11/01/2018 of the open medical record for Patient #7 revealed a 66-year-old female admitted on 10/29/2018 at 1536 with a diagnosis of respiratory distress and pneumonia. Review of the physician orders revealed orders written on 10/29/2018 at 1536 for Tylenol (pain medication) 650 milligrams by mouth every 4 hours as needed for pain scale 1-3. Review of the Medication Administration Record revealed Tylenol 650 milligrams was administered on 11/01/2018 at 0627. Review of the medical record revealed no available documentation of a reassessment of the patient's response to the Tylenol medication intervention.

Interview on 11/01/2018 at 1030 with the Chief Nursing Officer (CNO) revealed the nursing staff were expected to document a response to any as needed, stat or now medication interventions to evaluate the effectiveness of the intervention. Interview revealed the nursing staff failed to follow the hospital policy for reassessment of responses to interventions. Interview revealed the nursing staff failed to reassess a patient's response to pain medication intervention within 60 minutes per hospital policy. Interview confirmed the above findings.

2. Review on 11/01/2018 of the open medical record for Patient #9 revealed a 72-year-old male admitted on 10/24/2018 at 2129 with a diagnosis of cellulitis. Review of the physician orders revealed orders written on 10/24/2018 at 2120 for Tylenol (pain medication) 650 milligrams by mouth every 4 hours as needed for pain or temperature. Review of the Medication Administration Record revealed Tylenol 650 milligrams was administered on 10/27/2018 at 1618. Review of the medical record revealed no available documentation of a reassessment of the patient's response to the Tylenol medication intervention.

Interview on 11/01/2018 at 1030 with the Chief Nursing Officer (CNO) revealed the nursing staff were expected to document a response to any as needed, stat or now medication interventions to evaluate the effectiveness of the intervention. Interview revealed the nursing staff failed to follow the hospital policy for reassessment of responses to interventions. Interview revealed the nursing staff failed to reassess a patient's response to pain medication intervention within 60 minutes per hospital policy. Interview confirmed the above findings.

3. Review on 10/31/2018 of the open medical record for Patient #2 revealed a 60-year-old female presented to the Emergency Department on 10/31/2018 at 0927 with a chief complaint of nausea and vomiting. Review of the physician orders revealed orders written on 10/31/2018 at 0952 for Ativan (anxiety medication) 2 milligrams intravenously now times one and Phenergan (nausea medication) 50 milligrams intramuscularly every 4 hours as needed for unresolved nausea and vomiting. Review of the Medication Administration Record revealed Ativan 2 milligrams was administered on 10/31/2018 at 1018 and Phenergan 50 milligrams was administered at 1058. Review of the medical record revealed no available documentation of a reassessment of the patient's response to the Ativan and/or Phenergan medication interventions.

Interview on 11/01/2018 at 1030 with the Chief Nursing Officer (CNO) revealed the nursing staff were expected to document a response to any as needed, stat or now medication interventions to evaluate the effectiveness of the intervention. Interview revealed the nursing staff failed to follow the hospital policy for reassessment of responses to interventions. Interview confirmed the above findings.

4. Review on 11/01/2018 of the open medical record for Patient #3 revealed an 103-year-old female admitted on 10/28/2018 at 1231 with a diagnosis of respiratory distress and left lower lobe pneumonia. Review of the physician orders revealed orders written on 10/30/2018 at 1853 for Ativan (anxiety medication) 0.5 milligrams intravenously every 4 hours as needed for agitation or anxiety. Review of the Medication Administration Record revealed Ativan 0.5 milligrams was administered on 11/01/2018 at 0535. Review of the medical record revealed no available documentation of a reassessment of the patient's response to the Ativan medication intervention.

Interview on 11/01/2018 at 1030 with the Chief Nursing Officer (CNO) revealed the nursing staff were expected to document a response to any as needed, stat or now medication interventions to evaluate the effectiveness of the intervention. Interview revealed the nursing staff failed to follow the hospital policy for reassessment of responses to interventions. Interview confirmed the above findings.

5. Review on 11/01/2018 of the open medical record for Patient #10 revealed a sixty year old male admitted on 10/31/2018 at 1941 with a diagnosis of foot infection and Diabetes type 2 (condition that affects the way the body processes blood sugar). Review of Physician order dated 10/31/2018 at 1943 revealed Glutose 40% gel 15 gram (medication used to treat low sugar) by mouth as needed per adult hypoglycemia protocol (protocol to treat low blood sugar). Review of the adult hypoglycemia protocol revealed administer 15 grams of Glutose for a BG (blood glucose) of 50-69 in alert patients and reassess BG in 15 minutes. Review of the documented BG dated 11/01/2018 at 1119 revealed a BG of 60. Review of the medication administration record dated 11/01/2018 at 1124 revealed Glutose 40% gel 15gm tube was administered. Review of the documented BG dated 11/01/2018 at 1237 (1hour and 3minutes after glutose was administered) revealed a BG of 142. Review of the medical record revealed no documentation of a BG reassessement within 15 minutes of Glutose administration.

Interview on 11/01/2018 at 1609 with CNO revealed staff were expected to follow the hypoglycemia protocol. Interview revealed the BG reassessment was "to far out the window" for reassessment per protocol. Interview revealed staff did not follow the hypoglycemic protocol.

6. Review on 10/31/2018 of the closed medical record for Patient #5 revealed a 71-year-old male admitted on 08/10/2018 at 1223 with a diagnosis of shortness of breath, fever, chills, nausea and vomiting. Review of the physician orders revealed orders written on 08/10/2018 at 1908 for Ativan (anxiety medication) 1 milligram by mouth twice daily as needed for anxiety. Review of the Medication Administration Record revealed Ativan 1 milligram was administered on 08/10/2018 at 2119. Review of the medical record revealed no available documentation of a reassessment of the patient's response to the Ativan medication intervention. Review of the physician orders revealed orders written on 08/10/2018 at 1939 for Lyrica (pain medication) 300 milligrams by mouth twice every 12 hours as needed for pain. Review of the Medication Administration Record revealed Lyrica 300 milligrams was administered on 08/11/2018 at 2129 and on 08/12/2018 at 1724. Review of the medical record revealed no available documentation of a reassessment of the patient's response to the Lyrica medication interventions.

Interview on 11/01/2018 at 1030 with the Chief Nursing Officer (CNO) revealed the nursing staff were expected to document a response to any as needed, stat or now medication interventions to evaluate the effectiveness of the intervention. Interview revealed the nursing staff failed to follow the hospital policy for reassessment of responses to interventions. Interview revealed the nursing staff failed to reassess a patient's response to pain medication intervention within 60 minutes per hospital policy. Interview confirmed the above findings.

7. Review on 11/01/2018 of the closed medical record for Patient #4 revealed a 35-year-old female admitted on 10/01/2018 at 0104 with a diagnosis of breathing difficulty, vomiting and weakness. Review of the physician orders revealed orders written on 10/01/2018 at 0054 for Ativan (anxiety medication) 2 milligrams intravenously every 4 hours as needed for anxiety and agitation. Review of the Medication Administration Record revealed Ativan 2 milligrams was administered on 10/02/2018 at 0744. Review of the medical record revealed no available documentation of a reassessment of the patient's response to the Ativan medication intervention. Review of the physician orders revealed orders written on 10/02/2018 at 1134 for Ativan (anxiety medication) 4 milligrams intravenously times one dose and call MD for severe agitation or seizures. Review of the Medication Administration Record revealed Ativan 4 milligrams was administered on 10/04/2018 at 0055. Review of the medical record revealed no available documentation of a reassessment of the patient's response to the Ativan medication intervention. Review of the physician orders revealed orders written on 10/06/2018 at 1321 for Klonopin (anxiety medication) 1 milligram tablet by mouth every 6 hours as needed for anxiety. Review of the Medication Administration Record revealed Klonopin 1 milligram was administered on 10/08/2018 at 0139. Review of the medical record revealed no available documentation of a reassessment of the patient's response to the Klonopin medication intervention.

Interview on 11/01/2018 at 1030 with the Chief Nursing Officer (CNO) revealed the nursing staff were expected to document a response to any as needed, stat or now medication interventions to evaluate the effectiveness of the intervention. Interview revealed the nursing staff failed to follow the hospital policy for reassessment of responses to interventions. Interview confirmed the above findings.

NC00142707