HospitalInspections.org

Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure that a registered nurse performed a patient's initial assessment for 1 of 8 patients reviewed (Patient #1). Failure to ensure a registered nurse performed the initial assessment could potentially result in the nursing staff failing to identify the patient's nursing care needs and implement appropriate nursing interventions. The CAHs administrative staff identified an initial census of 7 inpatients upon entrance.

Findings include:

1. Review of the policy, "RN/LPN Scope of Practice," approved 7/2021, revealed in part, "The RN is accountable for the plan, direction, and supervision of call for all patients."

2. Review of the Job Description, "LPN," last updated 4/9/2021, revealed in part, " Under the direction and supervision of the Registered Nurse...Licensed Practitioner follows the nursing process ...contributes to the RN initial assessment and may perform re-assessment."

3. During a review of the medical record for Patient #1 revealed, Patient #1 was transferred from another facility to this CAH and admitted to swing bed for rehabilitation post-surgery. Patient #1 arrived at 4:37 PM on 4/13/2022. Initial assessment was performed by Licensed Practicing Nurse (LPN) A at 5:00 PM.

4. During an interview on 6/14/2022 at 2:32 PM with Patient #1 acknowledged LPN A did the initial assessment when they arrived.

5. During an interview on 6/15/2022 at 10:30 AM with Vice President (VP) of Patient Care Services, acknowledged RN C did not document the initial assessment, it was documented by LPN A.

Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure all medications were prepared and administered on the orders of a physician responsible for the patients care and acceptable standards of practice for 1 of 8 inpatients during a closed medical records reviewed (Patient #1). Failure to obtain a doctor's order may result in a patient not receiving medication in alliance with the doctor's plan for medical treatment and not be the appropriate medication type, dose, route, and time potentially resulting in a severe adverse reaction and/or death. The hospital's administrative staff identified a current census of 7 inpatients upon entrance.

Findings include:

1. Review of the "Medical Staff Bylaws", approved by the medical staff and governing body 6/2021, revealed in part, "All entries shall be accurately dates, times and signed by the author."

2. Review of policy, "Provider Orders-Receiving, Clarifying and Reviewing", approved 4/2021 revealed in part, "The nurse who is assigned to the patient is accountable for completion of orders." "Faxed orders will be scanned or placed into the medical record upon receipt." "Implementation of orders will be in a timely manner ..."

3. Review of policy, "Pain Management", approved 12/2020 revealed in part, "All patients have the right to receive adequate and appropriate pain management." " ...all health care professionals involved in the care of the patient have a role in the ongoing management of the patient's pain ..."

4. During a review of the medical record for Patient #1 revealed, Patient #1 was transferred from another facility to this CAH and admitted to swing bed for rehabilitation post-surgery. Patient #1 arrived at 4:37 PM on 4/13/2022. Initial assessment and pain assessment was performed by Licensed Practicing Nurse (LPN) A at 5:00 PM. Patient #1 was to receive 650 milligrams (mg) Tylenol on 4/13/2022 at 5:00 PM per surgeon's orders. Patient #1's initial assessment documented pain level was 1, Patient #1 did not receive Tylenol until 4/14/22 at 2:44 AM, which the Patient #1's pain level was a 5. Patient #1 was also to receive amiodarone 200 mg, biotin 10 mg, montelukast 10mg, simvastatin 10mg, megastrol 30 milliliters (ml), guaifenesin 600mg, docusate-senna 100mg, on 4/13/2022 when Patient #1 arrived at the hospital per discharge instruction from transferring hospital.

5. During an interview on 6/14/2022 at 2:32 PM with Patient #1 revealed, Patient #1 inquired about her medication including pain medication several times due to surgeon's discharge instruction which accompanied Patient #1 from the other hospital. Patient #1's daughter was present until approximately 8:00 PM on 4/13/2022. Patient #1 and Patient #1's daughter were told, the nurse is just down the hall and should have the medication shortly.

6. During an interview on 6/15/22 at 7:32 AM with Patient #1's Daughter revealed, Patient #1's Daughter received a phone call at 2:00 AM from Patient #1 stating that no medication has been given yet and Patient #1's pain level was very uncomfortable. Patient #1 was very upset and wanted to be removed from the facility. Patient #1's Daughter tried to call the supervisor and no answer, but was able to reach RN G. RN G acknowledged no orders placed in the system for Patient #1 at that time but would look into the problem.

7. During an interview on 6/14/22 at 6:00 PM with Physician B revealed, all orders should be in the system 1 to 2 hours after a person information is received by physician. If a person is transferred from a facility that does not use Epic (Electronic Medical Record) physicians have to enter all orders in the system, but it should still only take 1 to 2 hours once patient is settled in a room. If the patient needs something right away, the RN would make a call to the physician to get that order in, such as pain medication.

8. During an interview on 6/15/22 at 10:30 AM with VP of Patient Care Services acknowledged there was a delay in getting the orders in the system and no incident report was filed.