HospitalInspections.org

Based upon record review and interview; the facility failed to ensure drugs were administered in accordance with accepted professional principles for 1 (Patient #1) of 10 sampled patients. The facility failed to monitor blood pressure and administer medications as ordered.

The findings include:

1) Record review on 11/21/13 of Patient #1 ' s medical record revealed the patient was admitted on 9/24/13 with symptoms of an acute stroke. Tests revealed a right frontal CVA as well as a right carotid dissection. The patient was admitted to the ICU (intensive care unit) for critical care management.

Patient #1 ' s "Physician Orders" include PRN (as needed) "Labetalol" 10 mg (milligrams) by IV (intravenous) every 2 hours for a systolic blood pressure (SBP) that was over 160. This order was begun on 10/2/13 at 8:27 a.m.

a) Patient #1 ' s "Critical Care Flowsheet " dated 10/4/13, documents the patient's BP of 168/72 at 2:00 p.m. The "Medication Administration Record" dated 10/4/13 has no documentation that Labetalol was given at this time.

Patient #1 ' s "Critical Care Flowsheet" dated 10/4/13 documents the patient's BP of 171/76 at 3:00 p.m. The "Medication Administration Record" dated 10/4/13 documented Labetalol was given at this time. The Labetalol given was also noted in the Nurses Notes; the patient was re-assessed at 3:30 p.m., and had a BP of 160/72.

Patient #1 ' s "Critical Care Flowsheet" dated 10/4/13, documents the patient's BP of 176/78 at 4:00 p.m. The "Medication Administration Record" dated 10/4/13 documents Hydralazine 10 mg was given at 4:39 p.m. after the Labetalol was ineffective.

Patient #1 ' s "Critical Care Flowsheet" dated 10/4/13, documents the patient's BP of 161/67 at 5:00 p.m. The "Medication Administration Record" dated 10/4/13 has no documentation that Labetalol was given at this time.

Patient #1 ' s "Critical Care Flowsheet" dated 10/4/13, documents the patient's BP of 167/75 at 6:00 p.m. The "Medication Administration Record" dated 10/4/13 has no documentation that Labetalol was given at this time.

Patient #1 ' s "Critical Care Flowsheet" dated 10/4/13, documents the patient's BP of 175/71 at 7:00 p.m. The "Medication Administration Record" dated 10/4/13, documented Labetalol was given at this time as ordered by the physician. The Labetalol given was also noted in the Nurses Notes; however, the time noted in the nursing notes was 2000 and not the 1900 as given on the MAR. Also the MAR documents that the Hydralazine was given at 2014, which was 4 hours early. There is no order from the physician stating it is alright to give this medication early.

Patient #1 ' s "Critical Care Flowsheet" dated 10/4/13, documents the patient's BP of 177/78 at 10:00 p.m. The "Medication Administration Record" dated 10/4/13 has no documentation Labetalol was given at this time.

Patient #1 ' s "Critical Care Flowsheet" dated 10/4/13, documents the patient's BP of 171/70 at 3:00 a.m. The "Medication Administration Record" dated 10/4/13, has no documentation Labetalol was given at this time.

Patient #1 ' s "Critical Care Flowsheet" dated 10/4/13, documents the patient's BP of 182/73 at 5:00 a.m. The "Medication Administration Record" dated 10/4/13 has no documentation Labetalol was given at this time.

On 10/4/13 from 8:00 a.m. until 10/6/13 at 7:00 a.m., - Patient #1 ' s BP was documented with a systolic BP over 160 9 times. The "Medication Administration Record" only documented Labetalol was given twice. The patient ' s blood pressure was not documented on 10/4/13 at 8:00 p.m. and on 10/5/13 at 4:00 a.m., 6:00 a.m., and 7:00 a.m.

b) Patient #1 ' s "Critical Care Flowsheet " dated 10/5/13, documents the patient's BP of 198/78 at 8:00 a.m. Nurse #1 documented Labetalol was given on the Critical Care Flowsheet. The "Medication Administration Record" dated 10/5/13 documented Labetalol was given at 0805 for a BP of 182/74.

Patient #1 ' s "Critical Care Flowsheet" dated 10/5/13, documents the patient's BP of 187/80 at 9:00 a.m. Nurse #1 documented Labetalol was given on the Critical Care Flowsheet; however, the "Medication Administration Record" dated 10/5/13, has no documentation Labetalol was given at this time. If this dose was given at 0900 as written on the "Critical Care Flowsheet" it would have been given only 1 hour after the last dose. The Physician Order for Labetalol order is to be given as needed "every 2 hours."

Patient #1 ' s "Critical Care Flowsheet" dated 10/5/13, documents that the patient's BP of 162/68 at 10:00 a.m. The "Medication Administration Record" dated 10/5/13 has no documentation Labetalol was given at this time.

Patient #1 ' s "Critical Care Flowsheet" dated 10/5/13, documents the patient's BP of 169/70 at 12 p.m. The " Medication Administration Record" dated 10/5/13 has no documentation Labetalol was given at this time.

Patient #1 ' s " Critical Care Flowsheet" dated 10/5/13, documents the patient's BP of 169/70 at 1:00 p.m. The "Medication Administration Record" dated 10/5/13 has no documentation Labetalol was given at this time.

Nursing notes document that on 10/5/13, "Labetalol" was given at 2:00 p.m. for "blood pressure" with BP of 151/75. This dose should not be given as the physician orders are to give Labetalol for an SBP over 160.

Patient #1 ' s "Critical Care Flowsheet" dated 10/5/13, documents the patient's BP of 167/71 at 3:00 p.m. The "Medication Administration Record" dated 10/5/13 has no documentation Labetalol was given at this time.

Patient #1 ' s "Critical Care Flowsheet" dated 10/5/13, documents the patient's BP of 187/78 at 4:00 p.m. Nurse #1 documented Labetalol was given on the Critical Care Flowsheet; however, the "Medication Administration Record" dated 10/5/13, has no documentation Labetalol was given at this time.

Patient #1 ' s "Critical Care Flowsheet" dated 10/5/13, documents the patient's BP of 154/76 at 5:00 p.m. The "Medication Administration Record" dated 10/5/13, documented Labetalol was given at 5:26 p.m. for a BP of 190/79. Nursing notes document that on 10/5/13, the "BP was 190 systolically and Labetalol ineffective."

On 10/5/13 from 8:00 a.m. until 10/6/13 at 7:00 a.m., Patient's #1 BP was recorded on the "Critical Care Flowsheet" with a SBP over 160 7 times and the "Medication Administration Record" only documented Labetalol was given twice. There were 2 doses of Labetalol recorded on the "Critical Care Flowsheet" as given, but no documentation in the "Medication Administration Record" as administered.

In an interview on 11/21/13 at 3:00 p.m. the Director of the ICU stated "Medications should be given within 30-45 minutes of noticing the elevated BP." She confirmed that Patient #1 should be monitored for BP every hour by the nurse. She stated that Patient #1 "should receive the Labetalol as ordered every 2 hours for a systolic BP over 160 as per the physician orders. " The Director stated that the "nursing notes, medication administration records and the Critical Care Flowsheets should all flow in a progressive order." She admitted the documentation for Patient #1 on 10/4/13 and 10/5/13 "is a mess" and "does not match." She stated it would be "very difficult to re-create the timeline to understand what is going on." She stated she has "not been monitoring any issues in the ICU related to charting and consistent documentation, but she will probably begin that soon."

In an interview on 11/21/13 at 6:00 p.m., the Director of Quality Assurance (QA) said they have been auditing nursing and physician records, but have not found any issues like this. She stated "In the absence of an electronic record; it is difficult to document everything." She added "the fold-out forms get broken down and don't have dates on everything." She stated "They are moving towards the CPOE (computerized physician order entry) and nursing admission assessments electronically in January 2014."

In an interview via teleconference on 11/22/13 at 8:00 a.m., Nurse #1 said she did care for Patient #1 on 10/4/13 from 7:00 a.m. until 7:00 p.m. She said the patient was post-stroke in the ICU and required constant interventions through medications and observations. Nurse #1 admitted some of her documentation is not complete, documentation is inconsistent, and her notes do not reflect the care or medications that were given.
Nurse #1 said she was in the room every hour. She states that the reason why she did not treat the high BP on the flow sheet was because she "recycled" or "re-took" the BP - but she did not document the lower BP. She states that on 10/5/13 at 4:00 p.m., she "remember giving the Labetalol - but the patient medication system did not record the intervention."

Review of the policy titled "Medication Administration" revealed "each dose of medication shall be recorded properly in the patient's medical record" and "the MAR is used to document medications that are administered to patients."

The facility failed to ensure that the blood pressure medication Labetalol was given as ordered and failed to ensure accurate documentation for Patient #1.