HospitalInspections.org

Based on clinical and administrative record review and staff interview, the facility failed to ensure the nursing staff enforced the standards of nursing practice and related policies and procedures regarding conducting the appropriate assessments with as needed medications for 2 of 3 sampled patients (Patient # 1 and # 3).

The findings included:

The facility's policy regarding Medication Administration, revised as of 10/11/2018 documented, "Each patient's response to medication is monitored according to his or her clinical needs. All PRN (as needed) medication will be reassessed within the acceptable timeframes for the given dose and route. Generally, this is 60 minutes for all routes. Indications for all PRN medication doses administered will be documented in the eMAR."

1) Review of the clinical record for Patient # 3 revealed the physician prescribed for the patient to receive Hydrocodone-acetaminophen (NORCO) 5-325 mg per tablet one tablet every 6 hours as needed. A random check of the Medication Administration Record revealed that the nurses failed to follow the standards of practice by failing to perform a timely reassessment after administering the as needed pain medication on 2 of 4 doses as follows:

04/30/19 at 4:09 AM, the nurse administered the as needed pain medication for back pain at level 8 on a scale of 1-10. There is no evidence the nurse re-assessed the effectiveness of the medication within the 60 minutes of administering the medication.

04/29/19 at 4:31 AM, the nurse administered the as needed pain medication for back pain at level 10. There is no evidence the nurse re-assessed the effectiveness of the medication within the 60 minutes of administering the medication.

An interview was conducted on 04/30/19 at approximately 12:00 PM with the Director of Risk Management and the Director of Pulmonary Services, who confirmed the nurses did not follow the standards of practice to reassess the patient's level of pain within one hour of administering the as needed pain medication.


2) Review of the clinical record for Patient # 1 revealed that the physician prescribed for patient to receive Ativan 0.5 mg by mouth every 8 hours as needed. Further review of the Medication Administration Record documented the nurse administered the Ativan 0.5 mg to Patient # 1 on 04/04/19 at 9:31 PM and 04/05/19 at 1:14 PM. However there is no evidence the nurses followed the facility standards of practice to assess the patient following the administration of as needed medication.

An interview was conducted on 04/30/19 at approximately 4:00 PM with the Inpatient, Pulmonary Director, who confirmed the facility focus for as needed medication has been pain medication and have not enforced the standard of practice to assess the patient post all as needed medications.

An interview was conducted on 04/30/19 at 4:20 PM with the Staff A, Registered Nurse. She confirmed that she was the nurse who administered the as needed Ativan on 04/05/19 at 1:14 PM dose of the medication. She confirmed that she did not reassess the patient after administering the medication; nor did she reassess the patient prior to discharge at 4:00 PM to determine the patient's status prior to discharge. She stated that the patient was "anxious about everything". She stated they complete pain assessments after administering pain medications but "other meds, we don't necessarily do."

Based on clinical and administrative record review and staff interview, the facility staff failed to ensure the nursing staff enforced the standards of nursing practice and related policies and procedures regarding following the prescribed physician orders for 1 of 3 sampled patients (Patient # 3).

The findings included:

1) Review of the clinical record for Patient # 3 revealed the physician prescribed a sliding scale scale coverage for abnormal blood sugars which included the following:
On 04/23/19 the physician prescribed Lispro (Humalog) injection 0-10 units four times daily before meals and bedtime.
0-150 mg/dl = 0 units of insulin
151-200 mg/dl = 2 units of insulin
201-250 mg/dl = 4 units of insulin
251-300 mg/dl = 6 units of insulin
301-350 mg/dl = 8 units of insulin
351-400 mg/dl = 10 units of insulin
Greater than 400, give 10 units of insulin and contact the doctor

On 04/28/19 at 7:26 AM, a Blood Sugar of 142 was documented. However according to the Medication Administration Record, the nurse documented she administered 6 units of insulin on 04/28/19 at 7:45 AM. Based on the documented blood glucose, the patient did not require insulin coverage.


An interview was conducted on 04/30/19 at approximately 12:00 PM with the Director of Risk Management and the Director of Pulmonary Services, who stated, the nurse must have misread the blood glucose at 7:42 AM and gave insulin based on the previous blood sugar and not the current blood sugar.