HospitalInspections.org

Based on interview and record review, the facility's registered nurse (RN) did not supervise and evaluate the nursing care for 2 of 2 patients (Patients #2 and #3) in that:

A. Patient #2's RN did not promptly reassess the patient after administering medications twice on 11/6/16, citing 1 of 2 RNs (Personnel #11).

B. Patient #3 did not have an RN admission assessment within 8 hours of admission. Citing 1 of 2 RNs (Personnel #12).

Findings Included:

A. Patient #2 was admitted on 11/3/16 for alcohol detoxification.

Medication Administration Record (MAR) dated 11/6/16 at 1:00 AM and at 9:35 AM indicated Patient #2 received Tylenol 650mg for pain. The nurse's notes reflected no reassessment for pain medication effectiveness by Personnel #11

During an interview on 1/17/17 at 1:05 PM Personnel #8 confirmed there was not any follow up after the medication was administored.

The Pain Assessment and Management policy dated 1/23/06 and revised 7/09 reflected... Patients shall be reassessed within 45 minutes following any pain relief interventions ...

B.Patient #3 was admitted on 11/19/16 for Schizoaffective disorder, Bipolar type; Schizophrenia, catatonic type.

Patient #3's medical record reflected an admission date of 11/19/16 at 5:45 PM. The Admission Nursing Assessment reflected"...11/19/16 9:30 PM, Patient refused". Patient #3's admission assessment did not reflect any other attempts to complete the admission assessment.

During an interview on 1/17/18 at 3:15 PM Personnel #8 confirmed the admission assessment was not completed within 8 hours of admission. Personnel #8 was asked how many times the nurse is required to attempted to complete the admission assessment. Personnel #8 responded "we are required to try 3 times within 8 hours."

The Patient Assessment/Reassessment policy dated 1/23/06, and revised 7/09 reflected "...The nursing assessment is initiated and completed within the first 8 hours of admission..."

Based on interview and record review, the facilities Registered Nurse (RN) did obtain a physician's order for a drug for 1 of 1 patients (Patient #2), in that Personnel #10 did not obtain a physician's order to change Patient #2's oxygen from a nasal cannula to a face mask.

Findings Included:

Nurses notes dated 11/6/15 at 1:25 AM reflected...Patient indicated he did not like the nasal cannula up his nose. Patient was switched to a face mask...

During an interview on 1/17/17 at 1:05 PM Personnel #8 was informed of the above findings. Personnel #8 verified there was no physicians order to change the oxygen from a nasal cannula to a face mask.

The Drug Administration, General Guidelines policy, dated 1/23/06; revised 3/16 reflected...b. Drugs should be administered to patients only upon the receipt of the order from a practitioner who has clinical privileges and is legally authorized to prescribe/order drugs.

Based on interview and record, the hospital failed to complete a discharge summary within 30 days, in that 1 of 10 (Patient #4) patient's discharge summary was not completed within 30 days following discharge.

Findings Included:

Patient # 4's medical reflected no order for discharge, the last time Patient #4 had any information charted was on 11/7/16. As of 1/18/17 there was not a discharge summary in the medical record.

During an interview on 1/18/17 at 10:30 AM, Personnel #1 was informed of the above findings. Personnel #1 verfied there was not a discharge summary in the medical record.