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HCA FLORIDA BAYONET POINT HOSPITAL
PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION
Tag No.: A0133
Based on record review, facility policy review and interviews it was determined the facility failed to ensure a patient's legal representative was notified of changes in condition for one (#1) of ten sampled patients. The facility had no policy addressing notification of the patient's personal primary care physician
Findings included:
On 02/22/2016 at 2:30 p.m. a review of the patient's medical record for admissions dated 11/30/2015 to 12/07/2015; 12/14/2015 to 01/12/2016 and 01/14/2016 to 02/09/2016 revealed during the 12/15/2015 admission the patient developed a redden area on the sacrum area. There was no documentation the patient's legal representative or attending physician was notified of the change in condition.
On 02/23/2016 at 10:00 a.m. an interview with the Director of Patient Safety/Risk Management confirmed the above findings
On 02/23/2016 at 10:00 an interview with the Vice President of Quality and the Director of Patient Safety/Risk Management confirmed the facility did not have a policy regarding the notification of a patient's personal primary care physician whether on staff or not at the facility of an admission.
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on record review, facility policy review and interviews it was determined the registered nurse failed to supervise and evaluate nursing care related to implementing the policies regarding daily weights and medication administration for one (#1) of ten sampled records.
Findings included:
On 02/22/2016 at 2:30 p.m. a review of patient #1's medical record from 11/30/2015 to 12/07/2015 revealed the physician ordered Norvasc to be given daily at 9:00 a.m. On 12/1/2015 the medication was given at 10:38 a.m., 38 minutes past the policy time frame. A detailed review of the medical record revealed no documentation why the medication was given late. There was no documentation the physician was notified of the late administration per facility policy title " Medication Management-Administration and Monitoring".
On 02/22/2016 at 2:30 p.m. a review of patient #1's medical record from 12/15/2015 to 01/12/2016 and 01/14/2016 to 02/19/2016 revealed the patient was on a daily diuretic (Lasix). There was no documentation of daily weights as required per facility policy titled "Medical Surgical Standards of Care".
On 02/23/2016 at 10:00 a.m. an interview with the Vice President and Director of Patient Safety/Risk Management confirmed the above findings.