HospitalInspections.org

Based on review of the Texas Nursing Practice Act, review of medical records and staff interview, the facility failed to ensure drugs were administered in accordance with the orders of a practitioner responsible for the patient's care and accepted standards of practice.


Findings included:

Texas Nursing Practice Act amended September 2017 stated in part, "Professional nursing means the performance of an act that requires substantial specialized judgment and skill ... The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. Profession nursing involves:
...(C) the administration of a medication or treatment as ordered by a physician ..."

Review of the medical record for patient #1 revealed a physician order dated 10/26/19 at 12:49 am that stated in part, "D10W [dextrose in water, an infusion to increase blood sugar] start at 11 mL/hr [milliliters per hour]."
Nursing note dated 10/26/19 at 2:25 am stated in part, "Increase pump continuous 13.5 ml/hr."

Physician order dated 10/26/19 at 6:26 am stated in part, "D12.5% 250 mL at 15 ml/hr."
Nursing note dated 10/27/19 at 10:20 am stated in part, "Orders recd [received] to increase IV fluids to 16ml/hr."

There were no orders signed by the physician indicating the increases in rate.

Review of the medical record for patient #10 revealed an order dated 11/1/19 at 3:44 am that stated in part, "D10W at 7 mL/hr." Nursing notes indicated increases in the rate at 4:21 am, 4:53 am, and 7:26 am without signed orders by the physician.

In an interview with staff #12 on the afternoon of 2.12.20, when asked if there were orders for the increases in rate, they agreed there were no orders. They stated, "The nurses call the doctors with results, the doctor orders the increase. The nurses document in their nurse's note." When asked if the doctor signs an order for the increase, they verified there were no signed orders. When asked if there was a policy or protocol for the titration of the medication, they denied there were any.

In an interview with staff #11 on the afternoon of 2.12.20, when asked if there were other medications nurses titrated, they stated, "Yes, we have a protocol we follow. If it gets above a certain level, we call the doctor ..." When asked if there was a protocol or policy for the dextrose infusion, they denied there were any.

In an interview with staff #2, 11, 12, and 13 on the afternoon of 2.12.20, when asked if there were orders for the increase in rates for the above infusions, they verified there were no signed orders. When asked if there were policies or protocols related to the titration of the medication, they denied there were any.

Without signed orders, there was no evidence the physicians responsible for the care of the patients were aware of the increases in rates of the dextrose infusions.