HospitalInspections.org

Based on document review and interview, nursing services failed to ensure supervision of nursing care by failing to perform one of the 5 rights, right dose, for 1 medical record (MR) reviewed (P9); and failed to ensure completion of an incident report (IR) related to patient leaving against medical advice (AMA) in 1 out of 10 patient MRs reviewed (P9).


Findings include:

1. Facility Policy/procedure titled, "Medication Administration and Management," publication date 05/08/2023, indicates the following:
VI. Procedures:
Administration:
B. The team member administering medications must perform the 5 rights plus 4 checks (9 rights) on all medications prior to administering them to a patient. This includes right patient, right medication, right dose, right time, right route, right documentation, right action, right form, and right response. If bar code scan technology is available, scan patient identification band and patient medication.

2. Facility Policy/procedure titled, "Patient Leaving Against Medical Advice (AMA)," publication date 02/01/2023 indicates under:
Policy:
VI. PROCEDURES:
A. The patient requests to leave AMA.
5. Complete an incident report in the web-based incident reporting system.

3. Review of P9 MR indicated the patient was admitted on 08/27/24:
a. On 08/27/24 at 1202 hours P9 had orders to be nothing by mouth (NPO) except sips of water and Lactated Ringers 110 milliliters (ml) per hour, continuous infusion.
On 08/27/24 MR indicated 605.57 ml was infused. Per order, it should have infused 1320 ml over 12 hours.
On 08/28/24 at 0826 hours, P9 had an order for clear liquid diet, start no fluid restrictions, and Dextrose 5% Sodium Chloride 0.45% PREMIX + Potassium Chloride PREMIX IV (Intravenous) continuous 84 ml per hour. On 08/28/24 MR indicated 1218.42 ml was infused over 24 hours. Per order, it should have infused 2016 ml over 24 hours.
On 08/29/24 at 0721 hours, P9 had an order for full liquid diet, no fluid restrictions, and Dextrose 5% Sodium Chloride 0.45% PREMIX + Potassium Chloride PREMIX IV continuous 42 ml per hour. On 08/29/24 MR indicated 606.49 ml was infused. Per order, it should have infused 1008 ml over 24 hours.
On 08/30/24 at 0528 hours, P9 had an order to be NPO except ice chips and Dextrose 5% Sodium Chloride 0.45% PREMIX + Potassium Chloride PREMIX IV continuous 84 ml per hour. On 08/30/24 MR indicated 470.24 ml was infused. Per order, it should have infused 2016 ml over 24 hours.
On 08/31/24 at 0528 hours, orders continue from 08/30/24, NPO except ice chips and Dextrose 5% Sodium Chloride 0.45% PREMIX + Potassium Chloride PREMIX IV continuous 84 ml per hour. On 08/31/24 MR indicated 782.85 ml was infused. Per order, it should have infused 2016 ml over 24 hours.
On 09/01/24 at 1737 hours, P9's diet was changed to NPO except medications, Dextrose 5% Sodium Chloride 0.45% PREMIX + Potassium Chloride PREMIX IV continuous 125 ml per hour. On 09/01/24 MR indicated 0 ml was infused. Per order, it should have infused 3000 ml over 24 hours.

b. P9 MR indicated on discharge summary P9 requested to leave F1 against medical advice (AMA). MR indicated P9 had the capacity to leave AMA; they signed the AMA form and left. P9 was not medically ready to leave, but left AMA, not tolerating PO and with concern for anastomotic stricture.

4. Review of Incident Report Logs from 03/05/24 - 09/05/24 lacked trends related to allegations and indicated there were no incidents related to patients reviewed.

5. Interview with A1 (Manager Accreditation & Regulatory), on 10/08/24 at 4:15 p.m., confirmed there were no IR's related to P9 leaving AMA.

6. Interview with A2 (Clinical Nurse Specialist), on 10/08/24 at 4:30 p.m., confirmed P9's IV fluids were not given per physician order.