HospitalInspections.org

Based on medical record and policy review, nursing staff failed to implement the following Physician ' s Orders:
1. Turn and position Patient #1 every two hours, and
2. Obtain vital signs for Patient #21 every four hours.

Findings include:

1. Review of Physician Orders for Patient #1 revealed orders, dated 03/23/14 at 9:47am, 04/04/14 at 4:46am and 04/20/14 at 11:39pm, to change the patient ' s position every two hours and decubitus precautions nursing care.

Review of turning and positioning documentation, dated 03/23/14 through 05/01/14, revealed that Patient #1 was not turned and positioned every two hours as ordered on 03/27-29/14, 04/01/14, 04/05-06/14, 04/09-10/14 and 04/14/14.

Review of facility policy "Skin Assessment and Wound Prevention Guidelines- CSC0050", effective 02/21/14, revealed prevention measures will be implemented for all patients identified at risk according to the Braden Risk Assessment. Patients who are bed bound should be turned and repositioned every two hours and more frequently if needed.

2. Review of Physician Orders for Patient #21 revealed an order, dated on 04/10/14 at 11:50pm, to obtain the patient ' s vital signs every four hours.

Review of vital sign documentation, dated 04/11-17/14, revealed that Patient #21 ' s vital signs were not obtained every four hours as ordered for these dates.
Review of facility policy "Catholic Health Nurse Standards of Care for Medical Surgical/Critical Care Units-CSC032", effective 04/29/14, revealed vital signs including temperature, pulse, respirations and blood pressure are taken every 8 hours or as otherwise ordered by a provider.

Based on medical record review, nursing staff failed to ensure that medications were administered in accordance with Physician Orders for Patient #14.

Findings include:

Review of the medical record for Patient #14 revealed the following medication orders:

-"Amiodarone 400mg PO Q 8 HRS (by mouth, every 8 hours) for 30 days" was ordered by the Nurse Practitioner on 8/12/14 at 10:52am.

-"Amiodarone 400mg PO Q 8 HRS for 5 days, Clinician Dir: (directive) reduce to 400mg BID (twice a day) for five days starting 8/17" was ordered by the Physician ' s Assistant on 8/16/14 at 11:28am.

The medication administration record for Patient #14 revealed that on 8/17-19/14 Amiodarone 400mg was administered at 5:00am, 1:00pm and 9:00pm.