HospitalInspections.org

Based on medical record review, policy review and staff interview, it was determined that for 2 of 5 (40%) patients (Patient #'s 3 and 4) in the sample, nursing staff failed to administer medications in accordance with physician orders. Findings include:

The hospital policy entitled "Medication Ordering, Dispensing and Administration" stated, "...Each dose of medication administered must be properly recorded in the patient's medical record..."

The hospital policy entitled "Hospital Plan for Provision of Nursing Care" stated, "...Nurses engage in an infinite number of activities...Activities critical to the provision of patient care activities include...Implementation and management of physician's orders..."

A. Patient #3
Review of Patient #3's medical record revealed physician orders for:
1. Topamax 50 mg (milligrams) by mouth twice a day, dated 7/29/11
2. Clonidine 0.05 mg twice a day, dated 8/4/11
3. Cogentin 2 mg twice a day dated 9/3/11

Review of the hospital documents entitled "Medication Administration Record" and "Nursing Documentation" revealed no evidence that the following medication doses were administered on 9/7/11 at 9:00 AM as ordered by the physician:

1. Topamax 50 mg
2. Clonidine 0.05 mg
3. Cogentin 2 mg

These findings were confirmed with the Chief Nursing Officer during a review of Patient #3's medical record on 9/12/11 at 4:52 PM.

B. Patient #4
Review of Patient #4's medical record revealed physician orders for:
1. Combivent 2 puffs four times a day, dated 3/21/11
2. Prilosec 40 mg every morning, dated 3/22/11

Review of the hospital documents entitled "Medication Administration Record" and "Nursing Documentation" revealed no evidence that the following medication doses were administered according to the physician's order:

1. Combivent 2 puffs on 3/23/11 at 9:00 PM
2. Prilosec 40 mg on 3/22/11

These findings were confirmed with the Chief Nursing Officer during a review of Patient #4's medical record on 9/12/11 at 4:40 PM.

Based on medical record review, policy review and staff interview, it was determined that for 3 of 5 (60%) patients (Patient #'s 1, 2 and 4) in the sample, the medical record contained illegible entries. Findings include:

The hospital policy entitled "Chart Documentation Requirements" stated, "...documentation is to be concise, legible, and accurate...Each entry is to be dated and timed..."

Medical record review revealed the following illegible entries:

A. Patient #1

1. The times of the order authentications for the 7/29/11 9:00 AM and 11:59 AM telephone orders were illegible.

This finding was confirmed with the Chief Nursing Officer on 9/8/11 at 3:50 PM.

B. Patient #2

1. The "Psychiatric Progress Note" dated 7/18/11 contained physician entries which were illegible.

This finding was confirmed with the Chief Nursing Officer on 9/9/11 at 2:00 PM.

C. Patient #4
1. The "Psychiatric Progress Note" dated 3/24/11 contained physician entries which were illegible.

This finding was confirmed with the Chief Nursing Officer on 9/8/11 at 4:20 PM.

Based on medical record review, policy review and staff interview, it was determined that the hospital failed to ensure that physician orders for 4 of 5 (80%) patients (Patient #'s 1, 2, 3 and 4) in the sample, were dated and/or timed at the time of medical record entry or authentication. Findings include:

The hospital policy entitled "Verbal/Telephone Orders" stated, "...only licensed nurses may accept telephone or verbal orders from physicians...physician...responsible for authenticating the order within 24 hours of the verbal/telephone order...nurse receiving the verbal/telephone order must ensure that the order is dated, timed, at time of entry...the physician will authenticate, date, time and sign the order."

The hospital policy entitled "Chart Documentation Requirements" stated, "...Each entry is to be dated and timed, with the discipline writing the note identified..."

Medical record review revealed the following:

A. Patient #1
1. The physician failed to document the time of order authentication for the following telephone orders:
- 7/16/11 10:33 PM
- 7/17/11 6:54 AM
- 7/20/11 9:30 PM

2. The physician failed to document the date and time of order authentication for the telephone order given 7/21/11 at 4:30 PM.

These findings were confirmed with the Chief Nursing Officer on 9/8/11 at 3:50 PM.

B. Patient #2
The physician failed to document the time of order authentication for two (2) telephone orders given 7/15/11 at 1:30 AM.

These findings were confirmed with the Chief Nursing Officer on 9/9/11 at 1:57 PM.

C. Patient #3
The physician failed to document the time of order authentication for the following telephone orders:
- 7/29/11 2:40 AM (two telephone orders)
- 9/1/11 11:39 AM

These findings were confirmed with the Chief Nursing Officer on 9/12/11 at 4:50 PM.

D. Patient #4
1. The physician failed to document the date and time of order authentication for the following telephone orders:
- 3/21/11 1:55 PM
- 3/21/11 4:00 PM
- 3/22/11 10:30 AM
- 3/24/11 1:10 PM

2. The nurse failed to document the time of a telephone/verbal order dated 3/21/11. In addition, the physician failed to document the date and time this telephone/verbal order was authenticated.

3. The physician failed to document the time of the order written on 3/22/11 for "Prilosec 40 mg PO QAM".

These findings were confirmed with the Chief Nursing Officer on 9/12/11 between 4:10 and 4:40 PM.

Based on medical record review, policy review and staff interview, it was determined that for 2 of 5 (40%) patients (Patient #'s 1 and 4) in the sample, the medical record lacked evidence of a medical history and physical examination or a psychiatric assessment within 24 hours of admission. Findings include:

The hospital policy entitled "Chart Documentation Requirements" stated, "...Required documentation consists of the following...Initial evaluations completed no later as designated after admission for the following...Physician 24 hours...Psychiatric Assessment completed within 24 hours of admission..."

Medical record review revealed the following:

A. Patient #1 - Admitted 7/15/11 at 1:15 AM
The physician did not complete the medical history and physical examination until 7/16/11 at 1:00 PM (35 hours and 45 minutes after admission).

The Director of Risk Management and Performance Improvement confirmed this finding on 9/8/11 at 1:47 PM.

B. Patient #4 - Admitted 3/21/11 at 2:54 PM
The psychiatrist did not complete the initial psychiatric assessment until 3/23/11.

The Chief Nursing Officer confirmed this finding on 9/8/11 at 4:00 PM.

Based on medical record review, policy review and staff interview, it was determined that for 2 of 5 (40%) patients (Patient #'s 4 and 5) in the sample, the medical record failed to contain the results of laboratory testing necessary to monitor each patients' condition. Findings include:

The hospital policy entitled "Hospital Plan for Provision of Nursing Care" stated, "...Nurses engage in an infinite number of activities...Activities critical to the provision of patient care activities include...Implementation and management of physician's orders..."

A. Patient #4

Review of the "Physician's Admission Orders" revealed a physician order dated 3/21/11 for routine lab work including a chemzyme, complete blood count with differential, RPR (a screening test for syphilis) and thyroid level. No evidence was found to indicate that blood specimens were obtained and sent to the lab for testing.

This finding was confirmed with the Chief Nursing Officer on 9/8/11 at 4:15 PM.

B. Patient #5

Review of the "Physician's Admission Orders" revealed a physician order dated 8/14/11 for a routine lithium level. No evidence was found to indicate that a blood specimen was obtained and sent to the lab for testing.

This finding was confirmed with the Chief Nursing Officer on 9/7/11 at 3:50 PM.