HospitalInspections.org

Based on findings from medical record (MR) review and interview, in 1 of 15 MRs reviewed, nursing staff did not communicate significant findings regarding changes in a patient's (Patient A's) condition to the attending physician.

Findings include:

-- Review of Patient A's MR revealed Patient A had an elective right total hip replacement on 4/14/15. Postoperatively, after recovery in the post anesthesia care unit (PACU), Patient A was transferred to her inpatient room at 11:45 am. Patient was alert and oriented. Her vital signs (VS) were temperature (T) 94.3 Fahrenheit (F), pulse (P) 71, respirations (R) 16, blood pressure (BP) 111/56, oxygen saturation (O2 sat) 97%. At 3:30 pm nursing documented Patient A's VS were T 95.9 F, P 72, R 18, O2 sat 99%, BP 110/59. On 4/15/15 at 12:00 am nursing documented Patient A's VS were T 99.1 F, P 76, R 18, O2 sat 95%, BP 114/62. On 4/15/15 at 6:00 am, nursing documented Patient A's VS were T 98.4 F, P 78, R 18, O2 sat 97%, and BP 102/52. She was alert and oriented.

At 8:40 am, nursing documented Patient A was very sleepy and lethargic. At 9:00 am, Staff #1 documented that Patient A was very sleepy, lethargic, and unable to tolerate ambulation assessment. At 10:00 am, Staff #2 documented VS: T 99.2 F, P 74 , R 18, O2 Sat 69%, BP 98/51. Patient A was very sleepy, desaturated (oxygen blood concentration level decreased) while on room air. Oxygen was placed on Patient A and her O2 saturation improved.

The MR lacked nursing documentation that indicated Patient A's attending physician was notified of her change in respiratory status, VS, and mental status. Additionally, the MR lacked nursing documentation indicating the reason that Patient A's oxygen was removed and the length of time that Patient A was placed on room air.

-- During interview of Staff #1 on 9/9/15 at 3:00 pm, he/she stated that while doing the physical therapy evaluation on 4/14/15 at 9:00 am, Patient A constantly needed to be awakened to participate and was "too tired." Staff #1 notified Patient A's assigned registered nurse (RN) regarding the patient's lethargy and inability to stay awake during the evaluation.

--During interview of Staff #2 on 9/9/15 at 3:35 pm, he/she did not know the reason or length of time that Patient A's oxygen had been removed on 4/15/15 at 10:00 am and acknowledged that Patient A's physician should have been notified when Patient A's O2 Sat level was 69%.

Based on findings from document review, medical record (MR) review, observation and interview, in 5 of 6 obstetrical patient MRs reviewed (Patients B, C, D, E and F), nursing staff did not perform an assessment of fall risk on admission, per hospital policy and procedure (P&P). Additionally, in 2 of 2 MRs of Physical Medicine and Rehabilitation (P&MR) Unit patients identified as "high risk" to fall (Patients G and H), interventions used to identify patients as being at high risk to fall were lacking.

Findings include:

-- The hospital P&P titled "Fall Prevention," last revised 5/2015, indicated that a registered nurse (RN) should assess inpatients upon admission to determine risk for falls... obstetrical patients have minimal potential for falls therefore will be screened on admission and documented.

However, per MR review, Patients B through F lacked documentation of a fall risk screen on admission

-- The hospital P&P titled "Fall Prevention," last revised 5/2015, further indicated that patients identified at risk to fall will have interventions put in place based on their fall risk level. Interventions for patients identified as high risk to fall include application of an orange identification bracelet and placement of an orange falling star over the patient's bed and outside the door.

-- Review of Patient G's MR indicated she was a high risk to fall. However, during observation on 9/9/15 at 3:30 pm, Patient G did not have an orange identification bracelet indicating fall risk on and did not have an orange falling star posted outside her room or above her bed.

-- Review of Patient H's MR indicated he was a high risk to fall. However during observation on 9/9/15 at 3:30 pm, he did not have an orange star posted outside his room or above his bed.

-- During interview of Staff #3 on 9/9/15 from 2:20 pm to 3:30 pm, he/she confirmed the above findings.

Based on findings from medical record (MR) review, document review and interview, the nursing services department did not ensure that medication administration practices were consistent with hospital policy and regulatory requirements. Specifically, in 3 out of 15 MRs reviewed, nursing staff did not document the patient's sedation level at the time of administration of opioid medication to a patient, per hospital policy and procedure (P&P). As a result, this may have potentially placed patients at an increased risk for respiratory depression and over sedation. Also, hospital P&Ps did not address the timing of medication administrations based on the nature of the medication and its clinical application, per generally accepted standards of practice.

Findings include:

-- The hospital P&Ps titled "Assessment & Management of Pain & Sedation" last revised 5/2015, indicated that it is the responsibility of the Registered Nurse to assess the patient for pain. The assessment should include level of pain, sedation level and respiratory rate. Evaluation of sedation is done using the Pasero Opioid Induced Sedation Scale.

-- Review of Patient A's MR revealed physician orders dated 4/14/15 for hydromorphone (Dilaudid) 0.5 mg intravenously (IV) every 3 hours as needed for mild pain, Percocet 5/325 mg 2 tabs by mouth every 4 hours as needed for moderate pain or Percocet 1 tab by mouth every 4 hours as needed for mild pain.

On 4/14/15 at 1:00 pm, nursing staff administered Percocet 5/325 mg 2 tabs orally to Patient A. At 2:11 pm and 6:59 pm (on 4/14/15) nursing staff administered Dilaudid 0.5 mg IV. On 4/15/15 at 12:52 am and 5:16 am, nursing staff administered Percocet 5/325 mg 2 tabs orally to the patient. The MR lacked documentation of sedation level assessments with the administration of all the opioids.

-- Review of Patient I's MR revealed a physician order dated 9/8/15 for morphine 5 mg subcutaneous (SQ) once. On 9/8/15 at 11:58 pm, nursing staff administered morphine. The MR lacked documentation that nursing staff assessed the patient's sedation level prior to the administration of the morphine.

-- Review of Patient J's MR revealed a physician order dated 8/17/15 for morphine 2 mg IV every 2 hours as needed for pain. Nursing staff administered morphine on 8/17/15 at 11:04 am and on 8/18/15 at 3:19 pm. The MR lacked documentation that nursing staff assessed the patient's sedation level prior to the administrations of the morphine.

-- Per interview of Staff #4 on 9/9/15 at 3:50 pm, no sedation level assessment of Patient A had been performed.

-- Per review of the hospital P&P titled "Medication Administration Record Guidelines," last revised 11/2013, it indicated that medications must be administered within the time frame of 60 minutes before to 60 minutes after the scheduled time. The P&P did not identify the following:

*Medications not eligible for scheduled dosing times;
*Medications eligible for scheduled dosing times; and
*Administration of eligible medications outside their scheduled dosing times and windows.

-- During interview with Staff #5 on 9/10/15 at 1:50 pm, he/she acknowledged that the hospital does not have a P&P that addressed timing of medication.

Based on findings from document review, medical record (MR) review and interview, in 3 of 4 MRs reviewed, (Patients H, I, and K) telephone orders provided to nursing staff were not obtained for urgent or emergent situations, per hospital policy. In 1 of 4 MR's reviewed (Patient I), an obtained telephone order lacked documentation that read-back verification had occurred.


Finding include:

-- Per review of hospital policy and procedure (P&P) titled "Verbal Orders," last revised 1/2013, it indicated that verbal orders are either obtained on-site or by telephone and that telephone orders should be used infrequently, under urgent or emergent situations.

-- Per MR review, Patient H's MR contained a telephone order provided on 9/6/15 at 2:46 pm to renew Tramadol HCL 50 milligrams (mg) orally (po) every 6 hours as needed (prn). The initial order for the Tramadol was set to expire on 9/7/15 at 12:14 pm, 21 hours after the verbal order for the medication renewal was obtained.

-- Per interview with Staff #3 on 9/9/15 at 3:10 pm, he/she confirmed the above finding.

-- Per MR review, Patient K's MR contained telephone orders provided on 9/9/15 at 10:00 am to renew oxazepam 10 mg po every 8 hours and oxazepam 10 mg po every 4 hours prn. The initial orders were set to expire on 9/10/15 at 1:59 pm and 9/10/15 at 9:44 am, respectively, approximately 24 to 28 hours after the verbal order for the medication renewals were obtained.

-- Per MR review, Patent I's MR contained telephone orders provided on 9/7/15 at 5:20 pm and 5:30 pm to reorder numerous post operative orders (i.e., medications, laboratory tests, intravenous fluids and diet). Additionally, telephone orders for medications on 9/7/15 at 5:20 pm and medications, laboratory tests and diet on 9/7/15 at 5:30 pm lacked read-back verification.

-- During interview with Staff #5 on 9/10/15 at 11:00 am, the above findings were acknowledged.

Based on findings from document review, medical record (MR) review, and interview, in 1 of 1 MR reviewed for narcotic medication infusion, medication orders for Patient Controlled Anesthesia (PCA) infusion were not written per hospital policy and procedure (P&P) specifically the correct order form was not used and adequate monitoring was not ordered.

Findings include:

-- The hospital P&P titled "PCA, Patient Controlled Anesthesia," last revised 5/2015, directed that hospital medical personnel write all PCA orders on the hospital approved pre-printed PCA order form. The hospital approved preprinted "PCA Order Form," last revised 9/2013, indicated when a patient is placed on a PCA infusion the following should be implemented: Vitals signs, pain assessment and level of consciousness and sedation should be obtained every 1/2 hour x 2, every 1 hour x 4 and then every 4 hours.

-- However, per review of Patient L's MR, Staff #6 wrote post-operative PCA orders on a doctors order sheet, not a PCA Order Form and the required monitoring (VS, pain assessment and level of consciousness and sedation) was not ordered.

-- Per interview of Staff #5 on 9/10/15 at 1:50 pm, he/she acknowledged the above findings.