HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to provide documented evidence that nurses were notified by nursing assistants, and that nurses notified physicians per physician orders, when patient vital signs were outside expected parameters for 1 of 10 patient medical records reviewed (Patient #1).

Findings were:

A physician order entered upon admission for Patient #1 on 8/19/15 at 2:46 p.m. included the following:
"Notify physician if...HR (heart rate) greater than 110...SpO2 (arterial oxygen saturation) less than (%) 92..."

The medical record of Patient #1 included the following abnormal readings:
· 8/22/15 at 1:12 p.m. - blood pressure 161/96 (nurse notified)
· 8/22/15 at 7:05 p.m. - blood pressure 167/88
· 8/22/15 at 10:49 p.m. - blood pressure 171/89
· 8/23/15 at 7:03 a.m. - SpO2 91%
· 8/23/15 at 3:38 p.m. - Heart Rate 124
· 8/23/15 at 6:21 p.m. - Heart Rate 117
· 8/23/15 at 9:01 p.m. - SpO2 88% (an hour later at 10:14 p.m. was at 97%)

The record included no nursing documentation which addressed whether the physician had been notified of these findings. There was only one entry on 8/22/15 at 1:12 p.m. that indicated the nurse had been notified of the blood pressure level by the nursing assistant.

These findings were confirmed in an interview with the facility Vice President of Critical Care Services and other administrative staff on the afternoon of 10/11/16. No additional evidence was provided to refute these findings.

Based on a review of facility documentation and staff interviews, the hospital failed to ensure that the nursing staff implemented a nursing care plan that was consistent with patient nursing care needs and which documented nursing interventions related to the plan in a timely manner for 1 of 10 patient charts reviewed (Patient #1).

Findings were:

Facility policy #X.1150.3.100 entitled Care Plans, last review date 11/5/14, included the following:
"Each patient has an individualized care plan initiated by a RN/GN within 24 hours of admission...The care plan is based on the nursing assessment and is consistent with the prescribed medical treatment. The care plan is reviewed by the RN/GN at least once every 24 hours and revised as needs of the patient change. Nursing diagnosis not documented on within 48 hours are considered resolved...
The RN/GN:...
Updates the care plan as patient assessment findings warrant and documents accordingly..."

A review of the medical record of Patient #1 revealed a nursing care plan which included a list of patient problems. One of the problems was noted as "Nausea/Vomiting." Patient #1, admitted on 8/19/15, had documented emesis on 8/21/15, 8/22/15, and 8/23/15. There was no nursing care plan intervention documented regarding this problem until 8/23/15 at 3:55 p.m.

The patient received the following doses of anti-emetic/anti-nausea medications as needed while at the hospital. On 8/21/15, he received 4 doses. On 8/22/15, he received 2 doses. And on 8/23/15, he received 2 doses. It was documented that nausea and vomiting were significant issues for this patient.

In a telephone interview with the wife of Patient #1 on the evening of 10/10/16 at approximately 7:30 p.m., she stated, "He just kept throwing up...We didn't even know it [anti-nausea medication as needed] had been ordered until the next day...that [referring to vomiting problems] really started on the 20th."

These findings were confirmed in an interview with the facility Vice President of Critical Care Services and other administrative staff on the afternoon of 10/11/16. No additional evidence was provided at that time to refute these findings.