HospitalInspections.org

Based on clinical record review, review of personnel record reviews, and staff interviews, it was determined the hospital:

1. Failed to ensure nursing policies and procedures were developed for the care and treatment of patients withdrawing from alcohol and failed to ensure nursing staff were trained and competent to provide the specialized services required for 1 of 1 patient admitted for withdrawal of alcohol in the total sample of 20. (Patient # 9) This deficient practice poses the risk of potential life threatening signs and symptoms of alcohol withdrawal syndrome not promptly identified by and acted upon by trained nursing staff.

2. Failed to ensure staff assigned to monitor telemetry patients were trained and demonstrated to be competent in accordance with hospital policies and procedures.

Findings include:

1. Patient #9 was admitted for alcohol abuse with intoxification and fall. The physician documented in the Admission History and Physical that the patient was at risk for withdrawals and would be treated with [name of a Benzodiazepine medication] every four hours as needed. The actual order was: [name of a Benzodiazepine/ dosage of mg] intravenously every four hours as needed for "anxiety." The physician did not provide orders for nursing staff to initiate an alcohol withdrawal assessment protocol, however, documentation in the clinical record revealed nursing staff were utilizing an "Alcohol Withdrawal Nursing Assessment Tool" in the electronic record. The physician documented in a progress note at 9:49 a.m. the day after admission: "...Alcohol Intoxication and Alcohol withdrawal (sic) syndrome - continue CIWA protocol." CIWA A-R is a 10 item assessment tool that is commonly used to quantify the severity of Alcohol Withdrawal Syndrome and to monitor and medicate patients going through withdrawal.

Patient #9's clinical record was reviewed with Staff #2, and a copy of the hospital's policy and procedure for the alcohol withdrawal assessment protocol was requested. Staff #2 was not able to locate a policy and procedure, however, a paper "Alcohol Withdrawal Assessment Flowsheet" form was located at the nurses station which the nursing staff on duty reported was being used as a guideline. The form contained detailed criteria for the frequency of assessments based on the scoring system. If the patient scored greater than or equal to 8 at a time, nursing assessments were to be completed every hour for 8 hours, then every 2 hours for 8 hours if the scores were stable and then every four hours after that if the scores were stable. The frequency of nursing assessments was not consistent with the protocols. For example the day after admission at 2:46 a.m., the patient had a score of "10.0" but was not reassessed again until 8:46 a.m., a period of six hours, at which time the score had increased to "13.0"

Also, the indications for "PRN (as needed)medication administration" was based on a score. The actual physician order for medication administration was as needed for "anxiety" rather than a score utilizing the assessment tool.

A review of two personnel records for current Registered Nurses assigned to work on the inpatient unit revealed no documentation of training, education or competencies on the specialized care and services required by patients withdrawing from alcohol.

Staff #2 acknowledged during interviews that there was no policy and procedure for the use of an alcohol withdrawal assessment form and that the nurses had not been trained and deemed competent to provide care and services to patients withdrawing from alcohol.

2. The hospital's policy and procedure on the subject of "Monitoring of Telemetry Patient" included: "All patients admitted for telemetry monitoring will receive continuous cardiac monitoring by qualified staff...The cardiac monitor will be continuously monitored by an individual who has demonstrated competency in basic EKG monitoring. Monitoring staff will demonstrate competency by completion of an EKG course and successful completion of a competency exam, as well as completion of a minimum of four hours of preceptor monitoring experience. Experience may be substituted for the EKG class, but completion of the preceptorship and successful completion of a competency test will be required."

Random observations of the inpatient unit revealed a Unit Secretary seated near the telemetry monitor. Staff #2 reported that Unit Secretaries were assigned to monitor patients on telemetry and that a Unit Secretary was assigned on each shift.

Two of two personnel records of Unit Secretaries (Staff #16 and #17) revealed no documentation that they were provided with education and training and were deemed competent to monitor telemetry patients.

Staff #2 acknowledged there was no documentation that policies and procedures were followed to ensure telemetry patients were monitored by qualified staff.