HospitalInspections.org
Bringing transparency to federal inspections
VISTA MEDICAL CENTER EAST
RESPIRATORY SERVICES
Tag No.: A1164
Based on document review and interview, it was determined, that for 2 of 5 clinical records reviewed (Pts. 5 & 6), the Hospital failed to ensure physicians' orders were completed and/or documented in the clinical record, according to policy.
Findings include:
1. Hospital policy # MM.5.10, revised, 4/2012, titled, "Safe Medication Administration" was reviewed and required, "Documentation: 1. Administration of all medication is to be documented on the appropriate Medication Administration Record (MAR).,, 3 Reasons for hold or refusal must be documented in a nursing note..."
2. The clinical record of Pt. #5 was reviewed and included that Pt. #5 was a 63 year old female, admitted on 12/6/12, with a diagnosis of Pneumonia. A physician's order dated 12/9/12, included, "DuoNeb nebulizer QID (4 times per day)..." The MAR dated 12/10/12, lacked documentation for all 4 schedule doses (7:00 AM, 11:00 AM, 3:00 PM, and 7:00 PM) of DuoNeb and there were no progress notes to explain why the doses were or were not administered. Pt. #5's MAR dated 12/11/12, did not include documentation of administration of 1 of 4 schedule doses (7:00 AM) of DuoNeb and there was no progress note to explain why the dose was not administered.
3. The clinical record of Pt. #6 was reviewed and included that Pt. #6 was an 85 year old female, admitted on 12/7/12, with diagnoses of Chronic Obstructive Pulmonary Disease and Chronic Heart Failure. A physician's order dated 12/4/12 at 4:13 PM, included, "DuoNeb QID (4 times per day)..." Four doses of DuoNeb were documented in Pt. #6's progress notes on 12/9/12, at 9:50 AM, 12:45 PM, 4:00 PM, and 7:30 PM, but the MAR for 12/9/12 was not found in Pt. #6's clinical record. Four doses of DuoNeb were documented in Pt. #6's progress notes on 12/11/12 at 7:05 AM, 11:05 AM, 3:50 PM, and 10:00 PM, but were not documented on Pt. #6's MAR dated 12/11/12.
4. An interview was conducted with the Assistant CEO on 12/12/12 at approximately 10:00 AM, during the clinical record reviews. The Assistant CEO stated that there was no documentation in Pt. #5's clinical record to explain if DuoNeb was or was not administered and that nebulizer treatments are to be documented in the MAR.