HospitalInspections.org

Based on review of the facility's policies/procedures, medical records, and interview, it was determined that the facility failed to require that:

1. the patient received personal hygiene care; and
2. the patient received daily weights as ordered by the physician.

These deficient practices poses a risk to the health, and safety of the patient, when there is no registered nurse (RN) oversight or nursing documentation to confirm that basic hygiene care is provided to the patient, and that physician orders are noted, and implemented.

Findings include:

Policy titled "Standards of Nursing Practice" (#22.06.31; 01/2020), revealed: "...Professional Nurse...utilizes the nursing process to plan and implement nursing care for patients...based on assessment...plans strategies of nursing care and intervention...respects a patient's rights...dignity...advocates on behalf of the patient...."

Policy titled " Documentation" (#22.03.28; 05/2020), revealed: "...clinical staff employees who are assigned care and treatments of a patient will document this information in the nurse's notes, flow sheets, and specific discipline formats in the electronic medical record (EMR)...Registered Nurses (RN's), Licensed Practical Nurses (LPN's)...are authorized to evaluate and document regarding the patient's illness, generalized condition, response to treatments, improvement or decline, and medications...entries made...will include...a treatment or procedure...."

Policy titled "Nursing Documentation in the Electronic Medical Record (EMR)" (#22.02.29; 01/2020), revealed: "...all nursing staff employees...have the responsibility of documenting pertinent information of their services to the patient, in the patient's EMR...ensure the hospital of a record which will convey the care rendered to a patient...nursing staff employees who are assigned care and treatments of a patient will document this information in the nurse's notes and flow sheets...document happenings as soon as they occur or as soon as treatments are performed...."

Document titled "Patient Rights & Responsibilities" (current as of 10/2020), revealed: "...have your personal privacy respected...make informed choices about your care and treatment...right to refuse treatment...."

Medical record review conducted 10/15/2020, revealed the following:

i. No documented evidence that personal hygiene care was provided;
ii. 01/23/2020 - Physician order for daily weights;
iii. 01/24/2020 - No documented evidence that the patient's weight obtained;
iv. 01/25/2020 - No documented evidence that the patient's weight obtained.

Personnel #16 confirmed during an interview conducted 10/15/2020 (0815), that the medical record showed documented evidence of when the patient's briefs were changed, but showed no documented evidence of the patient receiving personal hygiene care. Personnel #16 revealed that bathing, peri-care, and oral hygiene should be offered to the patients on a daily basis, and any care provided should be documented in the patient's EMR. Additionally, Personnel #16 confirmed that there was a physician order written for the patient to have daily weights, but there was no documented evidence that daily weights were obtained on 01/24/2020 or 01/25/2020.

Based on review of the facility's policies/procedures, medical records and interview, it was determined that the facility failed to require that medications were administered in a safe manner, and at the appropriate times. This deficient practice poses a risk to the health and safety of the patients when medications are administered, and staff does not know the potential medication interactions.

Findings include:

Policy titled "Medication Preparation and Administration Safety" (#24.02.12; 07/2020), revealed: "...guidelines for safety in medication...administration...safety precaution shall be observed by all personnel...preparing and administering medications...the pharmacist should know the expected effect and possible toxic reactions of the drugs being administered...when a pharmacist is on duty, all new medication orders will be checked by the pharmacist before given to the patient...the nurse should...check the patient's drug allergies against any medications...check for right drug...administered medications will be charted...."

Policy titled "Medication Administration" (#24.02.13; 07/2020), revealed: "...licensed nursing staff personnel may administer medication to hospital patients...pharmacist, providers, and nursing are all responsible for the correct ordering of medications to ensure safety in administration of medications to patients...nurse has the responsibility to...verify...correct medication, correct dose, correct route, and correct time...."

Medical record review conducted 10/15/2020, revealed the following:

i. Cholestyramine 4 gm, by mouth, every twenty-four (24) hours. Administered: 01/23/2020 (1103), 01/24/2020 (1148), and 01/25/2020 (1053);
ii. Lasix 40 mg, by mouth, two (2) times per day. Administered: 01/23/2020 (0847 & 1100), 01/24/2020 (0837 & 1018), and 01/25/2020 (0503 & 0951).

Personnel #28 confirmed during an interview conducted 10/15/2020 (1005), that the incorrect administration time of Lasix, could decrease the efficacy of Cholestyramine if given one (1) hour before or four (4) to six (6) hours after. Personnel #28 revealed that on 01/23/2020, Lasix was given at (1100), and Cholestyramine was given at (1103), which was less than the required one (1) hour before. Additionally, Personnel #28 confirmed that a medication error report was not completed.