HospitalInspections.org

Based on policy review, medical record review, and interview the facility failed to ensure nursing care was provided per physician's orders for 1 of 4 (Patient #4) sample patients.

The findings included:

1. Review of the facility's "Vital Signs" policy revealed, "...All patients admitted...will have vital signs taken on admission, and as ordered by the physician or as warranted by patient's condition..."

2. Review of the facility's "Medication Administration: General Guidelines" policy effective 4/2022 revealed, "...Medication preparation, administration, and documentation is carried out in a consistent and safe manner...Medications are not given without a physician's order...If patient refuses medication the nurse will enter the refusal in the system and notify the physician...Upon physician's order, alternate route or form of medication may be administered...concentrate or injection..."

3. Medical record review revealed Patient #4 was involuntarily admitted to the facility on 10/29/2022 with diagnoses of Psychosis, Schizoaffective Disorder, Hypertension, and Hyperlipedemia.

Review of a physician's order dated 10/29/2022 at 9:00 PM revealed the patient was to have his vital signs assessed twice a day for 4 days, then once a day unless otherwise ordered.

Review of the vital signs for Patient #4 revealed the patient's vital signs were taken once a day instead of twice a day as ordered on the following dates:
10/29/2022 - the patient's vital signs were assessed at 12:49 PM
10/30/2022 - the patient's vital signs were assessed at 9:37 AM
10/31/2022 - the patient's vital signs were assessed at 6:44 PM
11/1/2022 - the patient's vital signs were assessed at 4:24 PM
11/2/2022 - the patient's vital signs were assessed at 6:01 PM

Review of a physician's order for Patient #4 dated 10/31/2022 at 10:00 AM revealed the patient was to receive Haldol 5 milligrams per milliliter (mg/ml) intramuscular (IM) injection twice a day if the patient refuses oral Haldol.

Review of the Medication Administration Record dated 10/31/2022 at 10:00 AM through 11/2/2022 revealed the following:

11/1/2022 at 8:29 PM - Patient #4 refused his scheduled oral dose of Haldol. There was no documentation Haldol 5 mg IM was administered as ordered.

In an interview on 11/29/2022 at 11:33 AM, the Chief Executive Officer (CEO) verified the patient's vital signs were taken once daily instead of twice daily as ordered. The CEO further verified the patient only received 1 injection of Haldol.

In an interview on 11/29/2022 at 12:42 PM, the Chief Nursing Officer verified Patient #4's vital signs were not taken per physician's orders.