HospitalInspections.org

Based on observation, document review and staff interview it was determined the Intensive Care Unit's (ICU) registered nurse failed to ensure the stat carts on the unit were checked and recorded daily to ensure all cardiac and respiratory lifesaving supplies and equipment were available and working correctly. This deficient practice was identified on four (4) of four (4) stat carts located on the unit. This failure has the potential to negatively affect any patient who requires cardiac/respiratory resuscitation.
Findings include:

1. During a tour of the Intensive Care Unit (ICU) on 3/31/15 at 9:30 a.m., it was observed the "daily equipment worksheet" was incomplete on four (4) of four (4) stat carts, as follows: Stat Cart #1 had not been checked from 3/27/15 to 3/30/15. Stat Carts #2 and #3 had not been checked from 3/26/15 to 3/30/15. Stat Cart #4 had not been checked from 3/25/15 to 3/30/15.

2. Review of the policy titled, "Stat Carts", last revised 2/26/13, states, in part: "stat carts are to be checked at least one time during each calendar day."

3. An interview was conducted with the ICU Nurse Manager on 3/31/15 at 9:45 a.m. and he concurred with the above findings. He also stated, "It is the responsibility of the night shift Charge Nurse to check all stat carts daily."

Based on record review, staff interview and document review it was determined the hospital failed to ensure the medical record accurately reflected medication administered for one (1) of one (1) patients reviewed who received as needed (PRN) Ativan (patient #1). This failure creates the potential for inaccurate medication documentation and/or negative patient outcomes.

Findings include:

1. Review of the medical record for patient #1 (A visit) revealed the Registered Nurse (RN) documented two (2) doses of Ativan were administered on 3/9/15. At 11:11 a.m. the RN documented 0.5 mg Ativan was administered by mouth (PO). At 11:25 a.m. the RN documented 0.5 mg Ativan was administered intravenously (IV).

2. The above record was reviewed with the Staff Development Nurse at 2:00 p.m. on 3/30/15 and she confirmed the documentation reflected two (2) doses of Ativan were given.

3. On 3/31/15 the above record was reviewed with the Oncology Nurse Manager. She stated the PO dose of Ativan was not given and stated the RN wasted the dose. She provided an automated medication dosing machine record which indicated the PO dose of Ativan was wasted. After review of the patient's medication administration record (MAR) she acknowledged the record reflected the PO dose was given and did not reflect the PO dose was wasted. The Nurse Manager stated the nurse should have added a late note to amend the MAR in the patient's record.

4. The policy, "Medication Management", last reviewed 2/7/14, was provided for review. The policy states, in part: "The Medication Administration Record (EMAR) is used for regularly scheduled medications, one time orders, pre-operative medications, IV piggyback medications and PRN (as needed) medications and all IV solutions...All medications that are administered will be documented in the appropriate time column...medication prepared for administration, but not used, should be discarded...if a patient refuses a medication, the medication can be canceled prior to administration. Administer the medications to the patients. Click the 'medications administered' button."

Based on staff interview, record review and document review it was determined the hospital failed to ensure the medical record included a discharge order for home oxygen and related discharge counseling for one (1) of one (1) patients reviewed who was discharged with an order for home oxygen (patient #1). This failure creates the potential for an adverse outcome for patients who are discharged with oxygen orders.

Findings include:

1. A phone interview was conducted with the Chief of Hospitalists at 3:30 p.m. on 3/31/15. He confirmed he discharged patient #1 on 3/13/15 and acknowledged he provided the patient with an order for home oxygen at that time. He was not certain whether he or the pulmonologist wrote the order but stated the oxygen was provided per the direction of the pulmonologist.

2. Review of the medical record for patient #1 revealed no order for home oxygen or documentation related to the provision of an order for home oxygen. Review of the 'Discharge Reconciliation', completed by the Chief of Hospitalists on 3/13/15, and the 'Exitcare Patient Discharge Instructions', signed by the patient at 5:15 p.m. on 3/13/15, revealed no mention of oxygen. There were no instructions for post-hospital oxygen use provided to the patient.

The above record was reviewed and discussed with the Staff Development Nurse at 2:00 p.m. on 4/1/15. She agreed with the findings.

3. The policy, "Provision of Care, Treatment, Services: General", last reviewed 7/24/13, was provided for review. The policy states, in part: "The physician will assess, identify, and address in the medical record, the patient's needs related to self care. The physician's discharge instruction sheet will include: Use of medications; Activity restrictions, Appropriate diet; Use of medical equipment; and Follow-up care."