HospitalInspections.org

The Hospital failed to ensure a process was in place to document assessments for 1 patient (Patient #1) in a sample of 10 patients, who would either receive or not receive medication that was ordered for symptoms of alcohol withdrawal. Findings include:

For Patient #1, Physician Orders indicated that Serax 30 milligrams was ordered at 11:30 A.M. on 4/26/14 every 2 hours as needed.

Medication administration records, dated 4/26/14, indicated that from 11:30 AM on 4/26/14 to 1:10 AM on 4/27/14 Patient #1 received a total of 180 milligrams of Serax.

However, after 1:10 A.M. on 4/27/14 there were no further assessments to indicate that a decision was made to either administer or not administer Seax to Patient #1, as ordered.

Although the Hospital planned to use the Clinical Institute Withdrawal Scale (a tool used to help staff assess and treat alcohol withdrawal symptoms; based on a score of vital signs and symptoms that determine if a patient can be safely medicated for symptoms of withdrawal and the dose of medication a patient can safely receive), the Hospital had not yet implemented that plan.

The last documented vital signs for Patient #1 was at 1:05 A.M. Patient #1's vital signs were: oral temperature was 98.4 (normal 97.8-98.8 degree Fahrenheit; pulse was 64 beats per minute (normal 60-90); respirations were 18 breaths per minute (normal 12-22); blood pressure (B/P) was 132/90 (normal B/P 100-130/60-85). No further vital signs were documented to evaluate the effects and side effects of Serax administered.

A medical progress note, dated 4/27/14 at 8:07 A.M. indicated Patient #1 was found dead at 7:15 A.M., at which time, Patient #1 was stiff with rigor (recognizable sign of death; the corpse becomes stiff and difficult to move or manipulate caused by chemical changes in the muscles which starts two to six hours following death; rigor mortis begins with the eyelids, neck, and jaw) and because of the stiffness in Patient #1's jaw, it was impossible to establish an oral airway during resuscitation efforts.

Based on record review and interviews the facility failed to ensure telephone orders were not common practice for 4(Patient #1, #5, #6 and #8) patients in a sample of 10 patients.

The Hospital Policy and procedure for Verbal/Telephone Orders indicated that telephone orders are acceptable only when the physician/practioner is physically unable to write orders either on the physician order sheet or in the computer order entry system.

The Medical Staff bylaws, Page 20, indicated that telephone orders will be accepted to meet care needs if the physician is not physically present in the hospital.

Attending Physician #1 was interviewed at at 7:40 A.M. on 6/3/14. Attending Physician #1 said he gave verbal/telephone orders to the nursing staff which included medications because it was more convenient for a nurse to write the orders. Attending Physician #1 said at approximately 5:00 P.M. on 4/26/14, he was on the Behavioral Unit and saw Patient #1 appear tremulous. Attending Physician #1 said told the nurse (Nurse #3) to administer an extra dose of Serax to Patient #1.

For Patient #1, admitted for alcohol detoxification, the admission orders, dated 4/26/14, at 11:30 A.M. indicated the orders were documented as telephone orders, from Attending Physician #1. The orders included an order for Serax 30 milligrams (mg) every 2 hours as necessary. A telephone order, dated 4/26/14, at 5:00 P.M. indicated Nurse #3 documented a telephone order for a one time dose of Serax 60 mg, despite that Attending Physician #1 said he was on the unit.

For Patient #5, a telephone order was taken on 2/27/14 at 3:38 P.M. from a physician for Librium 50 mg every 2 hours as needed for withdrawal symptoms.

For Patient #6, a telephone order was taken on 1/12/14 at 5:01 P.M. from a physician for Serax 30 mg as necessary for agitation

For Patient #8, a telephone order from Attending Physician #1 was entered at 12:07 P.M. on 3/22/14 for Serax 30 mg as needed for agitation/withdrawal.