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RIVERWOODS BEHAVIORAL HEALTH SYSTEM
NURSING CARE PLAN
Tag No.: A0396
Based on review of medical records, policies and procedures, and a staff interview, it was determined that the facility failed to ensure that the nursing staff followed physicians' orders when developing nursing care plans for one (1) of four (4) sampled medical records (#3).
Findings were:
Medical record #3 was reviewed and revealeed the patient was admitted in order to receive detoxification treatment. The physicians' orders included placing the patient on the "Serax (medication used to relieve alcohol withdrawal symptoms) Detox - 5 Day Medication Orders".
Review of the "Serax Detox - 5 Day Medication Orders" revealed the nursing staff were to:
1. Complete the CIWA (Clinical Institute Withdrawal Assessment) Scale immediately upon admission,
2. Then complete the CIWA Scale every 4 hours, hold if sleeping, and
3. Administer Ativan 1 milligram for complaints of nausea up to four (4) times a day.
The initial nursing assessment was completed by a Registered Nurse (RN) within 45 minutes of the patient's admission (hospital day #1 at 5:33 a.m.) There was no documented evidence of the CIWA Scale being completed at the time of admission. The patient remained in the facility for a total of 51 1/2 hours and should have had up to 12 CIWA Scale forms completed to assess the patient for withdrawal symptoms. The initial CIWA Scale form was completed on hospital day #1 at 9:00 a.m. (3 1/2 hours after admission) and again on hospital day #2 at 9:00 a.m.
Review of facility policy entitled Nursing Care of the Patient During Medical Detoxification, policy number PC.078, issued 10/08, revealed the nursing staff was responsible for providing ongoing monitoring of symptoms and administering medications per physician's orders to decrease the likelihood of delirium tremens and seizure activity..
During an interview (#1) with thew Director of Nurses (DON) on 11/06/12 at 10:30 a.m. in the conference room. The DON confirmed that the CIWA Scale was to be performed as ordered every four (4) hours and that patient #3 had only had two (2) CIWA Scales performed.