HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the medical history and physical was documented in the patient medical record in a timely fashion per policy/bylaws for 4 (pts. #1, #2, #16, and #19) of 20 patients reviewed.

Findings:

A review of medical records showed that 4 (Pt #1, #2, #16, #19) patients did not have the H&P signed within 24 hours of admission. Documentation showed the folowing.

Pt. #1 was admitted on 10/04/24 and their H&P was signed on 10/07/24.
Pt. #2 was admitted on 10/07/24 and their H&P was signed on 10/10/24.
Pt. #16 was admitted on 09/18/24 and their H&P was signed on 09/23/24.
Pt. #19 was admitted on 04/23/24 and their H&P was signed on 04/27/24.

During an interview on 12/18/24 at 8:00 a.m., Staff L stated:
1. the hospital had no policy requiring completion of the H&P within 24 hours and
2. their policy required completion of the H&P within 30 days of discharge.

Based on record review and interview, the hospital failed to ensure:
1. organized nursing services were available and supervised to provided services per the facilities policies and procedures for 1 (Pt #2) out of 20 patients reviewed and
2. drugs and biological protocals for IV fluids were followed by nursing staff.

Findings:

A facility policy titled "Pain Management" read in part: that vistal signs should be monitored prior to administering the prn pain medication and the patient should be reassessed within 1 hour after receiving the medication.

Pain Reassessment for Patient #2
A review of clinical documentation showed on 10/08/24 at 8:22 a.m. Staff Q administered PRN pain medication (Demerol 50mg). Continued review showed no reassessed after the administration of the medication. On 10/08/24 at 10:09 a.m. Pt #2 was discharged to an outside facility without the post medication assessment completed.

IV fluids on the nursing floor
On 12/18/24 at 8:18 a.m. the surveyor observed a warming cabinet on the nursing floor with a sign that read "IV FLUIDS are to be warmed for 14 DAYS ONLY. Please write date 1st warmed on the bag." The surveyor opened the warmer to find 3 bags or NaCl inside the top warming cabinet and each bag had a sticker that read " in: 12-1 out 12-14".

A review the manufacturer recommended guidelines stated the IV fluids were to be stored at room temperature and not to be chilled or heated.

Staff L
During an interview on 12/17/24 at 8:30 a.m., Staff L stated the post medication administration assessments were to be completed within one hour after administration.

During an interview on 12/18/24 at 8:18 a.m. Staff L stated they were uncertain if there was a policy about warming IV fluids and that we should talk to the pharmacist.

During an interview on 12/18/24 at 8:25 a.m. Staff U stated:
1. there were no policies about warming IV fluids,
2. they do not allow IV fluids to be warmed in their facility, and
3. the IV fluids should not have been in the warmer.



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