HospitalInspections.org

Based on policy reviews, clinical record reviews and staff interviews the nursing staff failed to ensure the quality of nursing care provided to each patient is in accordance with established facility policies, and standards of practice of nursing care, chapter 464.003(5). This failure affected 5 of 10 sampled patients as evidenced by failure to monitor temperature for 3 sampled newborns (Patients # 3, # 4 and # 5) receiving phototherapy and failure to reassess for the effectiveness of pain medication as specified per facility policies and procedures for 2 sampled patients (Patient # 8 and # 9).


The findings include:

1) Facility policy titled " Phototherapy " approved on 09/2012 documents " To provide nursing care for an infant under phototherapy lights used to reduce serum Bilirubin by photo-oxidation. Check infant ' s temperature as needed until temperature stabilization has been assured and then every two hours. "

Clinical record review conducted on 11/03/14 revealed Patient # 3 was prescribed Phototherapy on 11/01/14 for abnormal Bilirubin levels. The nursing assessments, nursing notes and flow sheets dated 11/01/14 thru 11/03/14 failed to document evidence Patient # 3 ' s temperature was monitored every two hours per policy.

Physician ' s Order for Patient # 4, dated 11/01/14, documents initiate Phototherapy for abnormal Bilirubin level. The nursing assessments, nursing notes and flow sheets dated 11/01/14 thru 11/03/14 fail to document evidence Patient # 4 ' s temperature was monitored every two hours.

Physician ' s Order for Patient # 5, dated 10/31/14, documents initiate Phototherapy for abnormal Bilirubin level. The nursing assessments, nursing notes and flow sheets dated 10/31/14 thru 11/03/14 fail to document evidence Patient # 5 ' s temperature was monitored every two hours per policy.

Interview with The Nurse Manager of The Obstetric Unit, who navigated the electronic record, on 11/03/14 at 2:45 PM confirmed temperature readings were not monitored every two hours as specify per facility policy.


2) Facility policy titled " Pain Management " approved on 10/2011 documents " The effectiveness of pain relief interventions will be measured by the pain scale used to measure pain. Documentation of the effectiveness of pain relief will be in the E-MAR or other department specific Medication Administration Record (MAR), within one hour of the administration of pain relief medications or measures "

Clinical record reviews conducted on 11/04/14 revealed the following:

Patient # 8 was admitted to the facility on 11/02/14. Physician ' s Order dated 11/02/14 documents Hydromorphone 1 mg every four hours as needed. Medication Administration Record dated 11/02/14 thru 11/03/14 revealed Hydromorphone was administered on 11/02/14 at 8:51 PM; 11/03/14 at 12:53 AM; 11/03/14 at 5:10 AM and 11/03/14 at 10:11 PM.
Further review of the clinical record failed to yield evidence of pain reassessment to evaluate effectiveness of the interventions identified above.

Patient # 9 was admitted to the facility on 11/02/14. Physician ' s Order dated 11/02/14 documents, Dilaudid 2 mg every two hours as needed. Medication Administration Record dated 11/02/14 thru 11/04/14 reveal Dilaudid was administered on 11/03/14 at 1:41 PM and on 11/04/14 at 2:15 AM.
Further review of the clinical record failed to yield evidence of pain reassessment to evaluate the effectiveness of the administered pain medication.


Interview with The Registered Nurse who navigated the electronic record conducted on 11/04/14 at 10:35 AM confirmed pain reassessment related to Patients # 8 and # 9 is not documented as specified by facility policy.