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Based on record review and staff interview it was determined the Registered Nurse failed to supervise and evaluate nursing care for each patient for 4 (#3, #4, #8, #10) of 40 patients sampled. This practice does not ensure patient goals are met.

Findings include:

1. Patient #3 was admitted to the facility on 10/20/11 with the diagnosis of acute congestive heart failure. The physician wrote an order for daily weights on the day of admission. Review of nursing documentation revealed the patient was weighed on 10/21/11, but not on 10/22, 10/23 or 10/24/11.

The Vice President for Critical Care was interviewed on 10/25/11 at 8:45 a.m. and confirmed the staff failed to weigh the patient as ordered.

2. Patient #4 was admitted to the facility on 10/20/11. The physician wrote an order for Percocet 1 tablet every 4 hours as needed for pain. Review of the Medication Administration Record revealed the patient was medicated with Percocet at 10:00 a.m. on 10/22/11. Review of nursing documentation revealed the patient's pain level was not reassessed until 12:40 p.m., which was 2 hours and 40 minutes later.

The Vice President for Critical Care confirmed the above finding on 10/28/11 at approximately 10:30 a.m.

3. Patient #10 was admitted to the facility on 10/21/11. The physician wrote an order on 10/21/11 for Percocet 1-2 tablets every 4 hours as needed for pain. Review of the Medication Administration Record revealed the patient was medicated with Percocet at 4:30 a.m. on 10/24/11 for pain assessed as 5 out of 10 on a scale of 1 to 10 with 10 being the worst possible pain. Review of nursing documentation revealed the patient's pain level was not reassessed until 8:20 a.m., approximately four hours later.

Interview with the nurse manager on 10/24/11 at 12:55 p.m. confirmed the findings. The nurse manager stated the patient's pain level should be assessed within one hour of pain medication administration.

4. Patient #8 was admitted to the facility on 10/22/11. The physician wrote an order on 10/22/11 for Percocet 1-2 tablets every 4 hours as needed for pain. Review of the Medication Administration Record revealed the patient was medicated with Percocet at 3:37 a.m. on 10/24/11 for pain assessed as 8 out of 10 on a scale of 1 to 10 with 10 being the worst possible pain. Review of nursing documentation revealed the patient's pain level was not reassessed. On 10/24/11 at 9:05 a.m. the patient was medicated with Percocet for pain assessed as 3 out of 10. Review of the nursing documentation revealed the patient's pain level was not reassessed.

Interview with the nurse manager on 10/24/11 at 12:55 p.m. confirmed the findings. The nurse manager stated the patient's pain level should be assessed within one hour of pain medication administration.

Based on record review and staff interview it was determined that the facility failed to ensure medications were administered according to physician orders for 2 (#5, #11) of 40 sampled patients. This practice does not ensure patients achieve therapeutic goals.

Findings include:

1. Patient #5 was admitted to the facility on 10/21/11. On 10/21/11 the physician ordered Zosyn 2.25 Grams every 6 hours. Review of the Medication Administration Record (MAR) revealed that the dose due at 6:00 a.m. was not administered.

2. Patient #11 was admitted to the facility on 10/20/11 with a diagnosis of diabetes. The physician ordered Glucophage 850 milligrams by mouth twice daily with meals. Review of the MAR revealed the evening dose on 10/22/11 and the morning dose on 10/23/11 were omitted. There was no documentation as to why the medication was not given. There was no documentation that the physician was notified that the medication was not administered.

The Vice President for Critical Care Services was interviewed on 10/28/11 at approximately 10:30 a.m. She confirmed the above findings as inappropriately omitted medications.

Based on staff interview, review of policy and procedures, and observation it was determined the facility failed to maintain neonatal code carts according to facility policy. This does not ensure the level of safety and quality is maintained for the neonatal patient.

Findings include:

During tour of the NICU (Neonatal Intensive Care Unit) on 10/24/11 at 2:15 p.m. observations revealed three neonatal code carts, located within the unit, that were not checked on a daily basis as evidenced by the form #E6003 titled "Emergency Equipment Checklist". Review of the checklist revealed several days the code cart was not checked.

Interview on 10/24/11 at 2:30 p.m. with the NICU Nurse Manager confirmed the code carts are to be checked daily and the checks documented on the emergency equipment checklist located on the top of each code cart.

Review of the facility policy, "Code Blue Responsibilities", #TX-112, last revised 9/2006, stated the emergency equipment checklist (form #E6003) is initiated by unit personnel on the first day of each month and documented, as checked, every 24 hours at 7:00 a.m., when the unit is open. The Emergency Equipment Checklist is completed in black ink by the individual responsible for checking the code cart and defibrillator. The completed record is maintained on the unit for the current month and one-month prior.

Based on record review, patient and staff interview, and policy review it was determined the facility failed to provide a list of Home Health Care Agencies for one (#2) of forty patients sampled. This practice does not ensure patients' right to choose is maintained.

Findings include:

On 10/24/11 at approximately 2:30 p.m. an interview was conducted with patient #2. During the course of the interview, the patient was asked if he was going to be receiving Home Health Care (HHC) services upon discharge. He stated that he was and that the Social Worker (SW) had verbally provided him with names of two HHC providers but not a list for him to choose from. He was not aware that a list was available for him to make a choice.

Interview with the SW on 10/24/11 at approximately 1:30 p.m. revealed that on 10/20/11 the discharge needs were discussed with the patient. Electronic medical record review was conducted with the SW on 10/24/11. There was no documented evidence in the medical record to indicate that anyone had provided the patient with a list of HHC providers. The social worker stated that she discussed with the patient possible HHC services but did not provide the patient with a list.

Interview with the Director of Case Management was conducted at 10:30 a.m. 10/25/11. He stated that the SW had attended an in-service on 10/13/11 in regards to discharge planning covering the topic of providing the patient with a list of options for home care providers.

A review of form #80728 with a revision date of 10/24/08 indicated under the heading: Home Health Care Important Facts: Medicare allows you to choose a HHC company. Other insurances may have certain HHC agencies you must use. Your care coordinator or social worker will provide you with a list.

A review of the facility's Discharge Planning Policy CC-14, with a revision date of 10/11/11 indicated under the heading responsibility of Social Worker: When the discharge planning evaluation indicates a need for home health care or post hospital extended care services, included in the discharge plan a list of participating Medicare home health agencies or skilled nursing facilities that are available and serve the patients geographic area. A review of Policy CC-13 Home Health Referrals that was last reviewed on 10/11 noted under the heading Social Worker: Provide Patient and/or family with a list of home health care agency options.

Interview with the SW and the Risk Manager 10/27/11 at 1:23 p.m. was conducted She was asked to produce the original SW note without the amended portion for the date of 10/24/11 at 11:42 a.m. She stated that she could not pull it up in the new system. There was an amended section of the note that was changed on 10/25/11 at 8:19 a.m. indicating that the patient was provided with a list of options for after hospital continuing care needs. Patient agreeable to use above agency. Again, she was asked if she had provided a list and she stated she gave the patient names of providers verbally, not a written list.

Based on observations, interviews, and review of policy and procedure it was determined the facility did not have available defibrillators to meet the needs for each patient in the operating room suites. The practice may cause a delay in emergency treatment resulting in a negative outcome.

Findings include:

A tour of the surgery departments was conducted on 10/25/11 at approximately 10:20 a.m. accompanied by the Vice President of Surgical Services. During the tour it was observed there were (19) Operating Room (OR) Suites in the Main OR and (2) Code Carts with a Defibrillator. One of the code carts and defibrillator was designated for the Trauma OR.

Observation during the tour of the Surgery Center revealed there were (9) OR suites and (1) code cart with a defibrillator.

Observation during tour of the Women's Center revealed there were 11 bays for pre and post-surgery and 4 OR suites. There was 1 code cart with a defibrillator. An interview with the Vice President of Surgical Services was conducted during the tour. The Director confirmed that none of the above surgical suites contained a defibrillator.

An interview with the Main OR Manager was conducted during the tour. When questioned on the process for a patient in OR needing a defibrillator, she responded that the code button would be pushed and a team member would take the code cart to that OR suite. If both defibrillators were in use than a code cart would be brought from the recovery or holding areas.

An interview was conducted with the Vice President of Surgical Services on 10/25/11 during the tour and on 10/28/11 during the exit conference. When questioned if the facility had a policy addressing the required emergency equipment for the Operating Room Suite, he responded there was no policy.