HospitalInspections.org

Based on document review and interview, the facility failed to ensure physician orders were followed for 1 of 10 medical records (MR) reviewed (#1).

Findings included:

1. Medical record #1 indicated the patient was admitted on 04/15/15 after an automobile accident with a subdural hemorrhage, fractures of the cervical spine, pelvis, sacrum, and femur, and burns to the right lower extremity. On 06/09/15, there were physician orders for Hydromorphone 0.5 mg. (milligrams) IV (intravenous) push daily with burn dressing changes only, apply clean dressing to wound located on pelvis and leg daily and more frequently if necessary, dress with gauze and medipore, and Oxycodone HCl 5 mg./Acetaminophen 325 mg. 2 tabs, via feeding tube every 6 hours, scheduled, and 1 tab. every 6 hours as needed for pain or signs of distress/neurostorm (heart rate greater than 130, respiratory rate greater than 35). Review of the record indicated the following dates and times for the dressing changes and medication administration: 06/10/15- Hydromorphone at 2050 hours and dressing change at 2210 hours, 06/11/15- Hydromorphone at 1821 hours and dressing change at 1956 hours, 06/12/15- Hydromorphone at 2131 hours and dressing only checked at 2200 hours, 06/13/15- no Hydromophone and dressing only checked, 06/14/15- no Hydromorphone and dressing change at 0110 hours, 06/15/15- no Hydromorphone or dressing change, 06/16/15- no Hydromorphone and dressing change at 0005 hours, 06/17/15- no Hydromorphone and dressing change at 1420 hours, 06/18/15- no Hydromorphone and dressing change at 1458 hours, 06/19/15- no Hydromorphone and dressing change at 1523 hours, 06/20/15- Hydromorphone at 1821 hours, but no dressing change, and 06/21/15- Hydromorphone at 1942 hours, but no dressing change.

2. At 3:15 PM on 08/07/15, staff member #5, the Acuity Adaptable Clinical Manager and staff member #6, the Acuity Adaptable Service Line Administrator, confirmed the lack of documentation indicating the medication was given prior to the dressing changes or reasons for the omission.