HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 1 (Pt #3) clinical record reviewed of a patient receiving dialysis, the Hospital failed to ensure the patient's plan of care was complete to include the patient's dialysis.

Findings include:

1. Hospital policy entitled, "Assessment/Re-Assessment - Interdisciplinary Patient," (release date 5/2015) required, "Procedure...3. Nursing Department: c. The admission assessment data is a primary source for the RN to develop and prioritize nursing care needs specific to the patient. A Patient Plan of Care developed and recorded within 24 hours of admission by the RN based on identified problems and patient specific needs."

2. The clinical record of Pt #3 was reviewed on 5/5/16 at approximately 10:30 AM. Pt #3 was a 36 year old male admitted on 4/21/16 with a diagnosis of respiratory failure. Pt #3's clinical record contained a physician's order dated 4/22/16 that required Pt #3 start dialysis on 4/23/16, three days a week. Clinical documentation included dialysis starting on 4/23/16 and continuing 5/3/16. Pt #3's clinical record contained a plan of care that lacked the inclusion of Pt #3's dialysis three days a week.

3. The Clinical Nurse Manager stated during an interview on 5/5/16 at approximately 10:30 AM that the plan of care did not contain Pt #3's dialysis which should have been included.

Based on document review and interview it was determined that for 2 of 2 (Pt #2 and 10) clinical records reviewed for pain control, the Hospital failed to ensure the completion and documentation of a pain assessment when a pain medicine was administered.

Findings include:

1. Hospital policy entitled, "Pain Management Plan," (undated) required, "Components...B. Ongoing Assessments/Reassessments by licensed nursing staff...2. When pain is identified, nursing assessment and documentation in the patient medical record include the pain scale rating, location, duration, intensity and character."

2. The clinical record of Pt #2 was reviewed on 5/5/16 at approximately 10:15 AM. Pt #2 was a 44 year old female admitted on 3/25/16 with a diagnosis of multiple fractures post surgery. Pt #2's clinical record contained a physician's order dated 4/7/16 that required Norco 325 milligrams (pain medication) every 4 hours as needed for severe pain. Pt #2's clinical record lacked documentation of the pain assessment required for the administration of the medication: 4/24 at 10:00 PM; 4/25 at 7:45 AM, 4:30 AM, and 9:00 PM; 4/26 at 230 PM, and 10:00 PM; 4/30 at 10:00 PM; and 5/1/16 at 9:00 PM.

3. The clinical record of Pt #10 was reviewed on 5/6/16 at approximately 10:45 AM. Pt #10 was an 84 year old female admitted on 5/3/16 with a diagnosis of lung disorder. Pt #10's clinical record contained a physician's order dated 5/4/16 that required tramadol 50 milligrams (pain medication) every 8 hours as needed for pain. Pt #10's clinical record lacked documentation of the pain assessment required for the administration of the medication: 5/5/at 3:30 PM and 5/6/16 at 3:17 AM.

4. The Clinical Nurse Manager stated during interviews on 5/5/16 at approximately 10:15 AM and 5/6/16 at approximately 10:50 AM that the patient's indication for the administration of the pain medicines was not assessed nor documented.

Based on document review and interview it was determined that in 2 of 3 (Pt #8 and 9) clinical records of patients that received blood transfusions, the Hospital failed to ensure the patients were assessed post transfusion as required.

Findings include:

1. Hospital policy entitled, "Transfusion Therapy," (release date 5/2015) required, "Procedure...10. Post -Transfusion: a. Obtain immediate post transfusion vital signs; b. Because patients can experience delayed transfusion reactions, caregivers should continue to monitor the patient for signs and symptoms of reaction during the first hour post transfusion. A final set of vital signs should be obtained 1 hour after the end of the transfusion..."

2. The clinical record of Pt #8 was reviewed on 5/5/16 at approximately 1:00 PM. Pt #8 was an 88 year old male admitted on 2/24/16 with a diagnosis of pressure ulcer. Pt #8's clinical record contained a physician's order dated 2/29/16 for 2 units of packed red blood cells. Pt #8's first unit (#W039716137088) was infused from 4:55 PM until 8:25 PM. The transfusion record for the first unit lacked a 1 hour post transfusion vital sign assessment as required. Pt #8's second unit of packed red blood cells(#W039716156477) was infused from 11:05 PM until 3:00 AM on 2/30/16. The transfusion record for the second unit lacked the end of transfusion vital sign assessment as required.

3. The clinical record of Pt #9 was reviewed on 5/5/16 at approximately 1:15 PM. Pt #9 was a 24 year old male admitted on 12/4/15 with a diagnosis of status post gun shot wound with a tracheotomy on a ventilator. Pt #9's clinical record contained physician's orders dated 2/23 and 3/26/16 that required the infusion of 1 unit of red blood cells each order. Pt #9's unit dated 2/23/16 (#W0397161537390 was infused on 2/23/16 from 3:05 AM to 6:00 AM on 2/24/16. The transfusion record lacked documentation of end of transfusion and 1 hour post transfusion vital sign assessments as required. The second unit dated 3/27/16 (W039716149481) was infused from 3:15 AM to 6:15 AM on 3/27/16. The transfusion record lacked documentation of the end of transfusion vital sign assessment as required.

4. The Clinical Nurse Manager stated during an interview on 5/6/16 at approximately 11:00 AM that the transfusion records should have been completed after the transfusion.