HospitalInspections.org

Based on interview and record review, the hospital failed to ensure two of 30 sampled patients (13 and 17) were asked if they had an advance directive on admission which had the potential to result in a violation of patient rights to request or refuse care.

Findings:

1. During a concurrent interview and electronic record review with Registered Nurse (RN) 5, on 10/15/15 at 10 AM, the Patient Data Profile for Patient 13 was viewed. The screen for "Advance Directive" was blank. The electronic record indicated Patient 13 was admitted to the hospital on 9/29/15. RN 5 verified the advance directive assessment was not completed.

2. During a concurrent interview and electronic record review with RN 16, on 10/15/15 at 2:45 PM, the Patient Data Profile for Patient 17 was viewed. The screen for "Advance Directive" was blank. The electronic record indicated Patient 17 was admitted to the hospital on 10/13/15. RN 16 verified the advance directive assessment was not completed.

The hospital policy and procedure titled "Advance Health Care Directives, Surrogate Decision Maker and Decision Making for Patients Without," dated 5/11/13, indicated "During admission the nurse is required to ask if the patient has an Advance Directive. This is documented in the Advance Directive section of the Patient Data Profile (PDP)."

Based on interview and record review, the hospital failed to follow the hospital's policy and procedure to reassess one of thirty sampled patients (15) for pain relief following the administration of an increased dose of pain medication which had the potential to result in prolonged pain and discomfort.

Findings:

During a concurrent interview and record review with Registered Nurse (RN) 4 on 10/15/15 at 11 AM, the electronic medication administration record (MAR) for Patient 15 indicated she was on a fentanyl drip (narcotic pain medication delivered directly into the vein for continuous administration). The MAR indicated on 10/14/15 at 6:19 AM, the fentanyl drip rate was increased to 200 micrograms per hour due to an assessed pain level of 4 (using a standard pain scale of 0-10). There was no documented reassessment of the effects of the increased dose until 9 AM. RN 4 stated staff should have reassessed Patient 15's pain within an hour after the increased dose.

The hospital policy and procedure titled "Pain Management Assessment/Reassessment," dated 9/24/15, indicated "A pain reassessment shall be performed within approximately one hour after pain intervention and if pain level increases."

Based on interview and record review, the hospital failed to ensure a post procedure note was dictated timely for one of 30 sampled patients (15) which had the potential to result in a lack of information provided to the healthcare team to determine care needs.

Findings:

During a concurrent interview and review of the clinical record for Patient 15 with Registered Nurse (RN) 17, on 10/15/15 at 11:20 AM, the electronic clinical record was reviewed. The record indicated Patient 15 had a lung biopsy completed on 10/13/15. The "POST PROCEDURE NOTE", dated 10/13/15 at 2:40 PM, indicated a handwritten note by the physician that there was bleeding post procedure. There was no dictated note found in the electronic record. This was confirmed with RN 17.

During an interview with the Medical Staff Director, on 10/15/15 at 11:20 AM, she stated the dictated note following surgery or invasive procedure should be completed immediately after the case is finished.

The hospital policy and procedure titled "Medical Record Content and Suspension Policy", dated 1/2012, indicated "The operative report will be dictated or entered into computerized software application on completion of surgery/invasive procedure. No handwritten reports will be accepted."