HospitalInspections.org

Based on observation, policy review, clinical record review and interview the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care for 6 of 11 sampled patients (Patient # 1, 2, 4, 5, 6 and 8) as evidenced by failure to accurately assess patient's condition, failure to follow physician's orders and failure to reassess pain interventions.


The findings include:

Facility policy titled "Assessment and Reassessment-Patient Guidelines" last revised 08/2012 documents "Adult Assessment: Each patient will have an initial assessment completed upon admission based on unit specific parameters and interdisciplinary variables. Upon arrival to the nursing areas, the patient is assessed focusing on chief complaint, vitas signs and baseline data. Adult reassessment is completed every shift or more frequently as indicated by patient condition or unit specific parameters. Reassessment includes but is not limited to review of the following parameters, physiological, patient care needs and response to treatment".


1) Clinical record review on 09/15/15 revealed Patient # 1 was admitted to the facility on 06/19/15 with a cervical fracture.
Physician orders dated 06/19/15 documents cervical collar, change to pediatric size.
Initial nursing assessment and subsequent shift assessment dated 06/19/15 and 06/20/15 failed to document an assessment related to the implementation, use and fit of the cervical collar. The neurological, musculoskeletal and skin sections of the assessments do not indicate the patient had the cervical collar in place.
Interview with The Clinical Informatics who navigated the electronic record review on 09/15/15 at 9:32 AM revealed the comprehensive nursing assessments and nurses notes dated 06/19/15 and 06/20/15 do not include entries related to the prescribed cervical collar.


2) Clinical record review on 09/14/15 revealed Patient # 2 was admitted to the facility on 07/11/15 for a surgical procedure. Physician ' s orders dated 07/11/15 document Neurological checks every two hours for twenty four hours and then every four hours. Routine vital signs, Notify physician if heart rate greater than 110 or less than 60; systolic blood pressure greater than 120 or less than 95; diastolic blood pressure greater than 80 or less than 55 and respiratory rate greater than 20 or less than 12.
Further review of the clinical record failed to provide evidence neurological assessments were performed every two hours as ordered.
Vital signs documented on 07/11/15 revealed the following: At 12:58 PM blood pressure 153/98; at 2:41 PM heart rate 117 and blood pressure 135/77; at 4 PM blood pressure 136/87. The clinical record provides no evidence the physician was notified of vital signs readings outside the defined parameters.
Interview with Staff A, a Registered Nurse on 09/14/15 at 4:15 PM revealed the nurse was very familiar with Patient # 2 as he had multiple hospitalizations. Staff A explained she had been monitoring the vital signs and the readings were consistent with the readings in the recovery room, so she did not contact the physician. The readings outside the parameters were isolated events. Neurological assessment was done upon his arrival to the unit, around 1 PM and is not sure when she did the next one, she was in and out of the room. That day was very stressful as she had another patient who required a rapid response and her documentation was "not all that great".


3) Observation conducted on 09/14/15 at 12:55 PM revealed Patient # 4 lying in bed with eyes closed, the patient was receiving nutrition thru a feeding tube and was wearing a breathing mask. The patient did not have a pulse oximeter sensor in use.
Clinical record review on 09/14/15 revealed Patient # 4 was prescribed continuous pulse oximeter monitoring on 09/06/15.
Interview with The Nurse Manager who was navigating the electronic record on 09/14/15 at 1:48 PM revealed the manager was made aware Patient # 4 did not have the prescribed continuous pulse oximeter in use. The Manager sent a staff member to the room and confirmed there was no pulse oximeter in use.


4) Clinical record review conducted on 09/14/15 revealed Patient # 5 was prescribed Morphine 2 mg every four hours as needed for pain on 09/05/15. Medication administration records indicates Patient # 5 was medicated with Morphine on 09/14/15 at 8:22 AM; 09/13/15 at 9:56 AM and 3:15 PM. Further review of the record failed to provide evidence of pain reassessment.
Interview with The Nurse Manager who was navigating the electronic record on 09/14/15 at 2:12 PM revealed the manager reviewed the "PRN" (as needed) response screens, nurses' notes and administration records and was not able to provide evidence the pain reassessments were completed.


5) Clinical record review conducted on 09/14/15 revealed Patient # 6 was prescribed Oxycodone 1 or two tabs every four hours as needed for pain on 09/10/15. Medication administration records indicate Patient # 6 received the Oxycodone on 09/12/15 at 7:19 PM and on 09/14/15 at 11:07 AM. Further review of the record failed to provide evidence of pain reassessment.
Interview with The Nurse Manager who was navigating the electronic record on 09/14/15 at 2:36 PM revealed the manager reviewed the "PRN" (as needed) response screens, nurses' notes and administration records and was not able to provide evidence the pain reassessments were completed.


6) Clinical record review conducted on 09/15/15 revealed Patient # 8 was admitted to the facility on 08/06/15. Physician' s order dated 08/07/15 documents neurological checks every four hours for twenty four hours. Review of the assessments and reassessments failed to provide evidence neurological assessments were completed every four hours as ordered.
Interview with The Clinical Informatics who was navigating the electronic record on 09/15/15 at 10:06 AM revealed there is no evidence the neurological checks were completed as ordered.