HospitalInspections.org

Based on review of the patient's rights notice document and interview, it was determined the facility failed to include the State Agency's phone number and address on the Patient Rights documents given to patients on admission to the facility. The failed practice did not allow patients to place their complaints in writing or call them to the State Agency. The failed practice affected all patients admitted to the facility. Findings follow:

A. Review of the pamphlet titled, "A Guide for Patients, Your Rights," received from the Director of Nursing (DON) on 02/07/2019, showed the Arkansas Department of Health, Health Facility Services address and phone number were not listed in the pamphlet.

B. The DON verified the above findings during an interview at 9:30 AM on 02/07/19.

Based on clinical record review and interview, it was determined a registered nurse failed to assess and manage the patient's care, needs and response to treatment as ordered by the physician for 12 (#1-4, #9-10, #13, #16-20) of fifteen (#1-4, #9-10, #13-20) patients in that there was no evidence vital signs were performed twice a day and no evidence weights were obtained and documented weekly. Failure to ensure vital signs and weights were obtained and documented did not allow the responsible physician to have access to information needed to make informed decisions regarding the care and treatment of the patient. The failed practice had the potential to affect Patients #1-4, #9-10, #13, and #16-20. Findings follow:

A. Review of Patient #1's clinical record showed an admission date of 05/01/18 and a discharge date of 05/09/18. The clinical record showed orders authored by Physician #1 on 05/01/18 for vital signs BID (twice a day) and weight on admission and weekly. The clinical record showed no evidence vital signs were performed and documented BID for seven of seven (05/02/18 through 05/08/18) days. Review of the clinical record showed no weekly weight documented.

B. Review of Patient #2's clinical record showed an admission date of 05/01/18 and a discharge date of 05/07/18. The clinical record showed orders authored by Physician #3 on 05/01/18 for vital signs BID. The clinical record showed no evidence vital signs were performed and documented BID for five of five (05/02/18 through 05/05/18) days.

C. Review of Patient #3's clinical record showed an admission date of 04/29/18 and a discharge date of 05/06/18. The clinical record showed orders authored by Physician #1 on 04/29/18 for vital signs BID. The clinical record showed no evidence vital signs were performed and documented BID for six of six (04/30/18 through 05/05/18) days.

D. Review of Patient #4's clinical record showed an admission date of 04/26/18 and a discharge date of 05/07/18. The clinical record showed orders authored by Physician #1 on 04/26/18 for vital signs BID and weight on admission and weekly. The clinical record showed no evidence vital signs were performed and documented BID for ten of ten (04/27/18 through 05/06/18) days. Review of the clinical record showed no weekly weight documented.

E. Review of Patient #9's clinical record showed an admission date of 01/31/19. The clinical record showed orders authored by Physician #2 on 01/31/19 for vital signs BID. The clinical record showed no evidence vital signs were performed and documented BID for two (02/01/19 and 02/05/19) of five (02/01/19 through 02/05/19) days.

F. Review of Patient #10's clinical record showed an admission date of 02/01/19. The clinical record showed orders authored by Physician #2 on 01/31/19 for vital signs BID. The clinical record showed no evidence vital signs were performed and documented BID for two (02/03/19 and 02/06/19) of six (02/01/19 through 02/06/19) days.

G. Review of Patient #13's clinical record showed an admission date of 02/01/19. The clinical record showed orders authored by Physician #1 on 02/01/19 for vital signs BID. The clinical record showed no evidence vital signs were performed and documented BID for two (02/02/19 and 02/06/19) of six (02/01/19 through 02/06/19) days.

H. Review of Patient 16's clinical record showed an admission date of 02/01/19. The clinical record showed orders authored by Physician #1 on 02/01/19 for vital signs BID. The clinical record showed no evidence vital signs were performed and documented BID for four of four (02/02/19 through 02/05/19) days.

I. Review of Patient #17's clinical record showed an admission date of 12/21/18. The clinical record showed orders authored by Physician #1 on 12/21/18 for vital signs BID and weight on admission and weekly. Review of the clinical record showed no evidence vital signs were performed and documented BID for 30 (12/23/18, 12/24/18, 12/28/18, 12/29/18, 12/31/18, 01/04/19, 01/07/19 through 01/10/19, 01/12/19 through 01/16/19, 01/20/19, 01/21/19, 01/23/19 through 01/25/19, 01/27/19 through 01/31/19, and 02/02/19 through 02/06/19) of 47 (12/22/18 through 02/06/19) days. Review of the clinical record showed weekly weights were not performed two (week of 01/05/19 and 01/12/19) of six (12/29/19, 01/05/19, 01/12/19, 01/26/19 and 02/02/19) weeks.

J. Review of Patient #18's clinical record showed an admission date of 01/22/19. The clinical record showed orders authored by Physician #1 on 01/22/19 for vital signs BID. The clinical record showed no evidence the vital signs were performed and documented BID for two (01/25/19 and 01/26/19) of four (01/23/19 through 01/26/19) days.

K. Review of Patient #19's clinical record showed an admission date of 10/30/18 and a discharge date of 11/12/18. The clinical record showed orders authored by Physician #1 for vital signs BID and weekly weights. Review of the clinical record showed no evidence the vital signs were performed and documented five (11/04/18, 11/08/19 through 11/11/18) of twelve (10/31/18 through 12/11/18) days. Review of the clinical record showed no weekly weight documented.

L. Review of Patient #20's clinical record showed an admission date of 01/08/19 and a discharge date of 01/12/19. The clinical record showed orders authored by Physician #1 on 01/08/19 for vital signs BID. The clinical record showed no evidence the vital signs were performed for five (01/08/19 through 01/12/19) days as the graphic sheets were not in the clinical record and could not be located.

M. The Director of Nursing during an interview from 12:25 PM to 12:35 PM on 02/07/19 verified the findings in A through L.