HospitalInspections.org

The Hospital was out of compliance for the Condition of Participation for Nursing Services.

Findings included:

Based on record review and interviews, the Hospital failed to ensure physician orders (monitoring and medication administration) were followed for one Patient (#1) out of a total sample of ten patients.

Cross Reference:
482.23(b)(3) - A registered nurse must supervise and evaluate the nursing care for each patient. (395)
482.23(c) - Standard: Preparation and Administration of Drugs (405)

Based on record review and interview, the Hospital failed to ensure one Patient (#1) out of a total sample of ten patient ' s received Telemetry monitoring as ordered by the Physician.

Findings include:

Review of Patient #1 ' s medical records indicated that he/she was transferred from an outside hospital (OSH) on 12/24/24 for chest pain in the setting of dialysis with a concern for a NSTEMI (non-ST elevation myocardial infarction) given his/her known cardiac history. Patient #1 had a history of cardiomyopathy (a disease where the heart muscle becomes weakened, stretched, or otherwise structurally abnormal, making it harder for the heart to pump blood effectively), kidney disease stage 5 on hemodialysis (a procedure that cleans the blood outside the body using a machine that acts as an artificial kidney). Patient #1 was started on a Heparin (an anticoagulation medication) drip, telemetry monitoring and admitted to the cardiology service for further management.

Review of Patient #1 ' s medical record indicated that there was a physician order entered on 12/24/24 at 6:19 P.M., for Telemetry/EKG assessment (a method of remotely monitoring vital signs and heart activity).

Review of the Telemetry/EKG assessment flowsheet dated 12/26/24 at 12:00 A.M., indicated that Patient #1 had pulled off the leads to his/her telemetry monitor and the Physician was aware. Further review of Patient #1 ' s medical record failed to indicate the Patient was ever placed back on Telemetry monitoring as ordered, after he/she had removed the leads.

Review of the Nurse ' s Note dated 12/26/24 at 2:04 A.M., indicated Patient #1 wanted to leave against medical advice and asked the Nurse to take the IV out and despite attempts at redirection, Patient #1 continued to have behaviors and the provider was notified. The note indicates a code was called, Patient #1 was agitated, punched the psychiatric nurse and was unable to be redirected. The note further indicates Haldol (antipsychotic used to treat nervous, emotional, and mental conditions) 5mg (milligrams), Ativan (a benzodiazepine used to treat anxiety) 2mg and Benadryl (an antihistamine primarily used to prevent extrapyramidal side effects from antipsychotics) 50mg were administered for good effect. The note indicates vital signs were performed and nursing was to continue to monitor Patient #1.

Review of the Progress Note documented by the resident physician dated 12/26/24 at 6:56 A.M., indicated Patient #1 was agitated on 12/26/24 around 1:00 A.M. trying to leave the hospital and being aggressive. The note indicated Patient #1 was confused and a code gray was called; Patient #1 was given 5 mg of Haldol, 2 mg of Ativan and 50 mg of Benadryl. The patient went to sleep and was checked every hour. The last vital sign assessment was around 4:15 A.M, which were stable. The note indicated another checkup was completed around 5:30 A.M., the patient was sleeping comfortably and snoring loudly. The note further indicated that multiple attempts were made to put the patient back on Telemetry leads and IV lines, but the patient refused. The RN went to do the GlucoCheck (measures blood sugar) at 6:05 A.M. and found Patient#1 not responsive and pulseless.

During an interview on 4/16/25 at 1:45 P.M., the Cardiology Fellow said he saw Patient #1 on 12/25/24 around 7:00 P.M., and he/she was doing okay. He said he was made aware that the patient was refusing telemetry monitoring. The Cardiology Fellow said he checked in with the nursing staff overnight to see how the patient was doing. He said the nursing staff were also notifying the Resident Physicians of the patient refusing telemetry monitoring. He said he asked the nursing staff to keep trying to put the telemetry leads on. The Cardiology Fellow said the Patient (Patient #1) was stable.

During an interview on 4/18/25 at 9:45 A.M., the Nurse Manager of 6 West said if a patient removes or refuses telemetry monitoring the expectation is for the Nurse to document in a Nurses Note or telemetry intervention that the patient removed the leads and is refusing telemetry monitoring and that the MD was notified. The Nurse Manager further said if a patient continues to refuse attempts to reapply telemetry, the nurse should document patient continued to refuse and the MD was notified.

The Hospital failed to ensure Telemetry monitoring was completed as ordered by the Physician for Patient #1.

Based on record review and interview, the Hospital failed to ensure IV (Intravenous) Heparin (a medication used to decrease clotting ability of the blood and prevent clots from forming) was administered in accordance with a physician order for one Patient (#1) out of a total sample of 10 patients.

Findings included:

Review of the Hospital policy titled "Medication Administration Chapter: Medication Management Policy Number: MM 21 Last Revised 7/16/24, indicated the following:

A. Orders for Medication Administration: 2. Medications are prepared and administered in accordance with the orders of an Licensed Practitioner (LP) responsible for the patient ' s care, and in accordance with law and regulation.

D. Missed or Untimely Administration: 1. Missed administration of medications: The circumstances for missed administrations may include but are not limited to; the patient is in NPO status, the patient is off the unit, the medication dose is unavailable, the patient refuses the medication, or the patient is not able to take medication. In these circumstances the missed medication administration is reviewed with the provider and/or pharmacy to determine the next time of administration. Documentation is entered in the e-MAR including the reason for the missed administration.

Review of Patient #1 ' s medical records indicated that he/she was transferred from an outside hospital (OSH) on 12/24/24 for chest pain in the setting of dialysis with a concern for a NSTEMI (non-ST elevation myocardial infarction) given his/her known cardiac history. Patient #1 has a history of cardiomyopathy (a disease where the heart muscle becomes weakened, stretched, or otherwise structurally abnormal, making it harder for the heart to pump blood effectively), kidney disease stage 5 on hemodialysis (a procedure that cleans the blood outside the body using a machine that acts as an artificial kidney). Patient #1 was started on a Heparin drip, telemetry monitoring and admitted to the cardiology service for further management.

Review of the medical record indicated that an order was placed for intravenous (IV) Heparin on 12/24/24 at 6:03 P.M., to titrate per protocol.

Review of the Heparin Medication Detail Flowsheet indicated that on 12/25/24 at 10:54 P.M., the Heparin infusion was decreased by 1 unit/kg/hour per protocol.

Review of the IV/Invasive Line Assessment dated 12/25/24 at 7:35 P.M., indicated the IV to the right upper arm was asymptomatic, intact and patent.

Review of the Nurses Note dated 12/26/24 at 2:04 A.M., indicated that Patient #1 wanted to leave against medical advice. Patient #1 asked the Nurse to take the IV out, and the nurse attempted to educate and redirect without success. Patient #1 continued to act out and the provider was notified. The note indicates a code was called, the Patient was agitated, punched the psychiatric nurse and was unable to be redirected. The note further indicated medication (Haldol 5mg, Ativan 2mg and Benadryl 50mg) was administered for good effect. The note indicated that vital signs were performed, and nursing was to continue to monitor.

Review of the Progress Note documented by the resident physician dated 12/26/24 at 6:56 A.M., indicated that Patient #1 was agitated on 12/26/24 around 1:00 A.M. trying to leave the hospital and being aggressive. The note indicated Patient #1 was confused and a code gray was called; Patient #1 was given 5 mg of Haldol, 2 mg of Ativan and 50 mg of Benadryl. The patient went to sleep and was checked every hour. The last vital checks were around 4:15 A.M, which were stable. Another checkup was around 5:30 A.M., the patient was sleeping comfortably and snoring loudly. The note further indicates that multiple attempts were made to put the patient back on Telemetry leads and IV lines, but the patient refused. The RN went to do the GlucoCheck (blood glucose check) at 6:05 A.M. and found Patient #1 not responsive and pulseless.

During an interview on 4/17/25 at 10:42 A.M., the Cardiology Fellow said he was made aware the IV Heparin wasn ' t running after Patient #1 pulled his/her IV line. He said the resident physician also had a discussion with the Charge Nurse regarding the IV. He said the Charge Nurse was making attempts to place another IV. The Cardiology Fellow said the patient was stable.

During an interview on 4/18/25 at 9:45 A.M., the Nurse Manager of 6 West said the expectation when a medication is refused by a patient is to document in the Medication Administration Record (MAR) as well as a nurse ' s note and that the provider was notified. She said IV Heparin gets documented at change of shift and with any titrations. The Nurse Manager of 6 West said it is the expectation that the nurse documents when a patient removes their IV. She said if a patient refuses a new IV, the provider should be notified, and the IV Heparin order should be discontinued.

The Hospital failed to ensure IV Heparin was administered as ordered for Patient #1.