HospitalInspections.org

Based on document review and interview the facility failed to ensure that nursing staff followed their policy/procedure for assessing a patient's changes in condition and failed to follow physician orders related to medical precautions for a patient withdrawing from opiates in 1 (patient 2) of 10 medical records (MR) reviewed:

Findings include:

1. Policy/procedure, 800.18, Assessing Changes in Condition, revised/reviewed 1/19 indicated on page 1: "To identify warning signs of clinical deterioration in a patient's medical condition in order to provide early response treatment that may affect patient mortality. To ensure staff is trained to recognize warning signs of clinical deterioration in a patient's medical condition and know what action is to be taken.

2. Review of patient 2's MR lacked documentation of assessment of the patient withdrawing from opiates on 11/27/19 at 1900, 2100, 2300 hours and 11/28/19 at 0100 and 0300 hours.

3. Review of patient 2's MR lacked documentation of reinitiation for opiate withdrawal / detox precautions / assessments after patient complaints of nausea on 12/1/19. Review of Physician Order dated 11/30/19 at 2055 hours per medical staff D1 indicated: "Discontinue (D/C) COWS". Review of the Clinical Opiate Withdrawal Assessment form (COW) dated 11/30/19 at 1148 and 1548 hours indicated: "Gastrointestinal (GI) Upset: '2' Nausea" Review of Physician Order dated 12/1/19 at 2030 hours per medical staff D1 indicated: "Zofran 4 mg by mouth, 1 dose now related to nausea/vomiting". Review of Nursing Progress Note dated 12/1/19 at 1800 hours indicated: "...Patient stated he/she did not feel good and stayed on the unit for dinner". Review of Nursing Progress Note dated 12/1/19 at 2100 hours per staff N5 (RN) indicated: "...Patient complained of nausea with no episode of vomitus. Per medical staff D1, patient received Zofran 4 mg times 1 dose at 2100". Review of patient 2's MR indicated CPR was initiated at 1117 hours on 12/2/19 by staff N3 and N4 and discontinued at 1137 hours and transported to F1.

4. On 12/11/19 at approximately hours, 1400 staff N7 (Chief Nursing Officer) was interviewed and confirmed patient 2's observation precautions related to detoxification were not reinitiated after the patient began experiencing signs/symptoms of nausea on 12/1/19. Staff N7 confirmed patient 2's MR lacked documentation of an opiate withdrawal assessment on 11/27/19 at 1900, 2100, 2300 hours and 11/28/19 at 0100 and 0300 hours as ordered per medical staff D1 upon admission.