HospitalInspections.org

A. Based on document/record review and staff interview it was determined for 1 of 10 patients (Pt. #2), the Hospital failed to ensure identification procedures were followed. Findings include:

1. The policy dated 8/1/08, titled, "Identification (color-coded) Bracelet" was reviewed on 9/11/13. The policy indicated under "6. The registration Ident-a-band...Reminder: The ID band should be validated with every encounter with the patient."

2. The medical record of Pt. #2 was reviewed on 9/11/13. Documentation indicated Pt. #2 was transferred from another hospital on 8/14/13 and was a direct admit to the medical surgical unit for a left fractured hip. Pt. #2 arrived at approximately 12:10 PM for orthopedic treatment. Documentation indicated three (3) 3 ID bands were placed on Pt.#2 by the Primary RN (E#2) indicating patient name, birthdate, fall risk and allergies at the time of the admission at 12:15 PM.

3. The Hospital complaint log was requested on 9/11/13. The Event Detail Summary report was presented. This report indicates documentation of filed complaints. Documentation indicated Pt. #2's complaint had been logged on 8/14/13. Documentation indicated Pt. #2 wore the wrong identification band. "RN admitted to putting the wrong armband on and then checked and seen (sic) that it was wrong and changed it immediately". Documentation on the laboratory report indicated the first specimens were collected at 1750 by the technician. Documentation indicated two medications were given on 8/4/13 before laboratory specimens were collected. Documentation indicated Morphine was given at 1518 and Lispro insulin was given at 1656, before the laboratory technician noticed the wrong ID band at 1750.

4. An interview was conducted with the Primary RN (E#2) on 9/11/13 at 3:10 PM. E#2 confirmed the wrong identification arm band was placed on Pt. #2. E#2 was notified by the laboratory technician that the identification band was incorrect. E#2 stated "it was my fault, I put the wrong band on the patient. It was replaced immediately after it was noticed".

B.. Based on document/record review and staff interview it was determined for 1 of 10 patients (Pt. #2), the Hospital failed to ensure pain assessment and pain management was completed during the initial assessment. Findings include:

1. The Hospital policy review date 8/12 titled, "Pain Management" was reviewed on 9/11/13. The policy indicated under "Statement of Purpose: All patients have the basic right to the aggressive and effective management of pain....All patients, in any age group, presenting themselves to Heartland Regional Medical Center experiencing pain from medical....A. Assessment 1. Scope and complexity of care is determined through the assessment...G. PAIN RATING AND PAIN ASSESSMENT 2. The Numeric Scale will be used universally to assess pain. Patients will be asked to rate their pain on a scale of 0 to 10. Zero will represent no pain; a rating of 10 would indicate the patient is experiencing intolerable pain.".

2. The medical record of Pt. #2 was reviewed on 9/11/13. Documentation indicated Pt. #2 was transferred from another hospital and was a direct admit to the medical surgical unit for a left fractured hip on 8/14/13 at 1210. Pt. #2 arrived at approximately 1210. The initial nursing assessment on 8/14/13 at 1649 was reviewed. Documentation indicated Pt. #2 was questioned about history of chronic pain and acceptable chronic pain level. There was no documentation to indicate a pain level assessment was completed to determine severity of pain. Documentation indicated on the "Profile Override" on 8/14/13 at 1518, Morphine Sulfate 2 mg. was given. Documentation on the MAR indicated on 8/14/13 at 1734 Morphine Sulfate 2 mg given. Documentation indicated on the "Nursing-Pain Assessment-Reassessment" on 8/14/13 at 2000 a pain level of "8".

3. An interview with Admissions RN (E#6) on 9/12/13 at 10:40 AM was conducted. E#6 recalled completing the admission assessment on the medical-surgical unit. Pt.#2 was complaining of pain. E#6 stated it was reported to the Primary RN( E#2) after the initial admissions paperwork was completed. An interview was conducted with the Primary RN (E#2) on 9/11/13 at 3:10 PM. E#2 recalled the MAR was not updated with Pt #2's information due to patient not in the system. An override had to be done to get medications. E#2 recalled being more concerned about the high blood sugars and confirmed the pain was not assessed and medication was not given per policy and the blank MAR form should have been completed.

C. Based on document/record review and staff interview it was determined the Hospital failed to ensure medication administration policies were followed for new admissions. Findings include:

1. The Hospital policy revision date 7/2012, titled, "Computer Down-Time Operations" was reviewed on 9/12/13. The policy under "2.1.4.7. Blank Medication Administration Records (MARs) shall be distributed and made available in every patient care area for use with new admissions and new medication orders."

2. A review of the MAR was conducted on 9/11/13. Documentation on the MAR indicated administration of medication for pain on 8/14/13 at 1734. Documentation on the "Profile Override" (computer override for medications not available on the MAR) was reviewed. The "Profile Override" indicated pain medication was given on 8/14/13 at 1518. There was no documentation to indicate a blank MAR was completed for the administration of drugs during the computer down time.

3. An interview was conducted on 9/11/13 at 3:10 PM with the Primary RN (E#2). E#2 explained the process of when the computer system has not been updated to capture new admissions or new medications. During this time, the MAR is not available to access medications. E#2 explained this usually occurs if there are several admissions. This process could take up to 30 minutes or longer before a nurse is able to access the MAR. E#2 explained during this down time we are to do a "Profile Override" to obtain medications and complete a blank MAR. E#2 confirmed a blank MAR was not completed for administering medications during the computer down time before the medications were entered into the computer.