HospitalInspections.org

Based on interview, and record review the hospital failed to ensure 1 of 1 patient (Patient #1) who was admitted to the hospital for alcohol detoxification was evaluated by RN's (Registered Nurses) every shift and/or while awake on the CIWA (Clinical Institute Withdrawal Assessment). The facility further failed to re-check Patient #1's B/P prior to discharge on 01/20/15.

Findings included:

Patient #1's Physician's Preadmission Examination Orders and Preliminary Plan of Care dated 01/16/15 reflected, "Initiate Alcohol Detoxification Protocol...Librium protocol..."

The History and Physical dated 01/17/15 reflected, "Patient #1...wishes to detox on alcohol...blacked out on Monday and fell and hit her head...blood pressure 106/92, pulse 80 and respirations 18...has a bruise over her left eye...alcohol dependence, contusion to the left side of face, hypertension."

The Psychiatric Evaluation dated 01/17/15 reflected, "Reports she blacked out for the first time ever...started as a social drinker then progressed from there...last drink was Monday spent the first three days at home with phenergan...now she is on libruim...alcohol three liters a week..."

The Clinical Institute Withdrawal Assessment (CIWA) assessments for Patient #1's stay dated 01/16/15 through 01/20/15 were reviewed. Patient #1 had only one CIWA assessment completed during her inpatient stay.

The 01/19/15 CIWA assessment reflected, "B/P 98/58, pulse 82, respirations 18, temperature 96.5...mild nausea scored at 1, anxiety scored at 6, paroxysmal sweats scored at 1, tactile disturbances scored at 0, visual disturbances scored at 0, tremors scored at 3, agitation scored at 6, orientation scored at 0, auditory disturbances scored at 3 and headache scored 2...the CIWA was scored at 22." The CIWA score indicated increased risk of alcohol withdrawal signs.

The nursing progress note dated 01/20/15 timed at 1445 reflected, "At 0700 B/P 96/69...finished detox." No B/P re-check was completed for Patient #1 prior to discharge nor was a CIWA assessment completed.

On 06/11/15 at 1225 Personnel #2 was interviewed. Personnel #2 was asked to review Patient #1's medical record and locate Patient #1's CIWA assessments and nursing note documentation for 01/20/15. Personnel #2 verified a CIWA assessment had not been completed for 01/16/15, 01/17/15, 01/18/15 and for two other shifts on 01/19/15. Personnel #2 stated no CIWA was completed for 01/20/15. Personnel #2 verified Patient #1's blood pressure should have been re-checked and an assessment completed before the patient was discharged on 01/20/15.

The policy and procedure entitled, "Detoxification" with a review date of July 2012 reflected, "Each person entering treatment for chemical dependency that requires detoxification shall be admitted on a prescribed detox protocol...the following symptoms are commonly found and are to be observed for...nervousness, agitation, tremulousness, apprehension, anxiety, diaphoresis, nausea, vomiting, elevated vital signs, seizures, hallucinations, delirium tremens...nursing staff will provide close monitoring and comfort measures...patients must be offered fluids and light nourishment frequently...patients on Alcohol Detox Protocol will have Clinical Institute Withdrawal Assessment (CIWA) completed on them a minimum of each shift, while awake...this clinical tool assesses 10 common withdrawal signs...a score of 15 points is associated with increased risk of alcohol withdrawal effects, such as confusion or seizures...CIWA will be continued until discontinued by the physician..."

Based on interview, and record review the hospital failed to ensure 1 of 1 patient (Patient #1) who was admitted to the hospital for alcohol detoxification was provided the necessary care by RN's (Registered Nurses). CIWA (Clinical Institute Withdrawal Assessments) were not completed every shift. The facility further failed to re-check Patient #1's B/P prior to discharge on 01/20/15.

Findings included:

Patient #1's Physician's Preadmission Examination Orders and Preliminary Plan of Care dated 01/16/15 reflected, "Initiate Alcohol Detoxification Protocol...Librium protocol..."

The History and Physical dated 01/17/15 reflected, "Patient #1...wishes to detox on alcohol...blacked out on Monday and fell and hit her head...blood pressure 106/92, pulse 80 and respirations 18...has a bruise over her left eye...alcohol dependence, contusion to the left side of face, hypertension."

The Psychiatric Evaluation dated 01/17/15 reflected, "Reports she blacked out for the first time ever...started as a social drinker then progressed from there...last drink was Monday spent the first three days at home with phenergan...now she is on libruim...alcohol three liters a week..."

The Clinical Institute Withdrawal Assessment (CIWA) assessments for Patient #1's stay dated 01/16/15 through 01/20/15 were reviewed. Patient #1 had only one CIWA assessment completed during her inpatient stay.

The 01/19/15 CIWA assessment reflected, "B/P 98/58, pulse 82, respirations 18, temperature 96.5...mild nausea scored at 1, anxiety scored at 6, paroxysmal sweats scored at 1, tactile disturbances scored at 0, visual disturbances scored at 0, tremors scored at 3, agitation scored at 6, orientation scored at 0, auditory disturbances scored at 3 and headache scored 2...the CIWA was scored at 22." The CIWA score indicated increased risk of alcohol withdrawal signs.

The nursing progress note dated 01/20/15 timed at 1445 reflected, "At 0700 B/P 96/69...finished detox." No B/P re-check was completed for Patient #1 prior to discharge nor was a CIWA assessment completed.

On 06/11/15 at 1225 Personnel #2 was interviewed. Personnel #2 was asked to review Patient #1's medical record and locate Patient #1's CIWA assessments and nursing note documentation for 01/20/15. Personnel #2 verified a CIWA assessment had not been completed for 01/16/15, 01/17/15, 01/18/15 and for two other shifts on 01/19/15. Personnel #2 stated no CIWA was completed for 01/20/15. Personnel #2 verified Patient #1's blood pressure should have been re-checked and an assessment completed before the patient was discharged on 01/20/15.

The policy and procedure entitled, "Detoxification" with a review date of July 2012 reflected, "Each person entering treatment for chemical dependency that requires detoxification shall be admitted on a prescribed detox protocol...the following symptoms are commonly found and are to be observed for...nervousness, agitation, tremulousness, apprehension, anxiety, diaphoresis, nausea, vomiting, elevated vital signs, seizures, hallucinations, delirium tremens...nursing staff will provide close monitoring and comfort measures...patients must be offered fluids and light nourishment frequently...patients on Alcohol Detox Protocol will have Clinical Institute Withdrawal Assessment (CIWA) completed on them a minimum of each shift, while awake...this clinical tool assesses 10 common withdrawal signs...a score of 15 points is associated with increased risk of alcohol withdrawal effects, such as confusion or seizures...CIWA will be continued until discontinued by the physician..."