HospitalInspections.org

Based on policy review, medical record review and interview, the hospital failed to ensure nursing staff documented care in accordance with hospital policy for medication administration, repositioning and prevention of pressure sores for 1 of 3 (Patient #3) sampled patients.

The findings included:

1. Review of the hospital policy Medication Reconciliation revealed "...hospital staff will make a good faith effort to obtain a list of all medications used by each patient who enters [name of hospital] as soon as possible after admission...when the home medication list is completed, the attending provider will be made aware that the medication history has been completed and the pharmacy will validate upon availability...the provider will determine which home medications will be continued, changed or discontinued during admission within 24 hours of the patients admission..."

Review of the hospital policy Administration of Medications revealed, "...Medications will be given accurately, safely and appropriately...Medication will be administered using the 'Five Rights' approach: Right medication, Right dose, Right time, Right patient, Right route of administration..."

Review of the hospital policy Wound Care Pressure Ulcer Management revealed, "All patients will receive a thorough skin assessment upon admission and will be reassessed daily. Nursing will contact the physician to notify of skin breakdown and initiate wound care treatment...Procedures/Special Instructions: Establish a turning schedule. Reposition every 2 hours ...Nursing Interventions for existing skin breakdown... Document the following: size of wound (measuring in centimeters) length...X [by] width...X depth.... Wounds must be measured at time of admission or injury and every 7 days after... Notify the physician of skin break down. Obtain an order to initiate the Wound care treatment protocol set or other wound care orders as indicated by the physician..."

2. Medical record review for Patient #3 revealed a 78-year-old male admitted on 4/20/2021 with diagnosis of Sepsis, Urinary Tract Infection, Dementia and Altered Mental status. Review of the physician orders revealed an order for memantine (Namenda- used to treat symptoms of Alzheimer's disease) 10 milligrams 1 tablet daily after lunch at 1:00 PM. The medication order was electronically signed on 4/21/2021 at 11:52 AM. Review of the medication administration record for 4/21/2021 revealed the memantine was not given on 4/21/2021 at 1:00 PM as ordered. The nursing staff failed to administer the medication as ordered.

During an interview on 6/17/2021 at 10:00 AM, the Quality Manager verified the medication was not given as ordered by the physician on 4/21/2021.

Review of the nursing documentation for repositioning Patient #3 every 2 hours revealed the nursing staff did not consistently document repositioning as required by hospital policy from 4/21/2021 through 4/29/2021.

During an interview on 6/17/2021 at 11:20 AM, the Quality Manager verified the medical record did not always document Patient #3 was repositioned every 2 hours.

Review of the wound documentation revealed a sacral wound was identified on 4/30/2021 as a deep tissue injury. There were no measurements of the wound documented. The nursing staff documented a foam dressing was applied to the wound on 4/30/2021. There was no documentation the physician was notified of the wound development or that the physician ordered the foam dressing treatment.

During an interview on 6/23/2021 at 10:50 AM, the Quality Manager verified there was no documentation of the wound measurements and no physician orders for the foam dressing that was applied to the wound by nursing.