HospitalInspections.org

Based on policy and procedure review, medical record review, and staff interviews, the hospital nursing staff failed to supervise and evaluate the nursing care for each patient by failing to assess/reassess the risk for complications per hospital policy for 2 of 2 records reviewed with CIWA protocol orders (Pt #2, #11).

Findings included:

Review on 10/17/2024 of the policy and procedure titled, "Alcohol withdrawal management" revised 05/20/2024 revealed, "... Health care professional should be skilled in assessing and monitoring patients at risk for withdrawal signs and symptoms ... using the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) [assessment tool used to assess and manage alcohol withdrawal. Total score ranges: 7 or below: minimal to mild withdrawal, 8-15: moderate withdrawal, 16 or more: severe withdrawal with potential impending delirium tremens] assessment tool may help predict the severity of withdrawal symptoms... a high score can predict whether seizures and delirium are likely to develop... Administer prescribed medications, such as benzodiazepines [used to slow down the nervous system and treat anxiety disorders, insomnia, and seizures]....to control agitation and prevent progression to more severe withdrawal..."

Review on 10/17/2024 of the policy titled, "Assessment, general survey" revised 02/20/2024 revealed, "... Critical Notes ... Ongoing assessment will be completed....as patient condition warrants throughout hospitalization ... The goal of an assessment is to determine the care, treatment, and services that will meet the patient's initial and continuing needs..."

1. Review on 10/17/2024 of the medical record for Patient #2 revealed a 59-year-old female presented to the Emergency Department on 10/09/2024 at 2012 with a chief complaint of Altered Mental Status, Hallucinations and Confusion, who was admitted on 10/10/2024. Review of the History and Physical (H&P) on 10/10/2024 at 0005 by MD #3 revealed, "...recent diagnosis of colon ca [cancer] - s/p [status post] elective sigmoid colectomy 7/15/24, history of opioid abuse/addiction-in remission for 5 years was brought by family today with concerns of acute onset confusion/intermittently hallucinating and tremors... Apparently patient's friend died about 8 months ago and started drinking... last drink may have been on 10/6/24. Also she was recently prescribed Phenergan by surgeon.... of the 20 tables prescribed, only 2 were left... Patient admits to drinking copious amounts of vodka since her friend passed way ... Believe most likely diagnosis is alcohol withdrawal... Diagnosis: 1. Alcohol withdrawal syndrome, with delirium..." Review of the "Clinical Institute Withdrawal Assessment" standing order on 10/10/2024 at 0019 by MD #3 revealed, "Detoxification type: ETOH CIWA-AR assessment, Increase assessment to every 2 hours if CIWA GREATER THAN 15. Increase assessment to every 1 hours if lorazepam [benzodiazepine] administered. May resume every 4 hour assessment once CIWA-AR is LESS THAN 15 for 6 consecutive assessments. Nurse to D/C [discontinue] CIWA-AR when LESS THAN 8 for 6 consecutive Q4 [every 4] assessments." Medical record review revealed an order by MD #3 on 10/10/2024 at 0108 for "Ativan 0.5mg by mouth every 1 hour prn [as needed] for CIWA-AR between 8 and 15. Notify provider if patient requires 3mg of lorazepam [ativan] or greater in three hours." Further review of physician orders revealed another order by MD #3 on 10/10/2024 at 0108 for Ativan 1 mg by mouth "Every 4 hours PRN for anxiety." Review of the CIWA nursing assessment on 10/10/2024 at 0109 revealed a score of "31" (greater than 15) documented by RN #3. Review of the Medication Administration Record (MAR) revealed the patient received Ativan (Lorazepam) 1mg PRN for anxiety at 0152. Review of the CIWA nursing assessment documentation revealed the next assessment was completed at 0400 (2 hours, 51 minutes after administration of Ativan) with a score of "33" noted. Review of the MAR revealed Ativan was not administered per physician order. Further review subsequent CIWA nursing assessment documentation on 10/10/2024 revealed the next documented nursing assessment at 0800 (4 hours later) with a score of "23" noted by RN #4, 1200 (4 hours later) with a score of "22" noted, 1600 (4 hours later) with a score of "21" noted, and 2000 (4 hours later) with a score of "33" noted. Review of the CIWA nursing assessment and MAR revealed nursing staff failed to increase the assessment/reassessment frequency of the risk for complications per hospital policy.

Interview on 10/17/2024 at 1525 with the nurse manager (NM) of the Progressive Care Unit (PCU), following review of the CIWA and MAR documentation for Patient #2, revealed that per the ordered CIWA protocol, nursing assessments "should have been completed every hour following administration of Ativan" at 0152. In review of the ordered CIWA protocol and Ativan 0.5mg every 1 hour prn for CIWA-AR between 8 and 15, "At a minimum, Ativan should have been administered at 0400, 0800, and 1600 with provider notification." The NM stated, "[RN #3] is new to the unit (approximately 6 weeks) and [RN #4] just came off LPN to RN transition to practice. This is a great teaching moment for everyone." Interview revealed RN #3 and #4 were not available for interview.

Interview on 10/17/2024 at 1543 with the chief nursing officer (CNO), following review of the CIWA and MAR documentation for Patient #2 and #11, revealed, "The CIWA-AR is a necessary screening tool but it is confusing and fortunately, our nurses don't do it that often. There are so many variables of 'if this then that', it lends itself to confusion and steps get missed." The CNO stated, "We are missing the hourly assessments [following administration of Ativan]. It [CIWA protocol] is a confusing and complicated protocol for the team. This is an opportunity to look at the way it's [CIWA protocol] written from a system's level and a great opportunity to reach out to our Behavioral Health service line for assistance from them to help simplify the process."

2. Review on 10/17/2024 of the medical record for Patient #11 revealed a 67-year-old male presented to the Emergency Department on 10/08/2024 with a chief complaint of "Alcohol Problem" who was admitted with a diagnosis of "Alcohol Abuse." Review of the H&P by on 10/08/2024 at 1548 by MD #5 revealed, "...The patient was brought in by Emergency Medical Services after being found outside on his front porch. He admitted to becoming dizzy and laid down on his front porch and could not get up. He was a heavy drinker of at least a 12 pack a day and had withdrawals in the past." Medical record review revealed an order by MD #5 on 10/08/2024 at 1542 for "Ativan 0.5mg by mouth every 1 hour prn [as needed] for CIWA-AR between 8 and 15. Notify provider if patient requires 3mg of lorazepam [ativan] or greater in three hours." Review of the nursing assessments revealed a CIWA was completed by RN #5 at 1543 with a score of "8" documented. Review of the MAR revealed the patient received Ativan 0.5mg at 1629. Medical record review revealed the "Clinical Institute Withdrawal Assessment" standing order every 4 hours... Detoxification type: ETOH CIWA-AR assessment, Increase assessment to every 2 hours if CIWA GREATER THAN 15. Increase assessment to every 1 hours if lorazepam [benzodiazepine] administered. May resume every 4 hour assessment once CIWA-AR is LESS THAN 15 for 6 consecutive assessments. Nurse to D/C [discontinue] CIWA-AR when LESS THAN 8 for 6 consecutive Q4 [every 4] assessments" was placed by MD #5 at 1746 with a CIWA score of 3 documented by RN #5 at 1747. Review of the CIWA at 2050 revealed a score of "8" documented by RN #6. Review of the MAR revealed RN #6 failed to administer Ativan 0.5mg by mouth for "CIWA-AR between 8 and 15" per the physician order.

Interview on 10/17/2024 at 1525 with the nurse manager (NM) of the Progressive Care Unit (PCU), following review of the CIWA and MAR documentation, for Patient #11, "Ativan 0.5mg should have been administered at 2050, unless there was documentation indicating otherwise. This is a great teaching moment for everyone."

Interview on 10/17/2024 at 1543 with the chief nursing officer (CNO), following review of the medical record for Patient revealed, "The CIWA-AR is a necessary screening tool but it is confusing and fortunately, our nurses don't do it that often. There are so many variables of 'if this then that', it lends itself to confusion and steps get missed." The CNO stated, "We are missing the hourly assessments [following administration of Ativan]. It [CIWA protocol] is a confusing and complicated protocol for the team. This is an opportunity to look at the way it's [CIWA protocol] written from a system's level and a great opportunity to reach out to our Behavioral Health service line for assistance from them to help simplify the process."


NC00207608, NC002100130, and NC00215606