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Based on record reviews and interview, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by:
1) Failing to ensure each patient was assessed by a RN within 2 hours of arrival to SDS as required by hospital policy for 1 (#3) of 5 patient records reviewed for RN assessment in SDS from a total sample of 5 patients.
2) Failing to notify the physician of a patient's elevated blood pressure prior to transferring the patient from PACU to SDS for 1 (#4) of 5 patient records reviewed for physician notification of patient condition changes from a total sample of 5 patients.
Findings:

1) Failing to ensure each patient was assessed by a RN within 2 hours of arrival to SDS as required by hospital policy:
Review of the hospital policy titled "Assessment and Re-Assessment", presented as a current policy by S3DPI, revealed that the patient assessment is initiated within 2 hours of arrival on the nursing unit or as indicated by the patient's condition. The physical assessment is completed and documented by the RN within 24 hours of the patient's arrival on the nursing unit.

Review of Patient #3's medical record revealed she arrived to the SDS on 09/12/16 at 6:49 a.m. Further review revealed S9LPN performed her initial nursing assessment that included an assessment of her fall risk, pain, and respiratory,gastrointestinal, and integumentary systems. Patient #3 was transferred to the Pre-op Holding area on 09/12/16 at 12:34 a.m., 5 hours 45 minutes after she was admitted.

Review of Patient #3's medical record revealed no documented evidence that she received a nursing assessment by a RN within 2 hours of arrival to SDS as required by hospital policy.

In an interview on 01/25/17 at 2:30 p.m. with S8RN and S5DPS present, S5DPS confirmed there was no documented evidence that a RN conducted a nursing assessment for Patient #3 when she was in SDS. During the interview S3DPI accessed the hospital's computerized medical record system and confirmed she didn't see that Patient #3's vital signs had been assessed in SDS on 09/12/16 upon her arrival. She further indicated no vital signs were documented for Patient #3 until she arrived in the Pre-op Holding area.

2) Failing to notify the physician of a patient's elevated blood pressure prior to transferring the patient from PACU to SDS:
Review of the hospital policy titled "Assessment and Re-Assessment", presented as a current policy by S3DPI, revealed the physician is to be notified of deterioration of the patient's condition or change in status and for any unusual occurrence involving the patient.

Review of Patient #4's medical record revealed he was admitted to PACU on 09/30/16 at 12:06 p.m.

Review of Patient #4's "Vital Signs" revealed his blood pressure and pulse readings were as follows:
12:06 p.m. - 150/100; pulse 75;
12:15 p.m. - 169/119; pulse 84;
12:30 p.m. - 164/111; pulse 86;
12:45 p.m. - 160/105; pulse 87;
1:00 p.m. - 159/95; pulse 74;
1:30 p.m. - 165/198; no documented evidence of pulse rate.

Review of Patient #4's physician orders revealed an order on 09/30/16 at 12:23 p.m. to administer Labetalol 5 mg IVP every 5 minutes PRN for 4 doses for systolic blood pressure > 145 and to hold for a heart rate < 60.

Review of his MARs revealed he received Labetalol 5 mg IVP at 12:45 p.m. and 1:30 p.m.

Review of Patient #4's medical record revealed no documented evidence that he was administered Labetalol 5 mg IVP at 1:30 p.m. when his blood pressure was 165/98 and that his physician was notified of the continued elevated blood pressure when Patient #4 was transferred from PACU to SDS at 1:33 p.m.

In an interview on 01/27/17 at 10:45 a.m., S6CM indicated the nurse should have notified the anesthesiologist of Patient #4's blood pressure to get approval to transfer him to SDS. She confirmed Patient #4's medical record had no documented evidence that this report had been made by the nurse providing care to Patient #4 in PACU.

Based on observation, record reviews and interviews, the hospital failed to ensure drugs were administered in accordance with Federal and State laws, the orders of the practitioner, and accepted standards of practice as evidenced by:
1) Failing to have the RN document on the label of two syringes, one containing Labetalol and one containing Hydralazine, the time the medication was prepared, the initials of the nurse who prepared the medication, and the beyond-use date and time of each medication as observed on 01/24/17 at 10:36 a.m.
2) Failing to ensure medication ordered for the treatment of high blood pressure was administered as ordered by the patient's physician for 1 (#4) of 5 medical records reviewed for medication administration from a total sample of 5 patients and
3) Failing to ensure physician orders for medications contained the dose, frequency, and route, the exact strength or concentration, and specific instructions for use, and a clarification order was requested by the nurse when this information was not included in the order for 3 (#1, #3, #4) of 5 patient records reviewed for medication orders from a total sample of 5 patients.
Findings:

1) Failing to have the RN document on the label of two syringes, one containing Labetalol and one containing Hydralazine, the time the medication was prepared, the initials of the nurse who prepared the medication, and the beyond-use date and time of each medication:
Observation on 01/24/17 at 10:36 a.m. revealed Patient #1 was on a stretcher in PACU with S14RN providing her care. Further observation revealed 2 syringes were placed on the over bed table located at the foot of the stretcher labeled as follows:
1 syringe with a label with handwriting of "Hydralazine 20 mg/ml" with the vial of Hydralazine taped to the cap of the syringe;
1 syringe with a label with handwriting of "Labetalol 5 mg/ml" with no vial attached.
Observation revealed no documented evidence of the date and time the medications were drawn into the syringes, the initials of the nurse who prepared the medication, and the expiration date and/or beyond use date.

Review of the policy titled "Medication Administration", presented as a current policy by S3DPI, revealed that medication administration per anesthesia post-op powerplan may be given via a single dose vial. Ordered medication must be drawn up and administered from a separate syringe within the one hour time frame in PACU and SDS. ere was no documented evidence that the policy addressed the information that was to be included on the labels.

In an interview on 01/24/17 at 10:37 a.m., S14RN indicated she had drawn up the Labetalol about 10 minutes earlier and the Hydralazine about 30 minutes earlier. She further indicated the hospital policy required the date and time that the medication is drawn into the syringe to be documented on the label. She confirmed that she didn't document that information on the label. S14RN didn't indicate that the expiration and/or beyond use date were required to be on the label.

In an interview on 01/25/17 at 2:50 p.m., S6CM indicated the label should have the name of the drug, the concentration, the date and time the medication is drawn up, and the initials of the nurse who drew it up. She confirmed the label should have the time it was drawn up to be able to know when the hour discard time is.

2) Failing to ensure medication ordered for the treatment of high blood pressure was administered as ordered by the patient's physician:
Review of the hospital policy titled "Assessment and Re-Assessment", presented as a current policy by S3DPI, revealed the physician is to be notified of deterioration of the patient's condition or change in status and for any unusual occurrence involving the patient.

Review of Patient #4's medical record revealed he was admitted to PACU on 09/30/16 at 12:06 p.m.

Review of Patient #4's "Vital Signs" revealed his blood pressure and pulse readings were as follows:
12:06 p.m. - 150/100; pulse 75;
12:15 p.m. - 169/119; pulse 84;
12:30 p.m. - 164/111; pulse 86;
12:45 p.m. - 160/105; pulse 87;
1:00 p.m. - 159/95; pulse 74;
1:30 p.m. - 165/198; no documented evidence of pulse rate.

Review of Patient #4's physician orders revealed an order on 09/30/16 at 12:23 p.m. to administer Labetalol 5 mg IVP every 5 minutes PRN for 4 doses for systolic blood pressure > 145 and to hold for a heart rate < 60.

Review of his MARs revealed he received Labetalol 5 mg IVP at 12:45 p.m. and 1:30 p.m.

Review of Patient #4's medical record revealed no documented evidence that he was administered Labetalol 5 mg IVP at 12:06 p.m. when his blood pressure was 150/100, at 12:15 p.m. when his blood pressure was 169/119, at 12:30 p.m. when his blood pressure was 164/111, and at 1:00 p.m. when his blood pressure was 159/95. There was no documented evidence that Patient #4's blood pressure was assessed every 5 minutes once his blood pressure was determined to be >145 systolic.

In an interview on 01/27/17 at 10:45 a.m., S6CM confirmed the nurse did not administer Labetalol as ordered by the physician.

3) Failing to ensure physician orders for medications contained the dose, frequency, and route, the exact strength or concentration, and specific instructions for use, and a clarification order was requested by the nurse when this information was not included in the order:
Review of the policy titled "Medication Administration", presented as a current policy by S3DPI, revealed that "Range orders - The order contains 1 variable, the dosage or the frequency..." Further review revealed if the pain rate score is 1 to 5, medicate with the lowest dosage, and if the pain rate score is 6 to 10, medicate with the highest dosage. Frequency of medication is to be administered at the longest interval in the order. There was no documented evidence that the policy addressed that range orders were not acceptable and that medication orders were to include the specific dose, exact strength, and the indication for use.

Patient #1
Review of Patient #1's medication orders revealed an order on 01/24/17 at 9:44 a.m. for Hydralazine 5mg (equals 0.25 ml) IVP every 15 minutes PRN for 4 doses with no documented evidence of the indication for use and/or parameters for administration. There was no documented evidence that the nurse obtained a clarification order from the physician.

In an interview on 01/27/17 at 10:45 p.m., S6CM confirmed the above findings.

Patient #3
Review of Patient #3's medication orders revealed an order on 09/12/16 at 2:09 p.m. for Morphine 3mg (equals 0.3 ml) IVP every 2 hours PRN for mild pain with a pain rate score of 1-3 with a comment of "may give 3-5 mg." This order contained a range in dose. Further review revealed an order on 09/12/16 at 3:12 p.m. for Hydralazine 5 mg (equals 0.25 ml) IVP every 15 minutes PRN for 4 doses with no documented evidence of the indication for use and/or parameters for administration. There was no documented evidence that the nurse obtained a clarification order from the physician.

In an interview on 01/27/17 at 10:45 a.m., S6CM indicated the anesthesia medication orders were revised on 11/24/16 and didn't include the indication for use for Hydralazine. She confirmed the Morphine order included a range order, and both orders should have been clarified by the nurse.

Patient #4
Review of Patient #4's medication orders revealed an order on 09/30/16 at 12:23 p.m. for Hydralazine 5 mg (equals 0.25 ml) IVP every 15 minutes PRN for 4 doses with no documented evidence of the indication for use and/or parameters for administration. Further review revealed an order on 09/30/16 at 12:30 p.m. for Morphine 3mg (equals 0.3 ml) IVP every 2 hours PRN for mild pain with a pain rate score of 1-3 with a comment of "may give 3-5 mg." This order contained a range in dose. There was no documented evidence that the nurse obtained a clarification order from the physician.

In an interview on 01/27/17 at 10:45 a.m., S6CM indicated the anesthesia medication orders were revised on 11/24/16 and didn't include the indication for use for Hydralazine. She confirmed the Morphine order included a range order, and both orders should have been clarified by the nurse.