HospitalInspections.org

Based on review of hospital policies and procedures, medical record review, and staff interviews, it was determined the hospital failed to require nursing staff follow hospital policy when caring for patients requiring the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) assessment for three of three current patients (#1, 5, and 6). This deficient practice poses a risk to patient health and safety when nursing staff fail to assess and treat the patient for alcohol withdrawal as required by hospital policy.

Findings include:

The "Clinical Institute Withdrawal Assessment for Alcohol (CIWA)" policy, #PC 36, revised 8/19/2019, required: "...The patient will be assessed using the CIWA scale and vital signs according to the assessment algorithm as ordered by the practitioner...Vital signs are part of the CIWA assessment and will be taken and documented with every assessment ...The CIWA protocol may be discontinued if the CIWA score remains less than or equal to 8 and vital signs are stable for a 24 hour period. When CIWA is discontinued, only the CIWA assessment and Ativan are discontinued ...."

The "Detox Protocol" document, 1/2020, required: "...Alcohol & Benzodiazepine Detox/CIWA - Ar Protocol...If CIWA score over 15, GIVE LORazepam 2 mg by mouth and repeat Vital Signs and CIWA in 1 hour...If CIWA score 0-8, and HR greater than 100 and/or SBP >140 and/or DBP >90, GIVE LORazepam 1 mg by mouth and repeat Vital Signs in an hour and CIWA in 4 hours ...During the detoxification period, patients will be monitored by nursing for Temperature (Above 99.6 degrees F)."

Patient #1:

The "Withdrawal Assessment Profile" was reviewed on 1/21/2020 at 11:15 and contained the following:

Recovery day: 1
0200: Temperature 98.1, HR 78, BP 150/107, CIWA score of 21. The patient was medicated with Ativan 2 mg.
0600: Temperature 97.8, HR 82, BP 137/89. No assessment was documented.
1000: Temperature 98.1, HR 73, BP 137/80. No assessment was documented.
The CIWA assessment had not been completed again as of 1/21/2020 at 11:15.

The medical record did not contain a repeat CIWA assessment or vital signs an hour later for the elevated blood pressure at 0200 or the CIWA score of 21.

Recovery day: 2
The "Withdrawal Assessment Profile" 1/22/2020 contained the following:
0200: blood pressure 150/100 and CIWA score of 3. The patient was given Ativan 2 mg. The patient's temperature was not documented.
0350: blood pressure 156/113 and CIWA score of 3. The amount of Ativan administered was illegible. The patient's temperature was not documented.
0600: blood pressure 136/96, CIWA score 2. No Ativan was administered. The patient's temperature was not documented.
1000: blood pressure 133/95, CIWA score 0. No Ativan was administered. The patient's temperature was not documented.

Direct observations were conducted on 1/21/2020 at 11:15 am and 1/22/2020, of the Sabino unit. Three of three current patients on CIWA assessments (Patient #1, 7, and 8) did not have CIWA assessments completed by the day shift nurse at 11:15 and the night shift nurse failed to reassess the patient one hour after the CIWA score was elevated at 18.

Employee #4 accompanied the surveyor to the Sabino Unit on 1/21/2020 and 1/22/2020, confirmed the CIWA assessments were not completed per protocol. Employee #4 confirmed the CIWA protocol requires patients to be medicated with Ativan for systolic blood pressure greater than 140 and/or diastolic blood pressure greater than 90. The nursing staff is required to recheck the patient's vital signs one hour after medication is administered. The nursing staff failed to complete a repeat CIWA assessment (one hour later) for patient #1 when the CIWA score was greater than 15.1000: blood pressure 133/95, CIWA score 0. No Ativan was administered. The patient's temperature was not documented.

Direct observations were conducted on 1/21/2020 at 11:15 am and 1/22/2020, of the Sabino unit. Three of three current patients on CIWA assessments (Patient #1, 7, and 8) did not have CIWA assessments completed by the day shift nurse at 11:15 and the night shift nurse failed to reassess the patient one hour after the CIWA score was elevated at 18.

Employee #4 accompanied the surveyor to the Sabino Unit on 1/21/2020 and 1/22/2020, confirmed the CIWA assessments were not completed per protocol. Employee #4 confirmed the CIWA protocol requires patients to be medicated with Ativan for systolic blood pressure greater than 140 and/or diastolic blood pressure greater than 90. The nursing staff is required to recheck the patient's vital signs one hour after medication is administered. The nursing staff failed to complete a repeat CIWA assessment (one hour later) for patient #1 when the CIWA score was greater than 15.