HospitalInspections.org

Based on document review and interview, nursing services failed to document medication administration in 1 of 10 patient (Patient #7) medical records reviewed; failed to complete fall risk shift assessments in 2 of 10 patient (Patients #3 and #6) medical records reviewed; failed to complete neurological checks in 3 of 10 patient (Patients #4, #8, and #9) medical records reviewed; and failed to document activity and position change every 2 hours per policy in 2 of 10 patient (Patients #8 and #9) medical records reviewed.

Findings include:

1. Facility policy titled, Fall Prevention, PolicyStat ID 9099224, last approved 01/2021, indicated, under Policy, D. Assessment/Reassessment, 1. Will be completed upon admission, each shift, with any change in patient condition and with transfer from or to a higher/lower level of care; or at the frequency defined by the approved evidence-based fall risk tool. Safety interventions will be implemented according to identified levels of risk. Patient's scoring low fall risk will have all Basic Safety Needs interventions in place.

2. Facility policy titled, Medication Administration by Nursing Associates, PolicyStat ID 13606967, last approved 05/2023, indicated under Policy/Procedure, K., Record administration given or not given on MAR (Medication Administration Record).

3. Review of document titled Exhibit F Performance Standards indicated the key laboratory metrics that will be reported (including targeted performance) are noted in the following chart (the "Key Metrics"). Table 1: Metric, STAT testing turn-around-time (in patient locations not including ED/NICU/PICU/ICU) (measured from receipt in laboratory as evidenced by the time-stamp for entry into the system); Target 95% of STAT tests completed and resulted < 60 minutes.

4. Review of document titled Neuro Standard of Care and Documentation - RN indicated
a. Minimum Frequencies; Q4H, Vital signs & neuro checks unless ordered more frequently
b. Minimum Frequencies: Q2H, Position change, Activity, Safety Precautions, IV site for medicated drips i.e. cardizem, heparin, insulin, IVIG, blood

5. Review of Patient 1's medical record indicated a STAT urinalysis was ordered on 05/13/2024, no time documented, urine specimen collected at 11:37 a.m. on 05/13/2024; specimen received in the lab at 2:20 p.m.; urinalysis results were completed at 2:31 p.m. Medical record lacked documentation of why specimen was not taken to lab after collected.

6. Review of Patient 2's medical record lacked documentation of a fall risk shift assessment for the following shifts:
a. Day shift on 05/13/2024, 05/14/2024, 05/15/2024, 05/16/2024, 05/17/2024, and 05/18/2024, 05/20/2024, 05/21/2024, 05/24/2024, and 05/25/2024.
b. Night shift on 05/13/2024, 05/14/2024, 05/15/2024, 05/16/2024, 05/17/2024, and 05/18/2024, 05/19/2024, 05/20/2024, 05/21/2024, 05/22/2024, 05/23/2024, and 05/24/2024.

7. Review of Patient 3's medical record lacked documentation of a fall risk shift assessment for the following shifts:
a. Day shift on 05/13/2024, 05/14/2024, 05/15/2024, 05/18/2024, 05/19/2024, 05/20/2024, 05/21/2024, 05/22/24, 05/23/2024, 05/24/2024, 05/25/2024, 05/26/2024, 05/27/2024, and 05/28/2024.
b. Night shift on 05/13/2024, 05/14/2024, 05/15/2024, 05/16/2024, 05/17/2024, 05/18/2024, 05/19/2024, 05/20/2024, 05/21/2024, 05/22/24, 05/23/2024, 05/24/2024, 05/25/2024, 05/26/2024, and 05/27/2024.

8. Review of Patient 4's medical record lacked documentation of 4-hour neurological checks per Neuro Standard of Care and Documentation on 05/13/2024.

9. Review of Patient 5's medical record indicated a complete blood count (CBC) without differential was ordered STAT on 05/11/2024 at 11:40 a.m.; order noted on 05/11/2024 at 12:00 p.m. by a registered nurse (RN); lab resulted on 05/11/2024 at 2:21 p.m. Medical record lacked documentation of when lab was drawn, when specimen was taken to lab, or why it was not collected and resulted in less than 60 minutes.

10. Review of Patient 6's medical record lacked documentation of a fall risk shift assessment for the following shifts:
a. Day shift: 05/13/2024, 05/14/2024, 05/15/2024, 05/16/2024, 05/18/2024, 05/19/2024
b. Night shift 05/13/2024, 05/14/2024, 05/15/2024, 05/16/2024, 05/17/2024, 05/19/2024, 05/20/2024 and 05/21/2024.
c. Medical record lacked documentation of 1 of 6 neurological checks on 05/16/2024.

11. Review of Patient 7's medical record indicated that on 04/19/2024, the patient was ordered Amantadine 100 milligrams (mg) by mouth (PO) to be given at 09:00 a.m. and 1:00 p.m. daily. Medication administration records lacked documentation of the medication being administered or held on 05/11/2024.

12. Review of Patient 8's medical record lacked documentation of 1 of 3 neuro checks on 05/16/2024 per Neuro Standard of Care and Documentation and lacked documentation of patient's activity and position change every two hours on 05/16/2024 per Neuro Standard of Care and Documentation.

13. Review of Patient 9's medical record lacked documentation of patient's activity and position change every two hours on 05/18/2024 per Neuro Standard of Care and Documentation.

14. Interview with A1 (Director of Quality and Patient Safety) and A2 (Director of Accreditation) on 06/17/2024 at approximately 4:20 p.m. confirmed the information above for patients 1, 2, 7, and 9's medical record lacked the documentation as indicated above.

15 Interview with A1 on 06/18/2024 at approximately 4:00 p.m. confirmed the information above for patients 3, 4, 5, 6, and 8's medical record lacked the documentation as indicated above.