HospitalInspections.org

Based on document review and interview, the hospital failed to inform patients, or when appropriate, the patient's representative of the patient's rights for 1 of 1 patients who had a mild intellectual disability.

Findings include:

1. Review of the hospital policy titled Patient Rights & Responsibilities, Revised 7/20, indicated the following: The "Patient's Rights and Responsibilities" will be posted...and given to all patients at admission and registration.

2. The MR of patient P1 lacked documentation of the patient and/or guardian having received notice of their patient rights.

3. On 6/2/21, beginning at approximately 12:00 PM, A1, Director of Corporate Compliance and A4, Registered Nurse (RN)/Senior EPIC (electronic medical record system) Analyst, indicated written notice of patient rights was not given to patients and a copy of the rights was posted in admissions for the patient to review.

Based on document review and interview, the hospital failed to ensure nursing staff adhered to policies and procedures (P&P) of the hospital for 1 of 10 patients (P1) (see tag 398) and the nurse executive failed to ensure drugs were administered in accordance with policies and/or practitioner orders for 1 of 10 patients (P1) (see tag 405).
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The cumulative effect of these systemic problems resulted in the hospitals inability to ensure safe nursing care was provided.

Based on document review and interview, the hospital failed to ensure nursing staff adhered to policies and procedures (P&P) of the hospital for 1 of 10 patients (P1).

Findings include:

1. P&P review:
A. The policy titled Admission of Patients from Inpatient to Inpatient Hospice/Stopping High Flow or BIPAP (Bilevel Positive Airway Pressure), Approved 7/20, indicated the following:
The process and reason of weaning the patient off hi-flow or BIPAP will be explained to patient and patient's family.
After the patient has been discharged as an inpatient and readmitted as a hospice patient, the weaning and reason...will be explained to the patient and family again.
Weaning off hi-flow or BIPAP will NOT be started until the patient and family completely understand the process and are ready.
Once the patient and family understand the weaning process...the Hospice RN (Registered Nurse) will enter an order for respiratory therapy to begin the weaning process.
All communication with patient and family will be documented in the electronic medical record (EMR).

2. Review of the EMR for patient P1 indicated the following:
The patient presented to the Emergency Department (ED) on 8/24/20 and was admitted to the hospital that same date for COVID-19 symptoms. The History and Physical (H&P) indicated the patient had a "mild intellectual disability" and resided in a group home. Psychological: Awake, alert, oriented; appropriate affect; good judgment; adequate insight into illness. CODE STATUS: full code. Impression and plan was discussed with patient... Scanned documentation indicated that family members G1 and G2 were guardians of the "estate and person" of P1. SW (Social Worker) note 8/26/20 at 2104 hours indicated G2 and G1 wanted the patient's status changed from Full code to DNR (Do Not Resuscitate). Physician Progress Note at 1800 hours on 9/1/20, indicated that G2 and G1 decided to transition the patient to comfort care (hospice) now.
Nursing documentation dated 9/2/20 at 0030 hours indicated the following: This RN went to turn patient's O2 to nasal cannula and the patient started screaming out "Please don't do that. I don't want to die." Patient is on highflow oxygen. Patient is unaware that he/she is on hospice. This RN called patient's POA G1. G1 states that he/she is not comfortable with taking patient's high flow oxygen off if patient is A&O (alert and oriented) x 3. This RN explained the reason for hospice, POA very tearful and stated that he/she wishes to speak with the hospice doctor tomorrow and that he/she would feel comfortable for the high flow to be left on for the remainder of the night. Charge RN notified and agrees. 9/2/20 Hospice admission orders included the following new orders: At 1149 hours: oxygen therapy maintain O2 sat at or greater: 88%; Device: Heated High Flow Nasal Cannula and BiPAP Continuous, Maintain O2 sat at or greater: 88%. On 9/2/20 at 1514 hours, nursing documentation indicated the following: Patient is resting...in bed. High flow is currently being weaned... The MR lacked documentation of the patient having been explained the process and reason of weaning as per hospital policy. The MR lacked documentation of an order to wean the patient from oxygen.

3. The following was indicated in interview on 6/2/21:
Beginning at approximately 12:45 PM, A4 verified the MR of patient P1 lacked documentation of a physician order to wean the patient from oxygen and that nursing documentation indicated the patient was being weaned from oxygen.

Based on document review and interview, the nurse executive failed to ensure drugs were administered in accordance with policies and/or practitioner orders for 1 of 10 patients (P1).

Findings include:

1. A. Review of the policy titled Medication Ordering and Administration, Revised 10/20, indicated the following: Medications will be dispensed and administered only as ordered by a practitioner...

B. The policy titled Pain Assessment, Treatment Measures & Evaluation, Revised 1/19, indicated the following:
Purpose: To provide objective tool for the patient's evaluation of their pain.
Assessment and Planning:
The patient's evaluation of the intensity of their pain is the most reliable indicator of pain.
Administer medications as ordered, and/or use non-pharmacologic pain relief measures...
Pharmacologic interventions (range orders): Mild pain (intensity
Collaborate with physician and base initial choice of analgesic on intensity and type of pain: Mild pain (intensity rating of 1-3): Non-opioid analgesic... Moderate pain (intensity rating of 4-6): Non-opioid analgesic and/or opioid analgesics...
Pain Rating Scales:
Numerical (verbal) Rating Scale: 0 (no pain) - 10 (worst pain)
Wong Baker Faces: Smiling = 0 ("very happy because he does not hurt at all")... No smile/no frown = 4 ("hurts a little")...Frowning with tears = 10 ("hurts as much as you can imagine...")

2. The MAR (Medication Administration Record) of patient P1 indicated medications were administered as follows:
A. Order: Morphine injection 1mg, every 15 minutes for mild pain.
Given 9/2/20 as follows: 1mg at 1342 hours; 1mg at 1630 hours; and 1mg at 2041 hours.
Pain screening/assessments were indicated by verbal rating scale as follows on 9/2/20: At 1100 hours, 1200 hours, 1300 hours; 1400 hours, 1500 hours, 1600 hours and 1700 hours, the patient denied pain and rated such at 0/10. At 1728 hours pain screening scoring was indicated to have changed to use of the "Wong-Baker Faces Scale" and was rated at "4" (hurts a little more). The MR lacked documentation of the administrations on 9/2/20 at 1342 hours and at 1630 hours having been administered for pain (mild or otherwise). The MR lacked documentation of pain prior to the 1728 entry and lacked documentation of non-pharmacological and/or non-opioid interventions having been attempted.

B. Order: Lorazepam injection 1mg every 2 hours prn for anxiety, agitation. Given 9/2/20 as follows: 1mg at 1341 hours; 1mg at 1630 hours; and 1mg at 2041 hours.
The MR indicated a Warning Override alerted on 9/2/20 at 1:14 PM with note as follows: Dose: Lorazepam 0.5mg, intravenous, every 2 hours prn frequency exceeded by 4 doses/day (Reason; Benefit outweighs risk)
The MR lacked documentation of the patient having exhibited or expressed anxiety and/or agitation.

3. On 6/2/21, beginning at approximately 3:10 PM, A5, Director of Hospice, indicated both morphine and Ativan are typically ordered prn (as needed) and that the MS is given for pain and Ativan for anxiety. A5 indicated that MS is administered if the patient requests or exhibits pain and if not the they do not give it.