HospitalInspections.org

Based on medical record review and staff interview, in one (1) of 12 medical records reviewed, nursing staff did not report observations of elevated blood pressures to the medical staff to ensure prompt evaluation and treatment of the patient (Patient #1).

Findings include:

Review of medical record for Patient #1 noted the patient was admitted on 7/22/16 for evaluation of abdominal pain and possible hysterectomy. The patient's medical history was significant for hypertension. The home medication list included the following anti-hypertensive medications:
1. Coreg 6.25 mg tablet, 2 times per day
2. Hydrochlorothiazide 25-milligram (mg) tablet, once per day
3. Isosorbide mononitrate 30 mg, one tablet per day
4. Lisinopril 40 mg tablet, one tablet per day.

A preoperative note documented by a physician on 7/24/16 at 1:28 AM stated, "Would hold patient's home hypertensive medications on day of surgery (Lisinopril, Hydrochlorothiazide (HCTZ), Imdur) to prevent hypotension; would continue Coreg to prevent rebound Hypertension (HTN) or tachycardia."

On post-operative day #1, 7/25/16 at 7:18 AM, a physician noted "Status post Total Abdominal Hysterectomy, blood pressure (BP) was mildly elevated post-op." The plan was to continue monitoring and consider restarting home medications if the patient remains hypertensive.

Review of nursing documentation of patient's vital signs noted the following blood pressures were flagged as abnormal:
On 7/25/16 at 2:25 PM - BP 149/81 millimeter of mercury (mm/Hg). (Normal BP = 120/70 to 130/80).
On 7/26/16 at 01:20 AM - BP 172/99 mm/Hg.
On 7/26/16 at 06: 01 AM - BP 167/105 mm/Hg.

There was no evidence that the patient's abnormal BP was brought to the attention of the
physician.
The patient did not receive all of her anti-hypertensive medications until 2 days post operation on 7/26/16, when her BP rose to 168/98 mm/Hg.

During interview with Staff C, Director of Nursing, on 8/22/16 at 2:15 PM, she acknowledged that nursing did not document physician notification of the patient's blood pressure.

Based on observation and staff interview the infection control officer did not ensure that expired and contaminated items were not available for patients use.

Findings include:

During the tour of clean storage room on unit NW 5 on 8/22/16 at approximately 12:30PM, identified the following:

- 1 specimen collection container - expired on 5/31/16
- 25% Dextrose 250 milliliter- expired 8/1/16
- Lactated Ringers 1000 centiliter- expired 8/1/16
- 2 opened dressing trays.

During interview with Staff G, Registered Nurse on 8/22/16 at 12:40PM, she acknowledged the findings.