HospitalInspections.org

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Based on record review and interviews during a Federal Allegation Survey, the hospital failed to ensure there was clear and consistent documentation of the patient's Advance Directives for one (1) out of twenty-seven (27) medical records reviewed (Patient #16).

Findings:

Medical record review for Patient #16 revealed on 06/12/12 this 94-year-old patient was transferred from a nursing home lethargic and confused. The nursing home provided documentation of the patient's Advance Directives documenting the patient wanted cardio-pulmonary resuscitation.

The physician's History and Physical dated 06/12/12 documented a medical history of advanced Dementia and that the patient's family/representatives did not elect DNR status.

The Nursing Admission Assessment dated 06/12/12 documented the patient was confused and unable to provide a history.

The medical record contained an incomplete DNR consent form for a patient without capacity where all 4 sections must be completed. The partially filled out consent form was signed by the physician on 6/13/12 at 8:30 AM. in sections 1 and 3 but was not signed by a concurring physician. In addition, sections 2 and 4 which required the identification and signature of the patient surrogate were left blank.

The Critical Care Transfer Order Sheet dated 06/13/12 at 10:30 AM then incorrectly documented the patient was a DNR.

The facility's Medical Staff Rules and Regulations dated 06/11 states "The practitioner shall be responsible for entries into the medical record that accurately reflect the patient's medical condition and plan of care. The contents of the record shall be legible, pertinent and current."

Review of the facility's policy dated 09/11 entitled "Documentation of Nursing Care" states "Nursing personnel are responsible for the accuracy and completeness of all nursing documentation which must be clear, concise and consistent."

These discrepancies identified in the physician and the nursing documentation regarding the Advance Directives and the inconsistencies in the medical record were discussed at length and acknowledged by the Assistant Vice President of Quality and Resource Management and the Director of Nursing (Medical/Surgical Services) on 06/19/12.
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Based on record review and staff interviews during a Federal Allegation Survey, the facility failed to ensure that a physician examined and documented the medical condition at discharge of five (5) out of six (6) obstetrical patients as required by the Medical Staff Bylaws in a total sample of thirty (30) medical records (Patients #7, #11, #12, #14 and #15).

Findings:

Review of the medical record for Patient #7 during the morning of 06/20/12, revealed that the attending physician documented that the patient was to be discharged in the morning on 06/21/12. The attending physician had completed the discharge instructions and wrote a discharge order. On interview the nurse stated that the patient would be sent home the next day, but would not be seen by the physician.

Review of an additional four (4) out of five (5) post partum discharged medical records for Patients #11, #12, #14 and #15 revealed that the physicians wrote discharge orders, discharge instructions and dictated the discharge summary the day before the patient was sent home with no documented evidence of a patient evaluation on the actual day of discharge.

Review of the facility's Medical Staff Rules and Regulations dated 06/14/11 revealed that the practitioner of record, shall be responsible for making timely daily entries in the patient's medical record that accurately reflects the patient's medical condition/plan of care and that the final progress note at discharge must include the patient's diagnosis and condition on discharge.

These findings were confirmed with the Assistant Vice President of Quality and Resource Management and the Director of Performance Improvement.
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Based on observation, record review and interview during a Federal Allegation Survey, it was determined that the facility did not ensure that a plan of care was developed and implemented for two (2) out of two (2) patients who were determined to have difficulty swallowing in a total sample of thirty (30) records reviewed (Patients #21 and #27).

Findings:

A. Patient #27 was admitted to the hospital on 06/10/12 with diagnoses including Urosepsis and Dysphagia.

Observation of medication administration for this patient on 06/21/12 at 9:50AM revealed that the nurse administered oral medications to this patient with un-thickened water. The patient was observed to be unable to swallow the medication and the liquid despite being given continued amounts of this water. Fifteen (15) minutes later, at 10:05AM, the nurse asked the patient if he would like some applesauce to which he indicated yes. The patient was then able to swallow the medications with the applesauce.

Observation at this time also revealed there was a sign above the patient's bed that read "Aspiration Precautions".

Review of the record revealed a swallow evaluation was done on 06/11/12 and recommended a mechanical soft diet and nectar thickened liquids only to be given. This order was then subsequently written for implementation by the physician on 06/11/12.

Review of the multidisciplinary clinical pathway plan of care revealed that no care plan was developed to address this patient's diagnosis of Dysphagia. There was no mention that this patient was on "Aspiration Precautions".


B. Patient #21 was admitted to the hospital on 05/22/12 with a dislodged PEG tube and history of Dysphagia. The patient was NPO. Review of the multidisciplinary clinical pathway plan of care revealed that no care plan was developed to address this patient's diagnosis of Dysphagia on admission. There was no mention that this patient was on "Aspiration Precautions".


An interview was conducted with the Assistant Nurse Manager and the Director of Nursing for Medical/Surgical Services on 06/21/12 at 11:30AM, who reviewed the record and who verified these findings.
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Based on observation, record review and interview during a Federal Allegation Survey, it was determined the facility did not ensure that (A) one (1) of five (5) patients observed for medication administration received their medication as prescribed (Patient #27) and (B) the nursing staff failed to administer a blood transfusion within the specific timeframe ordered by the physician.

Findings:

A. Patient #27 was admitted to the facility on 06/10/12 with diagnoses including Urosepsis and Dysphagia.

Observation of medication being administered by the nurse to this patient on 06/21/12 at 9:50AM revealed that he received multiple medications including Omeprazole 20mg at this time.

Subsequent medication reconciliation revealed that Omeprazole (Prilosec) 20mg was ordered on 06/10/12 to given every morning before breakfast.

Review of the Medication Administration Record from 06/11/12 - 06/21/12 revealed that the instructions documented that this medication should be given at 7:00AM with breakfast. Yet, this review revealed that the documented times this medication was administered ranged from 9:28AM to 10:47AM on 06/11/12, 06/12/12, 06/17/12 and 06/21/12.

The medication was documented as not given on 06/19/12 at 11:22AM because the dose was previously given; however, there was no documentation in the record of when this dose was actually received by the patient.

Review of the meal delivery schedule for this unit revealed that breakfast is delivered to this unit at 7:30AM.

An interview conducted with the Assistant Vice President of Quality and Resource Management and the Vice President of Patient Care Services on 06/21/12 at 11:30AM verified these finding.




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B. Review of the medical record for Patient #11 revealed a physician's order on 02/15/12 at 10:00 AM documented "transfuse 2 units of PRBC each unit over 2 hours then CBC - 2 hours after the 2nd unit."

Review of the nurse's progress note on 02/15/12 at 11:15 AM documented "1 unit PRBC initiated (see blood administration check list)."

Review of the "Record of Transfusion" and the "Blood Administration Checklist" revealed that the first unit of blood was transfused over 1 hour and 15 minutes from 11:15 AM until
12:30 PM and not over 2 hours as ordered by the physician.

These findings were confirmed with the Assistant Vice President of Quality and Resource Management and the Director of Performance Improvement.
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Based on record review and interviews during a Federal Allegation Survey, the hospital failed to ensure that the physicians authenticated Telephone/Verbal Orders within forty-eight (48) hours in four (4) of thirty (30) medical records (Patients #16, #18, #21 and #23).

Findings:

Review of the physician's orders for Patient #18 dated 06/10/12 at 9:20PM documented a telephone order for Morphine intravenous bolus was received by the nurse and not authenticated by the physician with date, time and signature. On 06/09/12 at 6:00PM and on 06/15/12 at 7:00PM additional telephone orders were received and not authenticated by the physician.

Review of the physician's orders for Patient #23 dated 04/01/12 at 5:50PM documented a telephone order for multiple medicines was received by the nurse and authenticated by the physician did not include a date and time as required by hospital policy.

Review of the physician's orders for Patient #21 dated 06/06/12 at 10:35PM and on 06/08/12 at 3:45PM documented a telephone order for lab diagnostics and treatments was received by the nurse and authenticated by the physician but did not include a date and time as required by hospital policy.

Review of the physician's orders for Patient #16 dated 06/12/12 at 6:00PM documented a telephone order for Heparin intravenous infusion was received by the nurse and not authenticated by the physician with date, time and signature.

Review of the hospital policy entitled "Telephone/Verbal Orders, The Acceptance Of" dated September 2010 revealed that all verbal and telephone orders must be authenticated by the prescribing physician or appropriate designee within forty-eight (48) hours and include the date and time.

These findings were confirmed with the Assistant Vice President of Quality and Resource Management.