HospitalInspections.org

Based on document review and interview, nursing services failed to evaluate care for patients by not ensuring reassessments were completed per policy by a nurse on 4 of 10 medical records (MR) reviewed (Patient [P]4, P5, P6, and P10); failed to complete a Morse Fall Risk Assessment at the beginning of each shift on 1 of 10 MRs reviewed (P6); failed to assess vital signs per provider order on 2 of 10 MR reviewed (P1 and P5); failed to verify nasogastric (NG) tube placement and provide manual water flush every 4 hours with documentation for 1 of 10 MRs reviewed (P5); failed to follow the Clinical Institute Withdrawal Assessment Alcohol Scale Revised (CIWA-Ar) Protocol for 1 of 10 MR reviewed (P5).

Findings include:

1. Facility policy titled, Patient Assessment and Reassessment for All Departments, PolicyStat ID: 13198797, last revised 7/2/23, indicated on page 2 of 18, under II. ASSESSMENT OF PHYSICAL, PSYCHOSOCIAL AND CULTURAL STATUS OF PATIENT, A. Medical Staff Assessment, Documentation: Physician orders, consults and progress notes serve as mechanisms for the medical staff to communicate the patient's care, treatment needs and response to treatment, patient instructions, discharge plans and continued care requirements as appropriate. On page 15 of 18, under REASSESSMENT OF PATIENTS, 1. Med/Surgical, Oncology, Orthopedics, Pediatric, and OB/GYN Patient Care Units; All patients admitted to the Medical/Surgical, Pediatric, Oncology Orthopedics and/or OB/GYN patient care units will be reassessed every nursing shift by the RN/LPN. The RN Documents in the EMR the status of each patient with each tour of duty. RN will reassess and document in EMR any additional information based on patient Status/procedures.

2. Facility policy titled, Patient Fall Prevention and Post-Fall Management (Dr. Tumble), PolicyStat ID: 13315768, last revised 5/25/23, indicated on page 2 of 6, under IV. Fall Risk Assessment for Inpatients, Observation and Surgical patients: The Nurse will assess the patient using the Morse Fall Risk Assessment for their risk to fall: at the beginning of each shift.

3. Facility Policy titled, NG/OG/Dobhoff Tube Placement, PolicyStat ID: 12325432, last revised 1/19/23, indicated on page 2 of 3, under MAINTENANCE AND TUBE CARE: verify NG/OG/DHT tube placement every 4 hours and prior to each use. Observe visual characteristics of aspirate from tube. Check the marking on tube made at time of insertion. Manual flush with 30 cc's of sterile water, unless contraindicated by physician. Under DOCUMENTATION: document placement verification and manual water flush every 4 hours by completing task list and documenting on flow sheet. Document any feeding, water flushes and medications that are given volumes on I&O flow sheet in EMR.

4. Facility Policy titled, Alcohol Withdrawal CIWA-Ar Protocol, PolicyStat ID: 12903386, last revised 1/10/20, indicated on page 1 of 4, under 1. Inclusion criteria; protocol requires a physician order; under 4. CIWA-Ar withdrawal assessment, initial; RN to calculate initial CIWA-Ar score and administer medication for a score > 10 per protocol. On page 2 of 4, under 6. CIWA-Ar withdrawal assessment, recurrent; 1. if initial score <10, re-assess the CIWA-Ar score every 12 hours, or sooner if symptoms arise; 2. If oral benzodiazepine is administered, reassess the CIWA-Ar score in 4 hours for a previous score of 10-15, or in 2 hours for a previous score of 16-20, or in 1 hour for a previous score of 21 or more; 3. If intravenous (IV) benzodiazepine is administered, reassess the CIWA-AR score in 2 hours for a previous score of 10-15, or in 1 hour for a previous score of 10-16, or in 15 minutes for a previous score of 21 or more; under 7. Monitoring: 1. Document the CIWA-Ar score with each dose of benzodiazepine and at least every 12 hours.

5. MR of P1 indicated the following:
a. Facility admission 4/1/24 at approximately 10:20 pm through 4/5/24 at approximately 1:45 pm for Cholecystitis.
b. MR Provider order indicated vital signs every 4 hours on admission. MR lacked discontinuation of vital signs order. MR lacked documented vital signs every 4 hours during facility stay, included but not limited to; 4/4/24 at 4:00 am, 4/4/24 at 12:00 pm, 4/5/24 at 12:00 am.

6. MR of P4 indicated the following:
a. MR indicated facility admission 5/26/24 at approximately 6:34 pm through 5/31/24 at approximately 12:29 pm for Urinary Tract Infection.
b. MR lacked head to toe shift assessment completed on 5/28/24 morning shift, and 5/30/24 morning shift.

7. MR of P5 indicated the following:
a. Facility admission 6/13/24 at approximately 11:24 pm through 6/20/24 at approximately 2:14 pm for Cirrhosis with Alcoholism.
b. MR lacked nurse head to toe assessment, including lower extremity edema, completed on 6/14/24 evening shift and 6/18/24 morning shift.
c. MR Provider order indicated vital signs every 4 hours on admission. MR lacked discontinuation of vital sign order. MR lacked documented vital signs every 4 hours during hospital stay, included but not limited to; 6/14/24 at 12:00 pm; 6/15/24 at 12:00 am, 6/15/24 at 4:00 am, 6/15/24 at 12:00 pm, and 6/16/24 at 12:00 am.
d. MR indicated a nasogastric (NG) tube was placed 6/17/24 at 12:24 pm, and discontinued 6/18/24 at 9:26 am. MR lacked documented every 4 hour NG tube placement verification and manual water flush from 6/17/24 at 12:24 pm to 6/18/24 at 9:26 am.
e. MR lacked documented CIWA-Ar reassessments 2 hours after IV benzodiazepine administered, included, but not limited to: 6/15/24 at 10:15 am, 6/15/24 at 3:33 pm, and 6/16/24 at 6:23 pm.
f. MR lacked documented CIWA-Ar reassessment 1 hour after IV benzodiazepine administered 6/16/24 at 11:47 pm.
g. MR lacked documented CIWA-Ar reassessments 4 hours after oral benzodiazepine administered included but not limited to: 6/15/24 at 3:12 am, 6/18/14 at 1:50 am, 6/18/24 at 2:57 pm, and 6/19/24 at 2:36 pm.

8. MR of P6 indicated the following:
a. Facility admission 7/5/24 at approximately 9:02 pm through current on day of survey 7/10/24 for Peripheral Artery Disease.
b. MR lacked nurse head to toe assessment completed 7/6/24 morning shift.
c. MR lacked Morse Fall Risk Assessment completed on 7/6/24 morning shift, and 7/9/24 morning shift.

9. MR of P10 indicated the following:
a. Facility admission 7/6/24 at approximately 10:48 pm through current on day of survey 7/10/24 for Chronic Obstructive Pulmonary Disease.
b. MR lacked nurse head to toe assessment completed on 7/7/24 evening shift.

10. In interview, on 7/10/24 at approximately 12:00 am, A6 (Medical Surgical Unit Manager [MSM]) verified the shift assessment in the Patient Assessment and Reassessment for All Departments was a head to toe assessment. Patients on the Medical Surgical Unit received a full head to toe assessment each shift. A6 verified the MR of P1, P2, P3, P4 and P5 were as reviewed. The vital signs were not assessed per provider order on P1 and P5. Shift assessments, including head to toe assessment, were not completed per policy on P4 and P5. NG tube placement verification and manual water flushes were not documented every 4 hours per policy on P5.

11. In interview, on 7/10/24 at approximately 1:45 pm, A2 (Quality Director) verified the medical records were as reviewed. Shift assessments, including head to toe assessments, were not completed per policy for P6 and P10. Morse Fall Risk Assessment was not documented every shift per policy for P6. In interview, on 7/24/24 at approximately 9:10 am, A2 (Quality Director) verified the medical record was as reviewed, the CIWA-Ar assessments were not always completed per policy.