HospitalInspections.org

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Based on medical record and document review, the hospital failed to ensure that the Quality Assessment and Performance Improvement Program used all data collected from incident reports to assess and improve the delivery of care and services provided to its patients.

Finding Include:

Review of the hospital's occurrence reports for 1/20/18 to 12/18/18 showed evidence of incidents related to blood transfusion reactions, medications errors, adverse intravenous infiltrations.

Review of the Hospital Performance Improvement Minutes from 1/2/19 to 12/18/18 showed no evidence that these incidents/occurrences were reviewed, trended or analyzed to identify and address significant issues.

During interview on 2/19/19 at 10:16 AM, Staff A, Assistant Vice President of Regulatory and Quality Assurance stated that the "Risk Management Tool" was given to Nurse Managers, who are required to investigate and manage occurrences within their departments.

During interview on 2/19/19 at 1:51 PM, Staff M, Chief Nursing Officer acknowledged that not all incidents/occurrences were analyzed and reported in the Hospital-wide Performance Improvement Program.

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Based on medical record review, and interview, in two (2) of ten (10) medical records reviewed, nursing staff did not ensure continuous evaluation and treatment of patients in accordance with physician written orders (Patient #1 and #10).

Finding Include:

1. Review of medical record for Patient #1 showed a physician order dated 10/16/18 for "Accu-check" (Glucose testing) before meals and at hour of sleep which were scheduled for 7:00 am, 11:30 am, 4:00 pm, and 10:00 pm.

There was no documented evidence that the patient's glucose was monitored on 10/23/18 at 10:00 pm.

2. Review of the facility policy titled "Pain Assessment and Management," last revised 3/2017, notes "Pain must be reassessed following administration of an unscheduled analgesic ... Within 60 minutes following administration of an oral analgesic, or on an as needed basis."

Review of medical record for patient #10 identified a 58-year-old female who was admitted on 2/4/19 for Right Lower Extremity pain. On 2/5/19 at 4:26 pm, nurse documented a pain score of 9/10 (1 being the mildest and 10 severe). The nurse administered a pain medication at 4:50 pm.

There was no documented evidence of a reassessment of the patient's pain until 7:46 pm, almost three hours after the pain medication was administered.

On 2/11/19 at 1:17 pm, nurse documented a pain score of 8/10. A reassessment was not documented until approximately two hours later at 3:12 pm.

Similar findings regarding the lack of timely reassessment of the patient after pain management was noted on 2/14/19 at 1:22 am, when the patient reported a pain score of 7/10 and there was no reassessment over nine (9) hours later at 10:43 am.

3. On 2/5/19 at 6:25 pm, a physician order indicated vital signs every 4 hours (Q 4 hours) for Patient #10.

On 2/5/19, the nurse documented vital signs at 8:31 pm, the next vital signs were documented eleven hours after, on 2/6/19 at 7:32 am.

Similar findings regarding the lack of implementation of the Q 4 hours vital signs were noted on 2/6/19, when vital signs were documented at 2:50 pm, and the next at 9:43 pm. The patient's vital signs were not reassessed again until 6:29 am on 2/7/19.

During interview on 2/19/18 at 11:45 am, Staff B (Registered Nurse Informatics Specialist) confirmed these findings.