HospitalInspections.org

Based on policy and procedure review, medical record review and interview, nursing staff failed to follow accepted standards of nursing practice and hospital policy; specifically: 1) nursing did not document Patient #4's hypotensive episode and nursing assessment; and 2) nursing staff failed to follow facility policy and procedure regarding cardiac rhythm monitoring for 3 of 5 telemetry patients (Patients #6, 10 and 11).

Findings include:

Findings #1:
Review on 02/21/14 of policy "Assessment and Reassessment of Patients, CL.3" (effective 11/15/10) revealed reassessment of all patients is completed when there is a change in the patient's condition.

Review on 02/21/14 of policy "Documentation of Adult/Pediatric Patient Care, PE.2" (effective 04/05/14) revealed that progress notes are written by the registered nurse for the following: changes in patient condition not noted elsewhere, including critical events or incidents and the patient's response to interventions such as: improvement, no change, deterioration, compliance or non-compliance. Progress notes should be written to describe observations and interventions that are not charted elsewhere.

Medical record review with 2E Charge Registered Nurse (RN) Staff #6 on 02/19/14 at 11:15 AM for Patient #4 revealed an episode of hypotension with blood pressure of 96/49 on 02/15/14 at 1900 with no nursing documentation of assessment found. Patient #4 was administered a standing order for Lasix 40 mg on 02/15/14 at 2058 with no repeat blood pressure taken or other nursing assessment of hypotension. This finding was confirmed at the time of record review with Staff #6 and Vice President/Chief Nursing Officer Staff #11.

Interview on 02/19/14 at 11:30 AM with 2E RN Staff #8 revealed that if there were any type of abnormal results, she would notify the prescribing provider and document in the patient record that they were notified.

Findings #2:
Review on 02/21/14 of policy "Use of Cardiac Rhythm Monitoring: Telemetry, CL.25 and TX.CV.19" (effective 09/07/09) revealed a monitor strip will be recorded and placed in the patient's record every 12 hours.

Medical record review on 02/19/14 and 02/20/14 for telemetry Patient #6 revealed the following:
- On 02/01/14, although telemetry was ordered for the entire day, only one cardiac monitor strip was recorded at 1844 and placed in the medical record.
- On 02/06/14, although telemetry was ordered for the entire day, there is no evidence that a cardiac monitor strip was recorded and placed in the medical record.
These findings were verified on 02/19/14 at 12:10 PM with 2N Nurse Manager Staff #10 and Staff #11, and on 02/20/14 at 3:36 PM with 2SW Nurse Manager Staff #18.

Medical record review on 02/20/14 for telemetry Patient #10 revealed the following:
- From 01/24/14 at 1900 through 01/27/14 at 0651, although telemetry was ordered for the entire day on those dates, there is no evidence that a cardiac monitor strip was recorded and placed in the medical record.
- On 02/10/14, although telemetry was ordered for the entire day, only one cardiac monitor strip was recorded at 0726 and placed in the medical record.
These findings were verified on 02/20/14 at 10:30 AM with Medical/Surgical Nursing Director Staff #2, Staff #18 and Quality and Patient Services Staff #26. At 3:30 PM, Staff #18 confirmed that Patient #10 was on a cardiac monitor from 01/24/14 through 01/27/14.

Medical record review on 02/20/14 for telemetry Patient #11 revealed the following:
- On 02/14/14, although telemetry was ordered for the entire day, only one cardiac monitor strip was recorded at 0649 and placed in the medical record.
This finding was confirmed on 02/20/14 at 11:20 AM with Staff #2, ICU Nurse Manager Staff #14 and Staff #26.

Based on policy and procedure review, medical record review and interview, facility staff failed to ensure that provider's orders are signed off and/or authenticated by the provider, as evidenced for 2 of 22 patients. (Patients #6 and 10)

Findings include:

Review on 02/21/14 of policy "Transcribing/Verifying Physician Orders, ADM.6" (effective 02/02/09) revealed that a physician order must be signed off for completion by the registered nurse, unit secretary, certified medical assistant, or in long term care, licensed practical nurse, graduate nurse and medical office assistant. If the order is incomplete or needs clarification, the physician is contacted. Upon receipt of a valid physician order, check that the order form is labeled with the correct patient information and authorized physician signature.

Medical record review on 02/19/14 and 02/20/14 for Patient #6 revealed the following:
- On 12/26/13, 01/10/14 and 01/26/1: the orders were not signed off, but the orders were carried out by nursing staff.
- On 12/29/13, 12/31/13, 01/04/14, 01/05/14, and 01/06/14: the orders were not authenticated by the provider.
These findings were verified on 02/19/14 at 12:10 PM with 2N Nurse Manager Staff #10 and Vice President/Chief Nursing Officer Staff #11, and on 02/20/14 at 3:36 PM with 2SW Nurse Manager Staff #18.

Medical record review on 02/20/14 for Patient #10 revealed the following:
- On 02/10/14, the orders were not signed off, but the orders were carried out by nursing staff.
This finding was verified on 02/20/14 at 10:30 AM with Medical/Surgical Nursing Director Staff #2, Staff #18 and Quality and Patient Services Staff #26.