HospitalInspections.org

The Rehabilitation Hospital (rehab hospital) reported a current census of 23 patients. Based on review of closed and open medical records, review of policies and procedures and staff interviews the rehab hospital failed to assure a registered nurse (RN) evaluate the care for each patient upon admission for four of eight medical records reviewed (patient #'s 2, 5, 6, and 7), failed to assure the nurse evaluated the patient's response to pain medications for ??/8 medical records reviewed (patient #'s 1,?????), and failed to follow their policies and procedures. The overall effect of the lack of the RN's evaluation of the care of the patients upon admission and lack of evaluation of the patients response to pain medication leads to poor patient outcomes.


Findings include:


- The hospital's policy titled "Nursing Documentation" reviewed on 11/3/15 at 2:35pm directed, " ...The Admission Nursing Assessment will be completed by RN within two (two) hours of inpatient admission ..."
- The hospital's policy titled "Nursing Department Organization" reviewed on 11/3/15 at 2:15pm directed, " ...RN's who work under the direction of the Charge Nurse complete initial assessments on new admissions ..."
- The hospital's policy titled "Admission of a Patient" reviewed on 11/3/15 at 2:35pm directed, " ...The Admission Asssessment Record must be completed by the nurse admitting within four (12) hours of admission. It may be signed by a LPN (Licensed Practical Nurse) and co-signed by a RN indicating assessment by the RN ..."

- Patient #2's closed medical record reviewed on 11/3/15 revealed an admission date of 7/21/15 with diagnoses of falls, dementia, and unsteady gait and transferred to an acute care hospital on 7/23/15. The medical record revealed the admission assessment completed and only signed by a LPN. The staff failed to follow the hospital's policies that a RN will complete the admission assessment.

- Patient #5's medical record reviewed on 11/3/15 revealed an admission date of 10/30/15 with a diagnosis of bilateral knee replacement. The medical record revealed the admission assessment completed and only signed by a LPN. The staff failed to follow the hospital's policies that a RN will complete the admission assessment.
Interview with staff D RN, on 11/3/15 at 8:50am confirmed the LPN completed the patient's admission assessment while staff D completed the paper work. Staff D explained they were unaware that the RN had to complete the admission assessment.

- Patient #6's medical record reviewed on 11/3/15 revealed an admission date of 10/25/15 with a diagnosis of right hip fracture. The medical record revealed the admission assessment completed and only signed by a LPN. The staff failed to follow the hospital's policies that a RN will complete the admission assessment.

- Patient #7's medical record reviewed on 11/3/15 revealed an admission date of 10/23/15 to the traumatic brain unit with diagnoses of a motor vehicle accident with closed head injuries and cervical fractures. The medical record revealed the admission assessment completed and only signed by a LPN. The staff failed to follow the hospital's policies that a RN will complete the admission assessment.
Interview with staff G LPN on 11/3/15 at 8:10am acknowledged they performed admission assessments as well as having the patients and/or family sign the paper work. Staff G explained that sometime the RN and staff G will do the admission together.
Interview with staff A, Nursing Administration on 11/3/15 at 8:45m acknowledged the medical records with a lack of the RN performing the admission assessment. Staff A explained the LPN can perform part of the admission assessment then both LPN and RN have to sign the admission assessment form.

- The hospital's policy titled "MAR (Medication Administration Record) reviewed on 11/2/15 at 2:10pm directed, " ...Reassessment and documentation of patient response to prn (as needed) medications: A. Patient response to prn medications will be assessed 1 hour after administration. B. Patient response to prn medications will be documented in nursing notes (or flowsheet for pain medications) ..."

- The hospital's policy titled "Administration of Medications" reviewed on 11/2/15 at 2:10pm directed, " ...Document response to all prn medications ..."

- The hospital's policy titled "Nurses Role in Medication Administration" reviewed on 11/2/15 at 2:10pm directed, " ...Administering any meds ...monitor and evaluate the client response ..."

- The hospital's policy titled "Medication Variances" reviewed on 11/2/15 at 2:10pm directed, " ...All prn medications shall be documented in the appropriate medical record section entitled "PRN/STAT/unscheduled". The reason for administering the prn medication shall be documented as well as follow-up entry in the progress note section of the medical record as to patient's response to the intended therapeutic effect of the drug ..."
The Article titled "American Society for Management -Nursing Guidelines on Monitoring for Opioid Induced Sedation and Respirations" reviewed on 11/12/15 directed " recommendations for monitoring: frequency, intensity, duration, nature of monitoring (assessments of sedation levels and respiratory status and technology-supported monitoring) should be individualized ...serial sedation and respiratory assessments are recommended to evaluate patient response during opioid therapy by any route of administration ..."

- Patient #1's closed medical record reviewed on 11/3/15 revealed an admission date of 10/17/15 with diagnoses of severe spinal stenosis, falls, and to increase strength prior to potential surgery and was transferred on 10/27/15 to an acute care hospital. Patient #1's medication administration record (MAR) and nursing notes revealed the following:
The MAR on 10/18/15 revealed the patient received Noro (hydrocodone 5mg (milligrams) /acetaminophen 325mg) at 11:05pm, the nurses note lacked documentation of an assessment/evaluation before (location of pain, pain rating, quality, intervention, and route) or after (time, pain rating, level of sedation) the administration of the narcotic.
The MAR on 10/19/15 revealed the patient received Norco (hydrocodone 7.5mg/acetaminophen 355mg) at 5:00pm the nurses notes lacked documentation of an assessment/evaluation before or after the administration of the narcotic.
The MAR on 10/19/15 revealed the patient received a scheduled drug (OxyContin 10mg twice a day) at 8:00pm; the patient complained of back pain and rated the pain at a 3 on the pain scale of 0 to 10. The nurse's notes lacked documentation of an assessment/evaluation after the administration of the narcotic.
The MAR on 1/20/15 revealed the patient received Norco at 7:30am. The nurse's notes lacked documentation of an assessment/evaluation before and after the administration of the narcotic.
The MAR on 1/20/15 revealed the patient received the scheduled OxyContin 10mg at 8:00pm. The nurse's notes indicated the patient had no complaints of pain. The nurse's notes lacked documentation of an assessment/evaluation after the administration of the narcotic.
The MAR on 1/21/15 revealed the patient received Norco at 7:10am. The nurse's notes lacked documentation of an assessment/evaluation before and after the administration of the narcotic.
The MAR on 1/21/15 revealed the patient received the scheduled OxyContin 10mg at 8:00am. The nurse's notes lacked documentation of an assessment/evaluation before and after the administration of the narcotic.
The MAR on 1/21/15 revealed the patient received the scheduled OxyContin 10mg at 8:00pm; the patient complained back pain and rated the pain at a 5 on the pain scale of 0 to 10. The nurse's notes lacked documentation of an assessment/evaluation after the administration of the narcotic. The nurse's notes at 10:30pm indicated the patient sleeping.
The MAR on 10/22/15 revealed the patient received the scheduled OxyContin 10mg at 8:00am. The nurse's notes lacked documentation of an assessment/evaluation before and after the administration of the narcotic.
The MAR on 10/22/15 revealed the patient received Norco at 1:30pm; the patient complained of pain in legs and back. The nurse's notes lacked documentation of an assessment/evaluation before and after the administration of the narcotic.
The MAR on 10/22/15 revealed the patient received the scheduled OxyContin 20mg (dose changed from 10mg to 20mg) at 8:45pm; the patient complained of back pain at a 6 on a pain scale of 0 to 10. The nurse's notes lacked documentation of an assessment/evaluation after the administration of the narcotic. The nurse's notes indicate the patient sleeping at 21:45pm.
The MAR on 10/23/15 revealed the patient received the scheduled OxyContin 20mg at 8:00am. The nurse's notes lacked documentation of an assessment/evaluation before and after the administration of the narcotic.
The MAR on 10/23/15 revealed the patient received Norco at 10:12am. The nurse's notes lacked documentation of an assessment/evaluation before and after the administration of the narcotic.
The MAR on 10/24/15 revealed the patient received Norco at 6:10am. The nurse's notes lacked documentation of an assessment/evaluation before and after the administration of the narcotic.
The MAR on 10/24/15 revealed the patient received the scheduled dose of OxyContin 10mg (change in dose from 20mg to 10mg). The nurse's notes lacked documentation of an assessment before and after the administration of the narcotic.
The MAR on 10/24/15 revealed the patient received the scheduled dose of OxyContin 10mg at 8:00pm. The nurse's notes lacked documentation of an assessment/evaluation before and after the administration of the narcotic.
The MAR on 10/26/15 revealed the patient received Norco at 5:00am. The nurse's notes lacked documentation of an assessment/evaluation before and after the administration of the narcotic.
The hospital nursing staff failed to follow their policies regarding the assessment/evaluation of patients before and after the administration of prn medications.
Interview on 11/4/15 at 2:00pm with Staff A, Nursing Administration acknowledge the medical records lacked documentation of an assessment before and after the administration of the narcotics.