HospitalInspections.org

Based on document review and interview, it was determined, for 1 of 10 clinical records reviewed (Pt. #1), the hospital failed to ensure patient care plans were updated when the patient's needs/requests changed.

Findings include:

1. On 2/6/14 at 2:30 PM, hospital policy titled, "GMH Inpatient Electronic Medical Record (EMR) Documentation", effective date January 2013, was reviewed. The policy required, "J. Plan of Care: The nurse will begin documenting the plan of care... The RN will select an RN Diagnosis and document the current status... daily..."

2. From 2/5/14 at 10:00 AM through 2/6/14 at 3:00 PM, Pt. #1's clinical record was reviewed. Pt. #1 was an 87 year old male, admitted on 12/29/13, with a diagnosis of mental status changes. A physician's (MD #1's) order dated 12/29/13 at 3:38 pm included Ativan, 0.5 mg every 6 hours as needed for agitation. Ativan was administered on 1/5/14 at 11:58 PM. The ICU physician's (MD #2's) note dated 1/6/14 at 3:37 PM included, Pt. #1's daughters were upset because Pt. #1 was so drowsy and they requested Ativan not be administered to Pt. #1. MD #2 discontinued the Ativan order, which was transcribed by the ICU RN (E #7). However, the RN did not update Pt. #1's care plan to include the family request not to administer Ativan.

3. The 6 south unit RN's (E #4) note on 1/8/14 at 5:02 am, indicated Pt. #1 was agitated and MD #1 was called. MD #1's order dated 1/8/14, included Ativan 1mg intravenously now. Ativan was administered on 1/8/14 at 5:45 am, two days after the family requested no Ativan to be given.

4. On 2/6/14 at approximately 3:30 pm, the director of nursing stated that the request by the family to not administer Ativan should have been included in Pt #1's plan of care.