HospitalInspections.org

Based on interview and record review the facility failed to ensure adequate nursing care was provided for one of 15 sampled patients (Patient 1) when a Definitive Observation Unit (DOU- specialized unit where patients require close monitoring) LN (licensed nurse) was not assigned to provide continuous care for Patient 1.

This failure resulted in Patient 1 not receiving the necessary care, medication, and treatment in a timely manner.

Findings:

Patient 1 was admitted to the facility on 3/23/25 with diagnoses including heart failure, mitral valve regurgitation (MVR- failure of the heart valve to close tightly), and atrial fibrillation (irregular heart rate), per Patient 1's admission record.

Patient 1's physician order dated 4/6/25 at 8:28 A.M. indicated to transfer Patient 1 to the DOU from the telemetry unit (TU- unit where patients receive continuous heart monitoring).

Patient 1's physician order dated 4/6/25 at 8:29 A.M. indicated, "DBT (Dobutamine- medication to decompress the heart) 1 milligram (mg) per milliliter (ml) give intravenously (IV -through the vein) continuously."

A concurrent interview and record review was conducted with the telemetry unit charge nurse (TUCN) on 5/15/25 at 2:34 P.M. The TUCN reviewed the LN assignment for Patient 1. The TUCN stated that Patient 1 was not transferred to the TU and acknowledged that Patient 1 did not receive the DOU level of care for more than two hours. The TUCN stated that telemetry LNs were not trained to take care of DOU patients. The TUCN reviewed Patient 1's electronic medication record (EMAR-digital charting to document medication administration) and confirmed that the DBT was not administered to Patient 1. The TUCN further stated that a DOU LN should have stayed with the patient to provide the required level of care, and a DOU LN should have administered the DBT to Patient 1 within the hour that the DBT was ordered.

An interview was conducted with the telemetry unit manager (TUM) on 5/16/25 at 8:44 A.M. The TUM stated that Patient 1 required DOU care which was a higher level of care than the TU. The TUM acknowledged that Patient 1 was not transferred to the DOU, and that a DOU LN or Intensive Care Unit (ICU- unit that provides treatment to critically ill patients) LN should have stayed with Patient 1 and the DOU or ICU LN should have administered the DBT to Patient 1 per physician order.

A review of the facility's policy and procedure titled Medication Administration dated 2/2025 indicated, " ...5.0 Procedures ...5.2.1 Medications must be administered within 1 hour ..."