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Based on review of patient medical records and staff interview the facility failed to provide a safe environment for two of ten patients whose medical records were reviewed. (Patient #3 and #9)
The facility census was 421.

Findings included:

Review of the medical record of Patient #9 on 3/11/10, revealed this patient had been an inpatient at the hospital from 12/15/08 to 12/18/08. The patient's "Data Base Record" revealed the patient was allergic to latex and presented with a rash when in contact with latex and adhesives. An anesthesia note dated 12/17/08, revealed that the patient complained of a rash from a adhesive type dressing and tape applied at the anesthesia epidural site. Medications were provided to relieve this symptom. Nurse's notes dated 12/18/08 at 7:30 PM, revealed the patient had large inflamed areas on the back and an extensive red rash on the back and wrist due to the allergy.

Interview of Staff #2 on 3/11/10, during the afternoon revealed it was unknown why hospital staff used these products on the patient when the patient had a allergy known to the hospital staff.

Interview of Staff #9 at 12:00 PM, confirmed tape was used on Patient # 9's epidural catheter. Staff # 9 confirmed there was no documentation of a discussion with the patient of the risk of applying tape.




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Review of medical record for Patient #3 was conducted on 03/10/10 at 2:00 PM. Patient #3 seen on 09/03/09, for acute renal failure. At the time of triage in the emergency room at 6:36 AM, it was noted that the patient had an allergy to Dilaudid (narcotic pain med). Patient #3 received Dilaudid 2mg IV at 8:45 AM and Dilaudid 16 mg was given orally. A verbal order was received on 09/03/09 at 4:37 PM, for Dilaudid 1mg IV to be given every four hours as needed. At the time the order was entered into the system, the computer program prompted the nurse to enter a reason why the patient was getting a medication that was listed as an allergy. Review of the documentation listed the reason as "patient denies allergy". There was no documentation this conversation between the nurse and the patient had occurred. Patient #3 received subsequent doses of Dilaudid 0.5mg IV on 09/04/09 at 12:30 PM and 4:30 PM and on 09/05/09 at 9:33 PM. There was no documentation the patient suffered an adverse reaction from the administration of Dilaudid. This finding was confirmed with Staff #2 and #7 on 03/10/10 at 4:00 PM.

Based on staff interview and medical record review it was determined that the registered nurse failed to assess the nutritional needs for one of ten patients whose medical records were reviewed. (Patient #3) The facility census was 421.

Findings included:

Review of Patient #3's medical record on 3/09/10, of the documentation dated 09/03/09, revealed Patient #3 arrived at the Emergency Department (ED). During triage Patient #3 stated that he/she "was having thoracic pain and had a history of spinal surgery on 09/10/08 for spinal cord compression." The patient has a history of blindness, acute renal failure and insulin dependent diabetes. The Xray study ordered at that time was canceled due to patient refusal. At 10:45 AM, the patient returned to the ED and at 11:30 AM, was moved to a holding area to await hospital admission. On review of the medical record there was no documentation that the patient was offered or received any form of nourishment since the time of entrance into the hospital. The patient arrived to room at 1:25 PM. An accucheck (blood sugar test) was assessed at 1:55 PM and was documented at 89. A normal blood sugar range is 60 to 100. At 4:00 PM Patient #3 had more blood work drawn which revealed a blood glucose level of 67. An accucheck was performed at 4:00 PM, had a result of 75. An accucheck order was placed at 4:15 PM to be completed before meals and at bedtime. Although there was a diet order written at 5:47 PM for a diabetic diet, there was no documentation that the patient received or was offered any nourishment. At 6:15 PM Patient #3 went to have a Magnetic Resonance Imaging (MRI) study of his/her thoracic spine. At 7:47 PM Patient #3 returned from MRI to his/her room and he/she was unresponsive with an accucheck reading of 33, an blood oxygen saturation level was measured at 84% on room air, a blood oxygen saturation level of 90% or above on room air is preferred. Oxygen was placed on the patient at (2) two liters per minute per nasal canula and the patient's blood oxygen saturation level increased to 94%. Patient #3 also received Narcan (medication administered to reverse the effects of narcotics) 0.2 milligram intravenously at 7:55 PM. After administration of this medication the patient was able to be aroused. At 8:10 PM, the Medical Early Recognition Team arrived and documented that the patient was obtunded (dull) but would respond to name and stimuli.

Record review on 3/09/10, of a previous admission dated 09/05/08, revealed Patient #3 was admitted with weakness of the legs due to a spinal cord problem. There was no documentation that the patient received any nourishment for dinner or snack on 09/07/08. Patient #3 received a scheduled dose of Insulin 50 units subcutaneously at 9:00 PM. On 09/08/08, the meal intake information listed 0% for breakfast and the lunch, dinner and snack areas were blank. There was no physician's order present in the medical record for the patient to be NPO (nothing by mouth). Patient #3's accucheck (blood sugar test) tested at 5:45 AM on 09/08/08, read 41. A normal accucheck is 60 to 100. Other accuchecks taken during the day included: 6:15 AM, the accucheck was 20, at 8:00 AM, 120, at 2:50 PM, 20. At 9:00 AM on 09/08/08, Patient #3 received the scheduled dose of Insulin, 45 units subcutaneously. An Electromyogram (EMG) was ordered on 09/08/08, and the patient arrived for the EMG at 9:40 AM. At 10:28 AM, the patient was brought to radiology where he/she had a series of Xray studies. The patient then returned to his/her room at 2:30 PM. At 2:45 PM the registered nurse was called to the patient's room by a unit clerk and the patient was found lying on his/her abdomen on his/her bed and was unresponsive. The accucheck reading for this patient at that time was noted to be 20. Patient #3 was then turned on his/her back and was given Dextrose ( sugar solution) 50 milligrams intravenously at 2:50 PM and the patient then became responsive at 2:50 PM.

These above findings were confirmed by Staff #7 on 3/10/10 at 4:00 PM



This finding substantiates complaint number OH00052418.