HospitalInspections.org

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the RN to 1) obtain a urinalysis with culture and sensitivity as ordered by the physician upon admit, 2) document an assessment prior to administering a PRN antipsychotic medication and 3) notify the physician immediately of a change in condition for 1 of 5 sampled patients (Patient #1).
Findings:

1) Obtain a urinalysis with culture and sensitivity as ordered by the physician upon admit

Review of the record revealed Patient #1 was admitted to the hospital on 04/24/19 with diagnoses including Alzheimer's dementia and recent UTI. Review of the admission orders revealed an order for a urinalysis with culture and sensitivity. Further review of the order revealed that if patient was unable to void within four hours of admit, obtain urine through a straight catheter.

Review of the History & Physical dated 04/25/19 revealed the physician documented in the plan that he would follow her urine culture.

Further review of the record revealed no documented evidence that the urinalysis was collected.

On 10/29/19 at 10:30 a.m. interview with S1DON confirmed that there was no documented evidence that the urinalysis was obtained or that the physician was notified that it was not obtained as ordered.

2) Document an assessment prior to administering a PRN antipsychotic medication

Review of Patient #1's physician orders revealed an order dated 04/2419 for Zyprexa (antipsychotic) 5mg intramuscular every 12 hours PRN for agitation/aggression. Review of the patient's April 2019 MAR revealed an initial on the block dated 04/26/19, indicating the patient had received Zyprexa 5mg intramuscular PRN on that date.

Review of the psychiatrist progress note dated 04/27/19 revealed that the patient had "received Zyprexa 5mg IM last night". Review of the medical record revealed no documented assessment by the nurse prior to or after administering the PRN Zyprexa.

On 10/29/19 at 10:40 a.m., S1DON reviewed the patient's medical record with the surveyor and confirmed that there was no documented assessment by the nurse prior to or after administering the Zyprexa PRN.

3) Notify the physician immediately of a change in condition

Review of Patient #1's medical record revealed that she sustained falls on 04/25/19 at 1:50 p.m. and 04/27/19 at 2:40 p.m., in which she suffered a 3 centimeter hematoma to the back of her head.

Review of the nurses notes dated 04/27/19 at 5:30 p.m. revealed the patient was sitting in a chair by the nurses station, refusing to eat or drink supplement, stating "I'm not going to eat until y'all send me home; gets angry at times but able to redirect."

Review of the nurses notes dated 04/28/19 at 9:00 a.m. revealed the patient is "more alert and verbal this morning, some confusion, continues to refuse to eat until my daughter takes me home, then I will eat. Does drink supplements."

Review of the nurses notes dated 04/29/19 at 5:00 a.m. revealed "up frequently during the night, took some naps, slept about 2 hours total."

Review of the nurses notes dated 04/29/19 at 8:30 a.m. revealed S2RN documented that patient was "quiet and withdrawn, poor po intake noted, nonverbal, no aggression noted, almost full assist with adl's this a.m., blank stare noted". Further review of the nurses notes revealed at 10:40 a.m., S2RN spoke with the patient's physician regarding changes in mental status and physical presentation and the physician ordered a CT scan of the head. The nurses notes further revealed that after the family was notified, they requested for the patient to be transferred to the local emergency room.

On 10/29/19 at 10:30 a.m., an interview with S2RN was conducted. She stated that when she assessed Patient #1 at the beginning of her shift on 04/29/19, she noticed a change in her mental status and condition. She stated that she suspected a brain bleed due to the patient's recent falls and notified the physician. When asked why it took over two hours to notify the patient's physician of a change in condition, she had no response.

On 10/29/19 at 12:55 p.m., interview with S1DON and S3Administrator confirmed that the documentation in the patient's medical record stated that the physician was not notified of a change in the patient's condition for over two hours. They further confirmed that if the patient's medical physician could not be notified timely, the nurse should have contacted the patient's psychiatrist.