HospitalInspections.org

Based on record review and interview, the hospital failed to ensure:
1. completion of orders for one (Patient #3) of ten patients.
2. reassessment of pain medication administration for three (Patient #8, 9, and #10) of ten patients

This failed practice has the likelihood to result in no assessment of a patient's clinical condition and delayed intervention.

Completion of Orders

Review of the medical record showed no hour of sleep capillary blood glucose results for the nights of 11/08/20 and 11/09/20.

Review of the medical record showed an order for "Blood glucose monitoring POC QIDACHS" dated 11/08/20 at 1:20 PM.

On 11/10/20 at 12:24 PM, Staff A reviewed the medical record for Patient #3 and stated there were no finger stick blood sugars at bedtime on 11/08/20 and 11/09/20 and there should have been so that the data was available for the doctor.


Reassessment of Pain

Review of a facility policy titled "Pain Management" read in part, "document the patient's level of pain prior to and after analgesic administration."

Patient #8

Review of the electronic medication record (EMR) showed acetaminophen-hydrocodone was administered for pain on 09/04/20 at 11:56 AM and pain reassessment not completed per facility policy.

On 11/10/20 at 2:50 PM, Staff A reviewed the EMR for Patient #8 and stated the pain reassessment was not completed per facility policy.

Patient #9

Review of the EMR showed acetaminophen-hydrocodone was administered for pain on 08/03/20 at 4:37 AM and pain reassessment not completed per facility policy.

On 11/10/20 at 3:00 PM, Staff A reviewed the EMR for Patient #9 and stated the pain reassessment was not completed per facility policy.

Patient #10

Review of the EMR showed acetaminophen-hydrocodone was administered for pain on 09/04/20 at 2:52 PM and pain reassessment not completed per facility policy.

On 11/10/20 at 3:10 PM, Staff A reviewed the EMR for Patient #10 and stated the pain reassessment was not completed per facility policy.

Based on record review and interview, the hospital failed to ensure care plans addressed patient needs for three (Patient #2, #3 and #5) of ten patients.

This failed practice has the likelihood to result in unidentified patient problems and no or delayed intervention, thereby increasing risk for delayed healing.

Review of a policy titled "Multidisciplinary Care Plans" read in part, "It is the responsibility of the Registered Nurse to establish priorities of nursing intervention and implement the strategy of care based on the assessment data of the patient...individualized to the patient's needs. To identify and document patient problems, establish outcome and implement intervention."

Patient #2

Review of a document titled "Plan of Care" showed interventions for acute pain and did not show any other nursing patient problems.

Review of a document titled "History and Physical Reports" dated 11/05/20 showed the patient fell, possibly struck the head, had a femur fracture, and was diabetic.

On 11/10/20 at 11:30 AM, Staff A reviewed the medical record for Patient #2 and stated the following:
1. He or she expected to see a problem related to diabetes on the patient's plan of care
2. The patient was at risk of improper healing because of diabetes
3. The purpose of a care plan was to plan out care to help the patient improve to the point of discharge

Patient #3

Review of a document titled "Plan of Care" showed interventions for acute pain and did not show any other nursing patient problems.

Review of a document titled "History and Physical Reports" dated 11/08/20 showed the patient had a right upper extremity abscess and diabetes.

On 11/10/20 at approximately 12:20 PM, Staff A stated risk for infection and skin alteration should have been included on the care plan.

Patient #5

Review of a document titled "Plan of Care" showed interventions for activity intolerance and risk for infection and did not show any other nursing patient problems.

Review of a document titled "History and Physical Reports" dated 11/08/20 showed the patient had hypoxia, diabetes, diarrhea, and received 500 mL of fluids.

On 11/10/20 at 1:00 PM, Staff A stated the plan of care should have included problems related to diabetes and diarrhea.

Based on record review and interview, the hospital failed to ensure its written instruction was followed to provide patient education for one (Patient #2) of ten patients.

This failed practice has the likelihood to place patients at risk of being uninformed about their disease processes or how to manage them, thereby increasing the risk for readmission.

Review of a document titled "Admission Assessment of a Patient" read in part, "At time of admission complete: Education--Patient Teaching Record--Disease Specific"

Patient #2

Review of a document titled "Nursing Workflow" showed patient problems to include a femur fracture, diabetes, and a fall; and showed no patient education.

On 11/10/20 at approximately 11:40 AM, Staff A reviewed the medical record for Patient #2 and stated the following:
1. He or she did not see where education had been charted
2. He or she did not know when education was to be provided to patients
3. The purpose of education was for patients to understand their disease state and care