HospitalInspections.org

Based on a review of hospital policies, medical record reviews and staff interview, the nursing staff failed to ensure a physician's order was carried out as ordered and documented on the Medication Administration Record per hospital policy for 1 of 1 patients with an enema order.

The findings include:

Review of the hospital policy on 07/13/2017 titled "Medication Administration" effective December, 2016 revealed "Medication Orders 1. Medications shall be administered or discontinued only upon the order of a member of the medical staff, house staff, or other individual who has been granted clinical privileges to write orders. ...Medication Preparation and Administration ...2. No change may be made in the medication dosage...without an LIP (Licensed Independent Practitioner) order. ...Documentation 1. All medications including dose...and time of administration must be documented immediately on the MAR (Medication Administration Record)..."

Review of the medical record on 07/12/2017 for patient #5 revealed a 48 year-old-male presented to the Emergency Department on 05/02/2016 with a chief complaint of "Tracheostomy Tube Evaluation" and "after having lost his home aides, and he is now no longer able to be cared for at home." Patient #5 was subsequently admitted for placement. Review of the case management notes revealed Patient #5 did not require admission for a medical condition. Review of the record revealed Patient #5 had a history of quadriplegia (paralysis of all four limbs), tracheostomy (tube is inserted into the windpipe to open a restricted airway and enable breathing) and ventilator (breathing machine) dependence. Review of the physician orders revealed an electronic order on 05/30/2017 at 2225 for SMOG ( Saline, Mineral Oil, Glycerin) enema 720 mls (milliliters) rectally daily PRN (as needed) for constipation. Review of Medication Administration Record from 06/07/2017 through 07/11/2017 revealed a SMOG enema was administered as follows:

720 milliters on 06/07/2017 at 0255
480 milliters (240 milliters less than ordered by physician) on 06/12/2017 at 0100
Patient refused on 06/14/2017 at 0129
480 milliters (240 milliters less than ordered by physician) on 06/15/2017 at 0108
720 milliters on 06/19/2017 at 0047
240 milliters (480 milliters less than ordered by physician) on 06/21/2017 at 0123
720 milliters on 06/26/2017 at 0056
Patient refused on 06/28/2017 at 0148
480 milliters (240 milliters less than ordered by physician) on 06/29/2017 at 0045
720 milliters on 07/03/2017 at 0106
720 milliters on 07/05/2017 at 0055
720 milliters on 07/07/2017 at 0305
720 milliters on 07/10/2017 at 0138

Review of the nursing notes from 06/07/2017 through 07/11/2017 revealed a SMOG enema was administered patient as follows:

06/08/2017 at 2146 - "RN (Registered Nurse) asked pt (patient) about enema and he stated he would let RN know."
06/10/2017 at 0005 - Patient refused.
06/11/2017 at 0100 - Patient refused.
06/16/2017 at 0000 - Patient refused
06/18/2017 at 0045 - "...Pt given enema. Pt accused RN of not putting enema tube into pts rectum and demanded to see enema tube after withdrawn from rectum in order to verify stool was on enema tube..."
06/22/2017 at 0050 - Patient refused.
06/23/2017 at 0208 - Patient refused.
06/24/2017 at 0126 - "Pt stated to the RT (Respiratory Therapist) that he felt 'weird' and RT noted that his heart rate was slightly ST (Sinus Tachycardia) (106) this RN entered the room and informed the Pt that baseline vitals (temp and BP) should be taken since he felt weird. The Pt refused to have his temp or BP (blood pressure) taken and stated he wanted an enema right now. ...The Pt was informed that his NA was tied up with another Pt right at this moment and when he finishes we will be available to give him the enema he refused yesterday."
06/24/2017 at 0420 - Patient refused.

Review of the medical record revealed no documentation on the Medication Administration Record of a SMOG enema administered or refused on 06/10/2017, 06/11/2017, 06/16/2017, 06/18/2017, 06/22/2017, 06/23/2017 and 06/24/2017. (7 of 20 medication administrations or refusals) Further review of the medical record revealed documented dose of medication administered on 06/12/2017, 06/15/2017, 06/21/2017 and 06/29/2017 were not as the physician ordered with no further documentation for change of dosage. (4 of 12 doses administered)

Interview on 07/11/2017 at 1345 with Patient #5 revealed the staff did not give him his enema every other day. Interview revealed "I have not refused the enemas."

Interview on 07/12/2017 at 1100 with RN #2 revealed the enema should be administered every other day per the named patient's request. Interview revealed the staff did not administer the dosage amount ordered by the physician. Interview revealed the enema is considered a medication and should be documented on the Medication Administration Record. Interview confirmed the findings.

Interview on 07/12/2017 at 1115 with RN #3 revealed the named patient is offered the enema at night during his bath per the named patient's request. Interview revealed the enema was ordered daily as needed for constipation, but was offered every other day per patient's request. Interview revealed if the patient refused the enema during his bath, it should be offered again at a later time or during the next shift.

NC00129015