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Based on record and policy review and staff interview it was determined that the Registered Nurse failed to ensure appropriate assessment and implementation of nursing care related to skin care and medication response for 1 (#1) of 3 sampled patients. This practice does not ensure patient goals are met and may cause a prolonged stay.

Findings include:

1. Patient #1's emergency department (ED) documentation dated 8/22/10 indicated that the patient received intravenous (IV) Dilaudid 1 milligram at 1:45 p.m. for pain. The patient was administered Metoprolol 5 milligrams IV at 1:44 p.m. for an elevated blood pressure and heart rate. Vital signs recorded at 2:00 p.m. revealed an elevated blood pressure (150/94) and pulse rate (95). The patient's pain level had decreased to 3 on a scale of 0-10. No further vital signs were recorded. At 4:35 p.m. the nurse documented no change in condition, however, vital signs were not recorded. The patient was transported to the inpatient room at 5:00 p.m. No assessment was completed at the time of transfer and no vital signs were recorded. Review of the nursing documentation from the inpatient unit revealed that the patient's respiratory rate was 5-6 upon arrival. The physician was notified and an order for Narcan obtained.

Review of the ED policy "Reassessment of Patients" revealed that patients are to be reassessed following administration of medication and upon transfer to an inpatient unit. In addition vital signs are to be included in the reassessment.

The Assistant Vice President of Patient Care services confirmed the findings during interview on 9/21/10 at approximately 2:30 p.m.

2. Patient #1's skin assessments performed on the nursing unit on 8/22/10 and 8/23/10 revealed inconsistent documentation and failure to intervene when there was a change in condition. The skin assessment documented on 8/22/10 revealed an old bruise was present on the patient's right forearm. The documentation on 8/23/10 at 8:00 a.m. revealed multiple bruises to both upper extremities and a reddened right knee. Nursing documentation on 8/23/10 at 8:00 p.m. revealed the right knee was red and swollen. There was no evidence of any nursing intervention or notification of the physician regarding the condition change.

Interview on 9/21/10 at approximately 3:00 p.m. with the Director of Regulatory Compliance confirmed the above findings.

Based on record and policy review and staff interview, it was determined the facility failed to comply with policy regarding reporting of Adverse Drug Reactions for 1 (#1) of 3 sampled patients. This practice does not provide for safe administration of medications.

Findings include:

Patient #1 reported a pain level of 8 on a 0-10 pain scale. Review of the nursing documentation in the Emergency Department (ED) dated 8/22/10 revealed that 1 milligram of Dilaudid was administered intravenously (IV) at 1:45 a.m. Documentation on 8/22/10 at 5:10 p.m. revealed that the patient arrived on the nursing unit with a respiratory rate of 5-6 per minute. There were neurological changes noted. The physician was notified and ordered Narcan. Review of the history and physical noted the patient had a significant change in mental status from the Dilaudid administered in the ED.

The facility's policy "Adverse Drug Reaction Reporting" last reviewed 2/08 defines a significant drug reaction as "any unexpected, unintended, undesired or excessive response to a drug that requires discontinuing the drug" or "necessitates supportive treatment". The policy requires that nursing staff initiate the Adverse Drug Reporting (ADR) Process by completing the ADR form. The form is then to be forwarded to the Pharmacy department for review.

During interview on 9/21/10 at approximately 3:00 p.m. the Director of Regulatory Compliance confirmed that an ADR form had not been completed and forwarded to the Pharmacy for review as required by the policy.