HospitalInspections.org

Based on document review and interview, the facility failed to ensure nursing staff followed physician orders, facility policy related to assessing patients' vitals and physician notification of abnormal assessment/change in condition for 2 of 10 medical records (MR) reviewed. (Patients #1 and 2)

Findings include:

1. Facility policy titled "Physician Notification for Orders, Condition Report, and Management of Patient Care" last reviewed/revised 5/2019 indicated the following: "...GENERAL INFORMATION: 1.0 It is the responsibility of the nurse taking care of the patient to notify the appropriate physician of pertinent information and/or changes in the patient's condition...CHAIN OF COMMAND...2.0 Pertinent patient information is reported to the appropriate physician, depending upon the patient needs and/or problems...2.3 For abnormal assessment or deterioration in condition, notify both the attending and the appropriate consulting physicians...Documentation: 4.1 Document attempts to reach the physician in the electronic record..."

2. Facility policy titled "Vital Signs, Obtaining and Reporting" last reviewed/revised 2/29/2020 indicated the following: "...GENERAL INFORMATION...1.0 Vital signs include pulse (radial or apical), respirations, blood pressure and temperature...5.0 Vital signs may be monitored more frequently than unit policy based on...physician order...nursing judgement..."

3. Facility policy titled "Management of Hypoglycemia and Hyperglycemia" last reviewed/revised 6/2019 indicated the following: "...Hyperglycemia: 1. Staff to be alert for signs and symptoms of hyperglycemia which may include the following: excessive thirst, weakness, fruity breath, dry mouth, frequent urination, nausea and mental status changes..."

4. Review of Patient #1's medical record indicated the following:
Patient #1 arrived at the facility's preoperative area on 2/8/21 at 6:13 a.m. for bilateral total knee replacement arthroplasty, admitted inpatient to 3 West Unit and expired on 2/8/21 at 9:37 p.m.

a) Patient #1 had the following physician order: "Vital Signs: Every 1 hour times 1 occurrence, then every 2 hours times 1 occurrence, then every 4 hours times 24 hours, per unit standard..."ordered on 2/8/21 with a start time of 1:00 p.m.

b) The medical record for Patient #1 lacked documentation of a complete set of vitals and/or refusals every four hours times 24 hours including but not limited to a blood pressure, heart rate, respiratory rate and temperature on 2/8/21 at 7:00 p.m.

c) Patient #1 had the following physician order: "Notify physician if fasting blood glucose is above 180 mg [milligrams]/dl [deciliter] or pre-prandial glucose is above 350 mg/dl for dose adjustments to optimize blood glucose management ordered on 2/8/21 at 3:33 p.m.

d) On 2/8/21 at 4:11 p.m., Patient #1 had a blood glucose of 287. A nurse's note dated 2/8/21 at 5:00 p.m. indicated Patient #1 was very lethargic and tired. The medical record lacked documentation of physician notification of Patient #1's blood glucose of 287 and change in condition related to being very lethargic.

5. Review of Patient #2's medical record indicated the following:
The patient arrived at the emergency department on 2/6/21 with a fractured right femoral, admitted inpatient, had a right hip hemiarthroplasty on 2/8/21, transferred to inpatient 3 West Unit on 2/8/21 at 7:33 p.m. and was discharged on 2/10/21.

a) Patient #2 had the following physician order: "Vital Signs: Every 1 hour times 1 occurrence, then every 2 hours times 1 occurrence, then every 4 hours times 24 hours, per unit standard..."ordered on 2/8/21 with a start time of 8:00 p.m.

b) The medical record for Patient #2 lacked documentation of a complete set of vitals and/or refusals as ordered including but not limited to a blood pressure, heart rate, respiratory rate and temperature on 2/8/21 at 8:33 p.m. and 10:33 p.m.

6. During an interview on 4/29/21 at 4:50 p.m., A2 (Quality Care Program Coordinator) verified the medical record information for Patients #1 and 2.