HospitalInspections.org

Based on medical record review, the facility identified patient care issues and did not implement changes for improvement.

Findings Include:

Review of orders dated 5/19/10 at 1630 revealed an order for " abd gas start now" .

Review of the quality assurance patient complaint report (PCR) dated 5/27/10 revealed the blood gas was done in error. The PA ordered Gas X; the unit clerk misread the order and called respiratory therapy to draw an arterial blood gas ( ABG). Respiratory was unable to obtain the ABG after 3 attempts. The physician assistant was notified and stated it was not ordered to be done. There was no evidence that the facility addressed this issue.

Based on record review and document review, nursing services failed to evaluate the care upon admission for Patient #1.

Findings Include:

Review of policy " Nursing Admission Assessment " last reviewed 6/10 revealed all inpatients will have a completed admission assessment within 24 hours of admission to the facility. Same day surgery patients may have their admission assessment completed prior to the date of admission. The admission assessment will be updated and reviewed on the date of admission.

Review of the nursing admission assessment dated 5/17/10 at 0840 revealed the assessment sections regarding medications, skin, learning needs, orientation to room and the correct ID band are blank. Assessment sections for cardiovascular and gastrointestinal are not complete. The signature lines for " assessment data completed by " and " reviewed and updated on date of admission by " are blank. There was no evidence the admission assessment was completed.

Based on interview and medical record review, Patient #1's allergy status was not consistently documented.

Findings Include:

Review of the cardiac consult dated 4/22/10 and the preoperative orders dated 5/5/10 revealed allergies to Zocor and Lipitor are documented.

Review of the medical clearance form, the nursing admission assessment , the pre-operative checklist , the intraoperative nursing notes, the peri-operative transfer summary , the post anesthesia orders, the admission medication reconciliation record, admission orders and the medication administration record dated 5/17/10 to 5/22/10 documents no allergies.


Interview on 10/8/10 at 11:00AM with Staff #2 revealed the facility does not have a policy regarding documentation of allergy status.

Based on medical record review and document review, the facility did not ensure medications brought from home were distributed in accordance with applicable standards of practice for Patient #1.

Findings Include:
Review of policy " Medication from Home " last reviewed 1/08 revealed patients may bring in home medication for use while hospitalized. However the policy does not specify the verification process and documentation requirements for medications brought from home.

Review of the nursing admission assessment dated 4/28/10 revealed the medication section for documentation of medications brought from home was blank.

Review of orders dated 5/18/10 at 1305 revealed Patient #1 may use own meds from home.

Review of the medication administration record (MAR) dated 5/18/10 revealed the following documentation:

-Simvastatin/Zocor 10mg,1 tablet by mouth daily was listed as a substitute for Pravachol 20mg. A hand written note documents " wants to take own " . The 1800 space is circled and 2100 space is marked off and initialed by staff.
-Sotalol/Betapace 120mg by mouth twice daily. The 0900 space is circled with a hand written note of " wants to take own " . The 1400 and 2100 space is marked off with an " H " under the " X " and initialed by staff.
-Digoxin 250mcg by mouth daily. The 0900 space is circled with a hand written note of " wants to take own " . The 1400 space is marked off with an " H " under the " X " and initialed by staff.
-Niaspan 1000 mg by mouth daily. The 0900 space is circled with a hand written note of " wants to take own " . The 2100 space is circled as " refused and initialed by staff.
-Folic Acid 800mg mouth daily. The 0900 space is circled with a hand written note of " wants to take own " . The 1400 space is marked off with an " H " under the " X " and initialed by staff.

There was no evidence to indicate that medications brought from home were reviewed and/or verified by pharmacy prior to administration.