HospitalInspections.org

Based on document review and interview the facility failed to provide patient #1 the right to receive care in a safe setting. The facility failed to:

A. ensure nursing staff removed a Foley Catheter from patient #1as ordered by the physician.
Refer to tag A0144

B. ensure Nursing Instructors and Nursing Students followed the standards of care adopted by the facility. Patient #1 was placed in the Trendelenburg position for approximately 45 minutes while performing an in and out foley catheter procedure. (Source: nurseweb.ucsf.edu (University of California, San Francisco) The Trendelenburg position involves placing the patient head down and elevating the feet.)
Refer to tag A0144

C. ensure an RN supervised and evaluated nursing care of patient #1 (1 of 1 patients). Patient #1 was documented as having an Adverse Drug Reaction. Based on these finding the nursing staff failed to act on behalf of the patient and provide routine nursing care.
Refer to tag A395

D. identify a medication error. Documentation reviewed in patient #1's medical record revealed the patient did not receive the ordered intravenous fluids.
Refer to tag A405

Based on document review and interview the facility failed to provide a safe environment for patient#1 to receive care. The facility failed to:


A. Ensure nursing staff removed a Foley Catheter from patient #1as ordered by the physician. The patient retained a Foley Catheter from the insertion date of 09/04/2017 through 09/11/2017 at 07:10am when it was removed. The foley catheter should have been removed on 09/06/2017 per doctors order.


B. Ensure Nursing Instructors and Nursing Students followed the standards of care adopted by the facility. Patient #1 was placed in the Trendelenburg position for approximately 45 minutes while performing an in and out foley catheter procedure. Patient #1 was receiving continuous tube feedings. There was no evidence the tube feedings were held while the patient was placed in Trendelenburg.

(Source: nurseweb.ucsf.edu (University of California, San Francisco) The Trendelenburg position involves placing the patient head down and elevating the feet.)


A. A review of the document titled "All Order History: revealed:

Nursing Order: 09/04/2017 at 9:57pm "Foley to Gravity. Comments: Discontinue Foley on POD (Post-Op Day) #2." A review of the document titled Perioperative Record dated 09/04/2017 and timed 10:15pm revealed 16Fr. Foley Cath was inserted. There was no evidence the 16Fr. Foley Cath was discontinued on POD #2. A review of the document titled Clinical Documentation Report revealed the patient retained a Foley Catheter from the insertion date of 09/04/2017 through 09/11/2017 at 07:10am when it was removed.


B. A review of the document titled "History and Physical" revealed Patient #1 was a 58 year old female presenting from State School. ... she has profound intellectual disability. ... Inpaired cognition. ... Contractures of all four extremities. Difficulty using verbal communication. Needs assistance with activity of daily living. Feeding per PGD tube. ...Colostomy.

A review of the document provided by the facility titled Skills: Urinary Catheter, Procedure: 7. Position the patient...Female: in a dorsal recumbent position (patient on their back with the head of the bed flat or reclined.)

A review of the document titled Clinical Documentation Report dated 09/11/2017 time 7:10am revealed patient #1 was receiving continuous tube feedings at 40 ml/hr per PEG tube. There was no evidence the tube feedings were held while the patient was placed in Trendelenburg.


An interview on 09/20/2014 at approximately 12:20pm with staff #4 revealed he was notified by the hospital liaison from the State School that patient #1 was placed in the Trendelenburg position by a Nursing Instructor and a Nursing Student to do an in and out urinary catheterization. Staff #4 revealed it was a hospital practice that all State School patients would have the heads of their beds elevated at all times due to the patients contractures and abnormal organ placements. Staff #4 revealed the Nursing Instructor was spoken to regarding the positioning patient #1 in Trendelenburg. Staff #4 revealed there was no written documentation and/or incident report filled out relating to the incident. Staff #4 revealed incident report were only done when there was harm to the patient. Staff #4 was unable to address if patient #1's tube feedings were held while the patient was in Trendelenburg.


A review of the website nurseweb.ucsf.edu (University of California, San Francisco) revealed:

"Trendelenburg position involves placing the patient head down and elevating the feet. Complications of the Trendelenburg position are as follows:

Anxiety and restlessness
Progressive dyspnea
Hypoventilation and atelectasis caused by reduced respiratory expansion
Altered ventilation/perfusion ratios from gravitation of blood to the poorly ventilated lung apices
Increasing venous congestion within and outside the cranium leading to increased intracranial pressure
Pressure from abdominal organs is transmitted into the thoracic cavity, which can impair venous return to the heart, leading to a further decreased cardiac output and hypotension
Increase risk of aspirating gastric contents."




These deficient practices were determined to pose Immediate Jeopardy to patient's health and safety and placed patients at risk of the likelihood of harm, serious injury, and possibly subsequent death.

Based on document review and interview the facility failed to:


A. provide registered nursing staff to supervise and evaluate nursing care of patient #1 (1 of 1 patients). Patient #1 was documented as having an Adverse Drug Reaction. Based on these finding the nursing staff failed to act on behalf of the patient and provide routine nursing care.

Refer to tag A395


B. identify a medication error. Documentation reviewed in patient #1's medical record revealed the patient did not receive the ordered intravenous fluids.

Refer to tag A405


C. ensure nursing staff removed a Foley Catheter from patient #1 as ordered by the physician.

Refer to tag A0144


D. ensure Nursing Instructors and Nursing Students followed the standards of care adopted by the facility. Patient #1 was placed in the Trendelenburg position for approximately 45 minutes while performing an in and out foley catheter procedure.
(Source: nurseweb.ucsf.edu (University of California, San Francisco) The Trendelenburg position involves placing the patient head down and elevating the feet.)

Refer to tag A0144

Based on document review and interview, Nursing failed to ensure an RN supervised and evaluated nursing care of patient #1 (1 of 1 patients). Patient #1 was documented as having an Adverse Drug Reaction on 09/07/2017. There was no further evidence of what the drug reaction was and/or how the patient was affected by the drug reaction. Based on these finding the nursing staff failed to act on behalf of the patient and provide routine nursing care.


A review of the document titled "All Order History" revealed:

Pharmacy Order #2381701: 09/04/2017 at 23:08 (11:08pm) KCL 20meq in D5W- 1/2NS 1000ml at 125ml/hr. Start: 09/04/2017 at 23:07pm (11:07pm).
D/C Reason: Adverse Drug Reaction
D/C Comment: Order Discontinued 09/07/2017 at 12:39pm
D/C by: LVN #5

A review of the document titled "Policy Title: NURSE - Adverse Reactions" revealed:

1. Any and all adverse reactions to medications or treatment will be reported to attending physician and recorded in the patient's medical record.

2. An incident report must be written.


A review of Patient #1's Medical Record revealed there was not a Registered Nurse's assessment of the patient after an adverse drug reaction.


A review of the document titled Policy Title: 15.28 The Registered Nurse Scope of Practice,Evaluation and Re-assessmentrevealed:

"A critical and fourth step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions in comparison to benchmarks from evidence-based
practice and research findings, and plans any follow-up care and referrals to appropriate resources that may be needed. The evaluation phase is one of the times when the RN reassesses patient conditions
and determines if interventions were effective and if any modifications to the plan of care are necessary."


An interview with Staff #3 revealed there was no notification of an adverse drug reaction for patient #1.


These deficient practices were determined to pose Immediate Jeopardy to patient's health and safety and placed patients at risk of the likelihood of harm, serious injury, and possibly subsequent death.

Based on document review and interview the facility failed to identify a medication error. The documentation provided revealed the nursing staff on multiple occasions infused 1 of 1 patients (#1) with the incorrect Intravenous fluids. Nursing staff failled to follow physicians' orders.

A review of the document titled "All Order History" revealed:

Pharmacy Order: 09/02/2017 at 19:39 (7:39pm) D5W-1/2 NS at 100cc/hr IV.
Comment: ER order will expire in 24 hrs if not renewed by attending physician.
D/C Reason: Order Expired
D/C'd by day end processing 09/03/2017 at 23:30 (11:30pm)
Comment: Order discontinued- Completed Order


Review of the Pharmacy Orders in the medical record revealed:

"Pharmacy Order: 09/04/2017 at 21:55 (9:55pm) KCL 20meq in D5W-1/2NS 1000ml at 125ml/hr. Start: 09/04/2017 at 21:55pm (9:55pm). D/C Comment: Order deleted due to modify from RX Order entry process. Order modified. See new order #2381701"


"Pharmacy Order #2381701: 09/04/2017 at 23:08 (11:08pm) KCL 20meq in D5W-1/2NS 1000ml at 125ml/hr. Start: 09/04/2017 at 23:07pm (11:07pm).
D/C Reason: Adverse Drug Reaction
D/C Comment: Order Discontinued 09/07/2017 at 12:39pm"


"Pharmacy Order: 09/07/2017 at 12:40pm KCL 20meq in D5W-NS 1000ml at 100ml/hr. Start: 09/07/2017 at 12:40pm."



A review of the document titled Patient Care Notes revealed:


09/04/2017 at 6:00pm "IV to right upper arm 18g infusing D5W-1/2 NS at 100ml/hr". There was no order for patient #1 to receive these IV fluids. The origional order from 09/02/2017 at 19:39 (7:39pm) was D5W-1/2 NS at 100cc/hr IV. This ER order expireed on 09/03/2017 at 23:30 (11:30pm).


09/07/2017 at 12:40pm "spoke with Dr Le re: todays labs, order rec'd to change IV fluids to D5W-NS with 20KCL at 125/hr." Pharmacy Order on 09/07/2017 at 12:40pm read KCL 20meq in D5W-NS 1000ml at 100ml/hr. Start: 09/07/2017 at 12:40pm.) Documented rate by the nurse was 125ml/hr. Order was 100ml/hr.


09/07/2017 at 6:00pm "IV infusing at 125ml/hr." The documented rate was incorrect. Ordered rate was 100ml/hr.


09/08/2017 at 6:20pm "IV to Left forearm with D5W-1/2NS with 20 KCL at 100ml/hr." The documented fluid was D5W-1/2NS with 20 KCL at 100ml/hr. The Ordered fluid was D5W-NS with 20 KCL at 100ml/hr.


09/10/2019 at 05:11am "infusing D5W-½ NS with 20 KCL at 100ml/hr". The documented fluid was D5W-1/2NS with 20 KCL at 100ml/hr. The Ordered fluid was D5W-NS with 20 KCL at 100ml/hr.


09/10/2017 at 6:30am "IV to Left forearm with D5W-1/2NS with 20 KCL at 100ml/hr". The documented fluid was D5W-1/2NS with 20 KCL at 100ml/hr. The Ordered fluid was D5W-NS with 20 KCL at 100ml/hr.


An interview with staff #2 and staff #3 on 9/20/2017 at approximately 2:00pm confirmed the incorrect fluids were documented.




These deficient practices were determined to pose Immediate Jeopardy to patient's health and safety and placed patients at risk of the likelihood of harm, serious injury, and possibly subsequent death.