HospitalInspections.org

Based on review of facility policy and procedure, medical records (MR), and staff interview (EMP), it was determined the facility failed to follow the facility policy regarding admission of a patient for one of 10 medical records reviewed. (MR1)

Findings include:

Review on June 9, 2015 of facility policy and procedure "Admission Of A Patient," dated approved March 25, 2015, revealed "Patients admitted to Regional Hospital of Scranton for inpatient treatment will undergo a complete Nursing Admission Assessment. ... Procedure: ... 6. An initial assessment will include a past medical history, surgical history, immunization history, medication history, fall risk assessment, pressure ulcer assessment, and any medication allergies. ... 10. After complete review and verification of the Nursing Admission Assessment, the nurse will notify the patient's Physician of admission vital signs, SAO2 [blood oxygenation level] and any other pertinent patient care concerns and document. If unable to speak to the physician directly, record whether message was left with physician's office or answering service. 11. A Registered Nurse [RN] will receive Physicians orders. The RN or Unit Clerk will then transcribe Physician's [sic] start Kardex, etc. Disease specific ordersets / plan of care will be initiated when indicated. ..."

Review on June 9, 2015, of MR1 revealed the patient was admitted to the hospital from the personal care home on April 9, 2015, with a change in mental status. A Magnetic Resonance Image (MRI) was completed prior to admission to the hospital. The MRI revealed an acute ischemic stroke in the Right Frontal Cortex.

Continued review of MR1 revealed a medication transfer sheet from the personal care home indicating the medications the patient was on, and the medications the patient had not received prior to transfer to the hospital. Documentation from the transfer sheet revealed the patient was currently receiving Exelon Patch (for treatment of Alzheimer's disease), Namenda (for treatment of dementia associated with Alzheimer's disease), Prednisone (a steroid medication), Restoril (a sleep medication), Ultram (an opioid used to treat moderate to severe pain), and Zyprexa (an antipsychotic medication). Documentation revealed "need" followed all of these medications, indicating the patient had not received these medications for April 9, 2015. Further review revealed only the Zyprexa, Ultram and Restoril were ordered at the hospital. The patient became increasingly confused, combative, and agitated, requiring chemical sedation.

Interview with EMP3 on June 9, 2015, at approximately 2:15 PM confirmed discussion with the patient's family member regarding MR1's behavior. EMP3 confirmed reviewing the hospital Medication Administration Record (MAR) and the transfer sheet with the family member and confirmed the remaining medications were not ordered at the time of MR1's admission. EMP3 confirmed feeling very sorry the patient had gotten so confused and required the chemical restraint. EMP3 confirmed the admission nurse was responsible for notifying the physician regarding orders and the need for medications to be given if not received prior to the patient's admission.