HospitalInspections.org

Based on a review of facility documents, a medical record (MR1), and staff interviews (EMP), it was determined that Penn Highlands DuBois failed to follow adopted policies, by failing to evaluate the patient's response to care, in one of one medical records reviewed (MR1), and by failing to follow adopted policies by failing to document the administration of medication for one of one medical records reviewed. (MR1)

Findings include:

Review of facility policy "Assessment-Reassessment Patient", dated October 2016, revealed, "Purpose: To determine the appropriate health care setting and care through an assessment of the patient's health status and health care needs. To interpret the ongoing assessment data in order to determine the patient's response to care delivery and interventions ... Policy: Every patient seeking care is assessed by qualified individuals to determine health status and treatment needs. Patients's care is based on a documented assessment that contains input from the patient, significant other(s), and other care providers as well as information conveyed on medical jewelry ... Reassessments. Inpatient nursing reassessments are done at regularly specified times to evaluate the patient's response to care. The scope and frequency of the reassessment is based on the patient's diagnosis, ordered level of care, treatment setting, and course of treatment, complexity of care required and/or when a significant change occurs in the patient's condition of diagnosis ... ."

Review of the Patient Services policy "Scanning, Documentation, the 6 Rights of Medication Administration", dated December 2016, revealed, "... Purpose: To safely administer and manage medications ordered for a patient ... Procedure: ... Documenting of Medications. Each dose of medication administered is documented on the individual patient record at the time the medication is administered. Documentation includes ... 3. PRN medications ... All nursing personnel administering medications must document the administration on the EMR. The nurse needs to validate they are on the correct record and are the user logged into the workstation at the time of the documentation. The Medication Administration Record (EMR) is completed as follows: Charting is completed immediately after the medication is given and includes all additional information necessary to be documented surrounding the medication given as indicated on the EMR ... ."

1. Review of MR1 revealed approximately 15 nursing assessments dated August 24, 2017, at 18:00 to August 31, 2017, at 10:15, all stated that the patient had skin symptoms documented as itching.

Continued review of MR1 revealed a physician order dated August 24, 2017, at 18:19, for Benadryl 25 mg IV Push every six hours prn for itching.

A review of Medication Administration Records dated August 24, 2017 to August 29, 2017, revealed the patient received Benadryl once on August 24 and 25, twice on August 26, 27, 28, and twice on August 29, 2017. There is no documentation of nursing reassessments present in the medical record documenting the patient's response to Benadryl for itchiness.

Continued review of MR1 revealed the patient had a physician order dated August 25, 2017, at10:30, for Lubriderm Lotion 1 app BID prn for dry skin.

Medication Administration Records reveal documentation of one instance of administration of Lubriderm, on August 25, 2017, and one instance of administration on August 30, 2017.

2. An interview with EMP9 on September 21, 2017, at 10:35AM, revealed, "... (The patient) was itching. I gave Benadryl as ordered, and would give (the patient) Lubriderm all the time ... ."

3. An interview with EMP10 on September 21, 2017, at 10:40AM, revealed, "... I don't remember giving (the patient) Benadryl. I do remember getting (the patient) Lubriderm ... Lubriderm is supposed to be scanned. It was in the patient room due to isolation, and didn't go out of the room to be scanned. There is no task to document relief for Benadryl and Lubriderm ... ."

4. An interview with EMP11 on September 21, 2017, at 10:55AM, revealed, "... The patient was uncomfortable and red. We would use the Lubriderm on the table. I don't know if (the patient) was given Benadryl. (The patient) was very red from itching and uncomfortable ... ."

5. An interview with EMP1 on September 21, 2017, revealed that the Lubriderm could've been scanned, and not taken into the room.

6. An interview with EMP12 on September 21, 2017, at 11:05AM, revealed, "... The patient was itchy ... The patient was obviously itchy."

7. An interview with EMP13 on September 21, 2017, at 11:15AM, revealed, "... The patient was itchy, the patient did get Benadryl ... The patient kept itching and scratching ... ."

8. An interview with EMP16 on September 22, 2017, at 9:35AM, revealed, "... The patient was itchy all the time ... I applied the lotion because I knew the patient was uncomfortable."

9. An interview with EMP17 on September 22, 2017, at 11:30AM, revealed, "... A lot of the time, the patient was itchy ... ."