HospitalInspections.org

Based on document review and staff interview, the facility failed to ensure a registered nurse followed physician order and facility policy for checking vital signs for 5 of 5 patients (patients #N1-N5), failed to notify the physician of a change in vital signs for 1 of 5 patients (#N1) and failed to follow facility policy for new medications for 1 of 5 patients (patient #N4).

Findings include:

1. Review of patient #N1 medical record for the June 2010 stay indicated the following:
(A) The patient was admitted on 6/11/10.
(B) Facility document titled "Vital Signs/Blood Glucose Flowsheet" indicated the patients blood pressure was elevated on 6/12/10 (170/105). The record lacked documentation that the physician was notified of the change. Previous B/P reading was 138/86.

2. Review of patient #N1 medical record for the April 2011 stay indicated the following:
(A) The patient was admitted on 4/26/11.
(B) The admission nursing assessment was completed by RN #2 at 7:12 p.m. on 4/26/11. The document lacked admission vitals as well as an admission height and weight. The section for the vitals and weight was left blank.
(C) An order was written at 8:30 p.m. on 4/26/11 to obtain height, weight, and vital signs on admission and to obtain vital signs twice daily.
(D) Review of facility document titled "Vital Signs/Blood Glucose Flowsheet" indicated that the vitals were not documented as checked on 4/27/11, vitals were only documented as checked one time on 4/28/11, one time on 4/29/11 and not at all on 5/2/11. The document indicated the blood pressure was elevated on 4/30/11 at 170/100. The previous readings were 120/72 and 130/82. The record lacked documentation that the physician was notified of the elevated blood pressure.

3. Review of patient #N2 medical record indicated the following:
(A) He/she was admitted on 4/27/11.
(B) An orders was written on 4/27/11 for vital signs on admission and twice daily. Review of facility document titled "Vital Signs/Blood Glucose Flowsheet" lacked documentation of the vital signs on 4/27/11, the vitals were only taken once on 4/28/11 and were not taken at all on 5/2/11.

4. Review of patient #N3 medical record indicated the following:
(A) He/she was admitted on 4/24/11.
(B) An order was written on 4/25/11 for vital signs on admission and twice daily. Review of facility document titled "Vital Signs/Blood Glucose Flowsheet" lacked documentation that the vital signs were taken on 4/27/11 and were taken only once on 4/28/11.

5. Review of patient #N4 medical record indicated the following:
(A) The patient was admitted on 4/27/11.
(B) An order was written on 4/27/11 for vital signs on admission and twice daily. Review of facility document titled "Vital Signs/Blood Glucose Flowsheet" indicated the vital signs were only taken once on 4/28/11 and 4/29/11.
(C) The patient was started on Lexapro on 4/28/11. The medical record contained a document titled "First Dose Monitoring Form". The 24 hour monitoring section of the document was left blank.
(D) The patient was started on Trazodone on 4/29/11. The 24 hour monitoring section of the "First Dose Monitoring Form" for the Trazodone was left blank.

6. Review of patient #N5 medical record indicated the following:
(A) He/she was admitted on 4/28/11.
(B) An order was written on 4/28/11 for vital signs on admission and twice daily. Review of facility document titled "Vital Signs/Blood Glucose Flowsheet" indicated the vital signs were taken only once on 4/29/11, 5/4/11, 5/6/11, 5/9/11, and 5/10/11. The vital signs were not taken at all on 5/2/11.

7. Facility policy titled "First Dose Monitoring (Medications) last reviewed/revised 9/09 states on page 1 beginning with the last paragraph and continuing on page 2: "Once the administering nurse has completed the above sections the nurse will document in the medical record, the form is completed up to the 24 hour monitoring section. The nurse will also report during shift change that the 24-hour monitoring is in process and that the patient will need to be monitored for side effects. 4.0 The nurse who conducts the 24-hour monitoring is responsible for completing the following section:
4.1 24 hour response
4.2 Did the patient have any question/concerns
4.3 Nurse signature completing the 24 hour monitoring
4.4 Date
4.5 Time
4.6 Placing the completed (sticker) in the nursing progress notes."

8. Facility policy titled "Vital Signs & Weights" last reviewed/revised 11/10 states under Policy on page 1: "Al patients................will have vital signs taken on admission, three times a day at 8 am, 2 pm, and 8 pm for geriatric patients, twice daily at 8 am and 8 pm on all other patients......" and page 2 states: "All abnormal findings or warning signs should be immediately reported to the Charge Nurse and physician."

9. Staff member #1 indicated the following in interview beginning at 4:00 p.m.:
(A) He/she verified the medical record information as indicated above for patients #N1-N5.

Based on document review and staff interview, the facility failed to ensure medications were administered according to physician order for 1 of 5 patients (patient #N1).

Findings include:

1. Review of patient #N1 medical record indicated the following:
(A) The patient was admitted on 4/26/11.
(B) Medications taken prior to admission included, but were not limited to, Geodon daily and Lithium 300 mg in the morning and 600 mg at night.
(C) An order was written at 8:15 p.m. on 4/26/11 to change the Geodon to twice daily and to change the Lithium to 900 mg every night and 600 mg in a.m. The medications were set up for administration at 9:00 a.m. and 9:00 p.m.
(D) Review of the medication administration records (MAR) indicated that the patient did not receive any medication on the night he/she was admitted.

2. Facility policy titled "Medication Administration: General Guidelines" last reviewed/revised 2/11 states on page 4: "34.0 ..............The nurse is responsible for safe, and prompt administration of meds........" and page 6 states "43.0 If for some reason a medication has not been delivered from the pharmacy or is not available, the physician is notified. immediately for any STAT/Now doses; at least once a shift for any regularly scheduled medication."

3. The medical record did not indicate that the physician or pharmacy was notified that the medication could not be obtained from the med-dispense system on the evening of admission.

4. Staff member #1 indicated the following in interview beginning at 4:00 p.m.:
(A) He/she verified the medical record information as indicated above for patients #N1.

Based on document review and staff interview, the facility failed to ensure nursing had timely access to medications for 1 of 5 patients (patient #N1).

Findings include:

1. Review of patient #N1 medical record indicated the following:
(A) The patient was admitted on 4/26/11.
(B) Medications taken prior to admission included, but were not limited to, Geodon daily, Lithium 300 mg in the morning and 600 mg at night, and Paxil 15 mg daily.
(C) An order was written at 8:15 p.m. on 4/26/11 to change the Geodon to twice daily and to change the Lithium to 900 mg every night and 600 mg in a.m. The medications were set up for administration at 9:00 a.m. and 9:00 p.m.
(D) Review of the medication administration records (MAR) indicated that the patient did not receive any medication on the night he/she was admitted.

2. Review of a list of contents of the med-dispense system indicated that the med-dispense system contained Lithium and Geodon.

3. Facility policy titled "Medication Administration: General Guidelines" last reviewed/revised 2/11 states on page 4: "34.0 ..............The nurse is responsible for safe, and prompt administration of meds........" and on page 5: "42.0 If a new medication is ordered and needed prior to the next pharmacy delivery, the nurse is to fax the order to the pharmacy, call the pharmacy to speak directly to a pharmacy employee to request that the order be placed in the pharmacy MedDispense computer as soon as possible......Once the order is entered in the pharmacy computer, the nurse can obtain the medication from the MedDispense cart." Page 6 states "43.0 If for some reason a medication has not been delivered from the pharmacy or is not available, the physician is notified. immediately for any STAT/Now doses; at least once a shift for any regularly scheduled medication."

4. The medical record did not indicate that the physician or pharmacy was notified that the medication could not be obtained from the med-dispense system on the evening of admission.

5. Staff member #1 indicated the following in interview beginning at 4:00 p.m.:
(A) The pharmacy did not release the medications to be obtained from the medication dispense system for patient #N1 until 9:04 a.m. on 4/28/11.
(B) He/she verified the medical record information as indicated above for patients #N1.