HospitalInspections.org

Based on observation, record review, review of Hospital policy, and staff interview, the Hospital failed to ensure a patient's right to privacy for 1 of 1 inpatient (Patient #27) observed with a video monitor. Failure to provide privacy limited the patient's basic right to respect, dignity, and comfort while in the hospital.

Findings include:

Review of the Hospital policy titled "Right and Responsibilities" occurred on 08/01/17. This policy, revised September 2016, stated, ". . . Trinity Health respects, protects, and promotes patient's rights by: . . . Respecting the patient's right to privacy. . . . Trinity Health respects the patient's right to privacy and confidentiality by: . . . Respecting a patient's personal privacy to the fullest extent possible. . . ."

Review of Patient #27's medical record occurred on all days of survey. Diagnoses included weakness, diarrhea, and Parkinson's disease.

Observation on 07/31/17 at 3:00 p.m. showed Patient #27 visible on a video monitor at the nurse's station and also visible from the hallway. A nurse (#6) stated Patient #27 showed signs of confusion over the weekend so the hospital staff turned on a visual monitor in the patient's room.

Observation on 08/01/17 at 5:20 p.m. showed Patient #27 in his room, visible on a monitor from both the nurse's station and the hallway, and an unidentified person in the room with him.

Observation on 08/02/17 at 2:05 p.m. showed Patient #27 in his room and visible on a monitor from the nurse's station.

Patient #27's medical record failed to show either the patient or his representative were aware of the video monitor.

During an interview on 05/02/17 at 8:15 a.m., a nurse manager (#7) confirmed the video monitor may be an issue related of Patient #27's privacy and dignity.

Based on record review, review of facility policy, and staff interview, the Hospital failed to ensure nursing staff followed facility policy for the treatment and monitoring for 1 of 1 active patient record (Patient #11) reviewed with a diagnosis of diabetes and a documented hypoglycemic (low blood sugar) episode. Failure of nursing staff to treat, monitor, and/or notify the physician of a hypoglycemic (low blood sugar) episode may result in severe hypoglycemia, unresponsiveness, and/or further hypoglycemic episodes.

Findings include:

Review of the Hospital policy titled "Hypoglycemia Guideline" occurred on 08/01/17. This policy, revised June 2016, stated, ". . . If blood glucose is below 70 mg/dl [milligrams per deciliter], give 15 grams of carbohydrate and avoid exercise until blood glucose is 70 mg/dl or above. . . . Moderate Hypoglycemia: Blood Glucose 50-60 . . . Treatment: 1. Give 15 grams of carbohydrate as outlined above. 2. use a calm, direct, commanding approach . . . 3. Observe for dysphasia. If present, treat for severe hypoglycemia. 4. Recheck blood glucose and repeat 15 grams of carbohydrate in 15-30 minutes as needed. 5. Give 1/2 sandwich and 8 ounces of milk. 6. Keep patient warm. 7. Offer analgesic for headache. 8. Offer reassurance. . . ."

Review of Patient #11's medical record occurred on all days of survey. Diagnoses included diabetes.

Review of Patient #11's blood glucose monitoring on 07/28/17 showed the following:
* 5:12 p.m. a blood glucose of 55 mg/dl (Moderate Hypoglycemia: Blood Glucose 50-60)
* 5:39 p.m. a blood glucose of 71 mg/dl

Nursing staff failed to document any treatment provided for the patient's hypoglycemic episode of 55 mg/dl.

During an interview on the afternoon of 08/01/17, a nursing staff member stated nursing staff had not documented any treatment or physician notification in the patient's medical record related to the low blood glucose level.

REASSESSMENT OF PRN MEDICATIONS

1. Based on record review, review of facility policy, review of professional literature, and staff interview, the Hospital failed to assess and/or document in a timely manner the effectiveness of medications given to patients on an as needed (PRN) basis for 5 of 28 active patient (Patients #3, #12, #14, #16, and #17) records reviewed. Failure to evaluate the patients' responses to PRN medications limited the nursing staff's ability to assess whether the medication achieved the desired effect or if the patients experienced any side effects or adverse reactions from the medication.

Findings include:

Review of the hospital policy "Medication Administration" occurred on 08/02/17. This policy, revised May 2016, stated, ". . . Assess patient's response to medication including expected outcomes . . . PRN [as needed] medications will be charted in CareMobile or Flowchart/progress notes during CareMobile downtime. Route given, site of injection if parenteral, reason medication, and observed results afterwards will also be documented. . . ."

Review of the hospital policy "Pain Assessment" occurred on 08/02/17. This policy, revised April 2015, stated, ". . . Pain will be reassessed within one hour of an intervention and pain will be assessed and documented approximately every 2 hours. . . ."

Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 10th ed., Pearson Education, Inc., New Jersey, 2016, page 771, 774, and 778, states, ". . . Process of Administering Medications: When administering any drug . . . the nurse must do the following: . . . 6. Evaluate the client's response to the drug. . . . In all nursing activities, nurses need to be aware of the medications that a client is taking and record their effectiveness as assessed by the client and the nurse on the client's chart. . . . Skill 35-1 Administering Oral Medications: . . . Evaluation: Return to the client when the medication is expected to take effect (usually 30 minutes) to evaluate the effects of the medication on the client. Observe for desired effect (e.g. [example given], relief of pain or decrease in body temperature). . . ."

- Review of Patient #3's active medical record occurred on 08/02/17. Diagnoses included febrile urinary tract infection (UTI) with multi-resistant Escherichia coli (E Coli). The record identified a physician's order for:
* Promethazine 25 milligrams (mg) intravenous push (IVP) every four hours PRN for nausea/vomiting.
* Ativan 1 mg tablet by mouth (PO) every six hours PRN for anxiety.

Patient #3's medication administration record (MAR) showed nursing staff administered the promethazine two times on 07/29/17 and 07/30/17 and failed to reassess and/or document the patient's response to the medication.

Patient #3's MAR showed nursing staff administered the Ativan two times on 07/30/17 and failed to reassess and/or document the patient's response to the medication.

- Review of Patient #12's active medical record occurred on all days of survey. Diagnoses included altered mental state and acute kidney injury. The record identified a physician's order for Tylenol 325 mg every four hours PRN for mild, routine pain.

Patient #12's MAR showed nursing staff administered the Tylenol on 07/28/17 and 07/29/17 and failed to reassess and/or document the patient's response to the medication in a timely manner. The reassessments occurred between one and one half to three hours later.

- Review of Patient #14's active medical record occurred on all days of survey. Diagnoses included exploratory laparotomy, small bowel resection, ileostomy revision, repair of abdominal wall hernia. The record identified a physician's order for Ativan 0.5 mg IVP every eight hours PRN for agitation.

Patient #14's MAR showed nursing staff administered the Ativan on 08/01/17 and 08/02/17 and failed to reassess and/or document the patient's response to the medication.

- Review of Patient #16's active medical record occurred on all days of survey. Diagnoses included left tibia fracture. The record identified a physician order for Tylenol with Codeine, one tablet every four hours PRN for pain.

Patient #16's MAR for 07/27/17 through 07/30/17 showed nursing staff administered Tylenol with Codeine five times and failed to reassess and/or document the patient's response until two to four hours later.

- Review of Patient #17's active medical record occurred on all days of survey. Diagnoses included left hip fracture. The record identified a physician order for Tylenol 500 mg every 6 hours PRN for pain.

Patient #17's MAR showed nursing staff administered Tylenol on 07/26/17 at 7:55 p.m. and 07/29/17 at 1:27 p.m. and failed to reassess and/or document the patient's response to the medication until two to four hours later.

During an interview on the afternoon of 08/02/17, an administrative staff nurse (#3) stated staff are not required to follow-up PRN medications unless they are narcotics, and the Ativan is not a narcotic. This is not consistent with the Hospital's policy or the professional reference.

MEDICATION ADMINISTRATION

2. Based on record review, review of facility policy, review of professional literature, and staff interview, the Hospital failed to ensure staff followed physician orders when administering medications for 2 of 28 active patient (Patient #11 and #12) records reviewed. Failure to administer medications as ordered by the physician may increase the risk of patients experiencing side effects or adverse medication reactions.

Findings include:

Review of the Hospital policy titled "Medication Administration" occurred on 08/02/17. This policy, revised May 2016, stated, ". . . Institute necessary observations and measures before drug administration as needed based on patient condition . . . Administer medications as ordered and per policy. . . ."

Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 10th ed., Pearson Education, Inc., New Jersey, 2016, page 68, 779, stated, ". . . Nurses . . . need to provide accurate and complete documentation of the nursing care provided to clients. . . . Take the medications only as prescribed. Know which medications need to be taken on an empty stomach and which can be taken with food/meals. . . ."

Wolters Kluwer, "Nursing 2017 Drug Handbook," 37th ed., Philadelphia, 2017, page 1681, stated, "pentoxifylline . . . Indications & Dosages * Intermittent claudication from chronic occlusive vascular disease . . . with meals. . . . "

- Observation on 08/01/17 at 3:00 p.m. showed a staff nurse administered pentoxifylline (to improve blood flow to decrease the muscle pain) 400 milligrams (mg) extended release (ER) by mouth to Patient #11 without offering food.

Review of Patient #11's medical record occurred on all days of survey. Diagnoses included sepsis and hypokalemia. A physician ordered pentoxifylline 400 mg ER tablet by mouth three times a day. The nurse's hand held patient CareMobile identified a medication administration record (MAR) comment "Administer with food/meal."

- Review of Patient #12's medical record occurred on all days of survey. Diagnoses included altered mental status and acute kidney injury. A physician ordered labetalol 20 mg intravenous push (IVP) every 10 minutes (not to exceed 300 mg) for a systolic blood pressure (SBP) greater than 170.

Review of Patient #12's MAR identified labetalol 20 mg IVP administered on 07/29/17 at 8:31 p.m. without a blood pressure documented.

During an interview on the morning of 08/02/17, an administrative nurse (#1) stated the record failed to show staff documented a blood pressure prior to administering the labetalol.


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INSULIN ADMINISTRATION

3. Based on observation and review of policy and procedures, the Hospital failed to follow professional standards of practice for 3 of 3 patients (Patient #25, #29, and #30) observed receiving insulin during medication administration. Failure to prime insulin pens may result in an incorrect dose of insulin.

Findings include:

Review of the Hospital policy "Insulin Administration" occurred on 08/02/17. This policy dated June 2015, stated, ". . .FLEX PENS: POLICY: . . . 4. Perform "air shots" using two units of insulin in order to prime the pen. If no drop of insulin appears at the tip of the needle, repeat the air shot until the drop appears. . . . PROCEDURE: . . . 4. Remove the protective tab from the disposable needle and screw needle into the Flex Pen. 5. Dial the dose to 2 units. 6. Remove the protective tab from the needle. 7. With the needle pointing up, tap the reservoir gently a few times. 8. With the needle still pointing up, press the button at the end of the Flex Pen as far as it will go. This is called an air-shot. 9. If no insulin appeared at the end of the needle during the air shot, repeat the procedure until insulin appears. If no insulin has appeared after six air shots, do not use the Flex Pen and contact Pharmacy. 10. After performing a successful air shot, make sure the dose selector is set at "0".

- Observation on 07/31/17 at 4:40 p.m. showed a nurse (#5) prepared an insulin Flex Pen prior to injecting Novolog insulin to Patient #29. The nurse (#5) held the Flex Pen in a horizontal position, dialed one unit, and pressed the button at the end of the Flex Pen. The nurse (#5) failed to prime the Flex Pen with two units of insulin and failed to hold the Flex Pen in an upright position.

- Observation on 08/01/17 at 8:50 a.m. showed a nurse (#2) prepared an insulin Flex Pen prior to injecting Levemir insulin to Patient #25. The nurse (#2) held the Flex Pen in a horizontal position and did not remove the protective cover. The nurse dialed the Flex Pen to two units and pressed the button at the end of the Flex Pen. The nurse (#2) failed to remove the protective cover from the needle and failed to hold the Flex Pen in an upright position and observe for the appearance of insulin during the air shot.

- Observation on 08/01/17 at 5:15 p.m. showed a nurse (#6) prepared an insulin Flex Pen prior to injecting Novolog insulin to Patient #30. The nurse (#6) held the Flex Pen in a horizontal position, dialed two units, and pressed the button at the end of the Flex Pen. The nurse (#6) failed to hold the Flex Pen in an upright position.







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