HospitalInspections.org

Based on record reviews and interviews, the registered nurse failed to ensure each patient received care according to hospital policy and physician's orders. The deficient practice is evidenced by 1) failure of nursing staff to complete a progress note each shift per hospital policy; and 2) failure of nursing staff to perform the Clinical Opiate Withdrawal Scale (COWS) as ordered.
Findings:

1) Failure of nursing staff to complete a progress note each shift per hospital policy.

Review of Policy Number IM-005, "Documentation," reviewed 11/11/2021, revealed in part, "Progress Note Frequency . . . Nursing- One per shift."

Review of the medical record for Patient #1 revealed admission on 10/06/2024 and discharge on 10/17/2024. Review of the nursing progress notes revealed there was no nursing progress note in the record for 10/11/2024 for the 7:00 a.m. to 7:00 p.m. shift.

In interview on 12/02/2024 at 3:19 p.m., S4QARM verified the nursing progress note for the shift was missing and could not be found.

2) Failure of nursing staff to perform the Clinical Opiate Withdrawal Scale (COWS) as ordered.

Review of the medical record for Patient #2 revealed admission on 11/28/2024 for detox treatment and discharge on 12/02/2024.

Review of the physician's orders revealed , "Complete COWS every shift and always notify MD if score is greater than 7. Discontinue COWS 24 hours after last dose of Subutex is given." Further review of the orders revealed the orders were not altered or discontinued during the admission.

Review of the medical record revealed no COWS were performed.

In interview on 12/02/2024 at 2:54 p.m., S4QARM verified the COWS were not in the record and were not found on the unit.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered according to the physician's orders. The deficient practice is evidenced by failure of the nursing staff to monitor blood glucose and administer medications as indicated.
Findings:

Review of the orders for Patient #1 revealed checks of the patient's blood glucose levels were to be performed before each meal, at bedtime and at 1:00 a.m. The patient was to be administered insulin on a sliding scale before meals and at bedtime. The patient was to be administered glucagon 1 milligram intramuscularly if the blood sugar was less than 60. Further review of the orders revealed the orders were never altered or discontinued.

Review of the Diabetic Flow Sheet revealed the 1 a.m. check of the blood glucose level was not performed on 10/07/2024, 10/09/2024, 10/10/2024, 10/11/2024, 10/12/2024, 10/13/2024, 10/14/2024, 10/15/2024, 10/16/2024 or 10/17/2024.

In interview on 12/02/2024 at 3:15 p.m., S4QARM verified the glucose checks were not performed as ordered.