The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PALMS WEST HOSPITAL 13001 SOUTHERN BLVD LOXAHATCHEE, FL 33470 April 30, 2013
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record reviews and interviews, it was determined the RN failed to conduct an assessment in accordance with accepted standards of practice and hospital policy for 1 of 9 sampled patients (Patient #9).

The findings include:

1) The facility policy for reassessment of a patient is as follows: Each patient is reassessed and the plan of care is reviewed by an Registered Nurse (RN) at least once every 12 hours. Each patient is reassessed according to established unit time frames, when there is a change in condition or diagnosis, on patient transfer to another level of care.

The Director of Risk Management stated on 4/29/13 at 1140 hours the Registered Nurses (RNs) chart electronically every twelve hours on the 4 East Unit, Medical/Surgical Telemetry.

Patient #9 was admitted to the facility on [DATE] with diagnoses of Hypertension and Congestive Heart Failure and various other conditions. The patient's vital signs in the Emergency Department at 1252 hours were: Blood Pressure (B/P) 126/54, pulse 79 and respirations (R) 24. At 1442 hours the B/P 131/50, pulse 60 and R 18.
The patient's vital signs at 1739 hours: B/P 138/61, Pulse 62, and R 18.

The patient was transferred to 4 East Medical Surgical Telemetry at 1949 hours on 4/3/13. The RN assessed the patient's vital signs at 1958 hours: B/P 135/63, Pulse 65 and R 20.

The patient is receiving the following medications that can cause a decreased blood pressure and/or decrease in the heart rate: Nitro-Bid (Nitroglycerine) 1" ointment to the chest wall every 6 hours, Correg 3.125 mg. by mouth twice a day; Norvasc 5 mg. by mouth daily and Altace 2.5 mg. by mouth daily. There were no parameters for holding the medications.

The RN conducted a shift assessment for the (1900- 0700) hours on 4/3/13 at 2000 hours. The patient's vital signs are: B/P 136/63, pulse 65 and R 20.

The patient received the Nitro-Bid at 2100 hours on 4/3/13. At 2236 hours the nurse administered Coreg 3.125 mg. by mouth. The RN documented that she held the midnight dose of Nitro-BID because the patient ' s blood pressure was 85/50. The nurse administered 1" of Nitro-BID at 0600 hours on 4/4/13.

Review of the 4/4/13 Medication Summary revealed the RN administered Norvasc 5 mg. at 1129 hours on 4/4/13. The nurse documents a B/P of 91/48. The RN gives Correg 3.125 mg. at 1128 hour, and Nitro-BID 1" at 1130 hours and 1939 hours on 4/4/13. It was unclear if the physician was made aware of the change in the patient's blood pressure.

The Pharmacy Director and the Pharmacy Clinical Manager stated at 1150 hours that they would not expect decrease in blood pressure with Nitroderm patch 0.2 micrograms (mcg) release over 24 hours. If it is the Nitropaste, "I would expect a decrease in the blood pressure".

The physician stated on 4/29/13 at 1445 hours, the nurses know to hold the medication usually for a systolic blood pressure 90/60 or less and pulse less than 60 or Heart Block. The doctor ordering the medication always gives a range for the medication, according to the physician. The physician was made aware that the patient's blood pressure on 4/4/13 was recorded at 91/48. The physician stated the nurse always call to clarify the order.

Further review of the medical record on 5/1/13 revealed the record lacked documentation of a shift assessment by the RN for the 0700 - 1900 hours shift on 4/4/13. A call was placed to the facility on [DATE] at approximately 1000 hours to request a copy of the shift assessment with assessment of the patient's vital signs.

The Risk Manager and the Vice President of Patient Safety stated at 1127 hours they could not find the shift assessment documented by the RN for 4/4/13 (0700 - 1900 hours). The Risk Manager stated the nursing assistant did the vital signs every 4 hours. A copy of the vital signs was received at 1145 hours on 5/2/13.

The certified nursing assistant documented the following vital signs on 4/4/13:
0754 hours - B/P 91/48, pulse 63 and respirations 20.
1218 hours - B/P 94/48, pulse 60, and respirations 20.
1700 hours - B/P 93/50, pulse 59, and respirations 20.
1934 hours - B/P 89/44, pulse 68, and respirations 18.

The RN administered the medications (Coreg , Norvasc, Nitro-BID) based on a vital signs documented 3.5 hours earlier. The RN administered the second dose of Nitro-BID 1" at 1939 hours. The B/P was 89/44 at 1934 hours. The RN failed to clarify the physician's orders. The RN gave the Nitro-BID with a systolic pressure less than 90.

The RN failed to notify the physician of the change in blood pressure.
The RN failed to clarify the physician's orders.

The RN failed to conduct an assessment of the patient's needs as in accordance with the Standard of Care: Assessment, Problem Identification; Outcome Identification and Planning and facility policy.