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.
|VISTA MEDICAL CENTER EAST||1324 NORTH SHERIDAN ROAD WAUKEGAN, IL 60085||Dec. 13, 2012|
|VIOLATION: RESPIRATORY SERVICES||Tag No: A1164|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on document review and interview, it was determined, that for 2 of 5 clinical records reviewed (Pts. 5 & 6), the Hospital failed to ensure physicians' orders were completed and/or documented in the clinical record, according to policy.
1. Hospital policy # MM.5.10, revised, 4/2012, titled, "Safe Medication Administration" was reviewed and required, "Documentation: 1. Administration of all medication is to be documented on the appropriate Medication Administration Record (MAR).,, 3 Reasons for hold or refusal must be documented in a nursing note..."
2. The clinical record of Pt. #5 was reviewed and included that Pt. #5 was a [AGE] year old female, admitted on [DATE], with a diagnosis of Pneumonia. A physician's order dated 12/9/12, included, "DuoNeb nebulizer QID (4 times per day)..." The MAR dated 12/10/12, lacked documentation for all 4 schedule doses (7:00 AM, 11:00 AM, 3:00 PM, and 7:00 PM) of DuoNeb and there were no progress notes to explain why the doses were or were not administered. Pt. #5's MAR dated 12/11/12, did not include documentation of administration of 1 of 4 schedule doses (7:00 AM) of DuoNeb and there was no progress note to explain why the dose was not administered.
3. The clinical record of Pt. #6 was reviewed and included that Pt. #6 was an [AGE] year old female, admitted on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease and Chronic Heart Failure. A physician's order dated 12/4/12 at 4:13 PM, included, "DuoNeb QID (4 times per day)..." Four doses of DuoNeb were documented in Pt. #6's progress notes on 12/9/12, at 9:50 AM, 12:45 PM, 4:00 PM, and 7:30 PM, but the MAR for 12/9/12 was not found in Pt. #6's clinical record. Four doses of DuoNeb were documented in Pt. #6's progress notes on 12/11/12 at 7:05 AM, 11:05 AM, 3:50 PM, and 10:00 PM, but were not documented on Pt. #6's MAR dated 12/11/12.
4. An interview was conducted with the Assistant CEO on 12/12/12 at approximately 10:00 AM, during the clinical record reviews. The Assistant CEO stated that there was no documentation in Pt. #5's clinical record to explain if DuoNeb was or was not administered and that nebulizer treatments are to be documented in the MAR.