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.
|HAVENWYCK HOSPITAL||1525 UNIVERSITY DRIVE AUBURN HILLS, MI 48326||Feb. 20, 2015|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|Based on interview and record review the facility failed to provide 1 of 1 discharged patients who became unresponsive at the facility (patient #1) with medications and monitoring as ordered by the patient's physician, resulting in increased risk of poor health outcomes for all patients served by the facility. Findings include:
On 2/20/15 at 1430 patient #1's clinical record was reviewed with staff A. Record review revealed that on 11/19/14 Nurse G documented patient #1's pulse as 70-125 and BP (Blood Pressure) as 78/60. On 11/18/14 at 2220 physician E ordered "Change Lisinopril to 10 mg. by mouth daily. Hold if BP (Blood Pressure) under 120/80." On 11/19/14 physician E ordered "change Lisinopril to 20 mg PO (by mouth) once/day." The parameters for holding Lisinopril were not discontinued. On 11/21/14 at 0900 patient #1 received 20 mg. of Lisinopril despite having a Blood Pressure of 109/63. At 1400 on 11/21/14 patient #1's Blood Pressure was 105/67. Staff A confirmed that these findings during record review.
On 2/20/15 at 1440 patient #1's clinical record was reviewed with staff A. Record review revealed that on 11/18/14 the Registered Dietitian (staff F) documented that patient #1 should have a daily fluid intake of 2250-2625 ml fluid/day. A physician's order for "I and O" (Intake and Output) was noted on 11/19/14. I & O documentation forms in patient #1's clinical record contained no information of output on 11/19/14, 11/20/14 or 11/21/14. Fluid intake documentation for the last three days of the patient's life (11/19/14-11-21/14) ranged from 800-1200 ml daily. On 11/21/14 abnormal lab values for patient #1 related to kidney function included: a BUN (Blood Urea Nitrogen) of 56.0 mg/dl, (Reference Range 6.0-20.0), Creatinine of 2.8 mg/dl, (Reference Range 0.5-0.9) and a GFR (Glomerular Filtration Rate African American) of 21 (Reference Range of 60 or above). On 11/22/14 patient #1 became unresponsive and was transferred to an acute care hospital where the patient was pronounced dead. These findings were confirmed by staff A on 2/20/15 during the records review.
|VIOLATION: NURSING CARE PLAN||Tag No: A0396|
|Based on record review and interview the facility failed to ensure that staff maintained an updated nursing plan of care for 1 of 1 patients with failure to record Intake and Output deficits (patient #1), resulting in increased risk of poor health outcomes for all patients. Findings include:
On 2/20/15 at 1440 patient #1's clinical record was reviewed with staff A. Record review revealed that a physician's order for "I and O" (Intake and Output) was noted on 11/19/14. Patient #1's Care Plan was not updated to include the intervention of documenting input and output and output was not documented on 11/19/14, 11/20/14 or 11/21/14. These findings were confirmed by staff A on 2/20/15 during record review.