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.

OLD VINEYARD YOUTH SERVICES 3637 OLD VINEYARD ROAD WINSTON SALEM, NC 27104 Oct. 31, 2013
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on policy and procedure reviews, medical record reviews, and staff interviews, the hospital nursing staff failed to supervise and evaluate care of a patient by ensuring the patient medication was administered according to the physician order and failed to notify the physician of critical laboratory results for 1 of 7 patients (#5)

The findings include:

Review of the hospital policy, "Nursing Services Critical Lab Values - Reporting of", with a review date of June 2011 revealed, "...PROCEDURE: 1. When the nurse (RN/LPN-Licensed Practice Nurse) received results from (the laboratory company), he/she will review the results for any abnormal values. These labs will include all lab work that has been done on a patient. 2. The nurse will immediately notify the attending physician or on-call physician of any results outside of the established normal parameters as defined by (laboratory company)...3. Documentation will be done on the lab report that the physician was notified by the nurse to include date and time."

Review of the hospital policy, "Nursing Services Laboratory Services for Acute Patients", with an "Original Date:" of August 2010 revealed, "...11. Results can be found through (the lab collection website), via auto print twice daily, or by phone."

Review of the hospital policy, "MEDICATION ADMINISTRATION-General Overview", with a revision date December 2009 revealed, "...28. A facility incident report is to be completed by the nurse or other staff member that discovers a medication error and forwarded to the Risk Manager...."

1. Medical record review revealed patient #5 was involuntary committed to the hospital on July 4, 2013. Review revealed on July 16, 2013 at 1145, the physician ordered an ammonia level lab. Review revealed on July 17, 2013 at 0000, the ammonia lab was the collected by (the lab collection company). Review revealed the ammonia lab result was 129 on July 18, 2013 at 1437 (1 day after collection). Review revealed the normal range for ammonia was 19-102. Review revealed the physician was not aware of the ammonia level lab prior to July 29, 2013 (11 days after lab result). Review revealed no documented physician notification related to ammonia lab result prior to July 29, 2013.

2. Review revealed on July 31, 2013 at 1120, the physician ordered Magnesium Citrate, a laxative that aids in lowering ammonia levels, for patient #5. Review of physician order revealed "first dose now, second dose in 8 hours if no bowel movement." Review revealed on July 31, 2013 at 1130, the nurse administered the first dose of Magnesium Citrate to patient #7. Review revealed no further documentation.

Interview conducted on October 30, 2013 at 0950 with nurse #1 confirmed there was no documentation of a bowel movement nor documentation of the second dose administration of Magnesium Citrate nor documentation of physician notification of the ammonia critical lab result prior to July 29, 2013.

Interview conducted on October 30, 2013 at 1100 with the Risk Manager confirmed there was no documentation of fluid intake nor physician notification documentation of critical lab results prior to July 29, 2013 (11 days after lab result).

Interview conducted on October 30, 2013 at 1310 with physician #1 confirmed no physician notification of the ammonia critical lab result was made prior to July 29, 2013 (11 days after results).

NC 796