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|STRATEGIC BEHAVORIAL CENTER-GARNER||3200 WATERFIELD DRIVE GARNER, NC 27529||April 28, 2017|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on facility policy review, medical record reviews, interviews with patients, families and staff, the facility's nursing failed to notify family of medication changes; perform lab tests and notify physician of laboratory results in 1 of 2 sampled medical records with patients requiring laboratory studies (#8).
The findings include:
1. Review of "Informed Consent and Medication Education for Patient Medication" dated 4/7/17 signed by (patient's listed mother) for patient #8 revealed " ...I understand the above information and give permission for my child to receive this medication, as it is ordered by the physician. I have been informed that I will be notified upon the initiation of a new medication for discussion and to obtain consent to administer the medication. It has been explained to me that I will notified if any change is made (increase, decrease, discontinuation of, or renewal) to a previous medication that I have given consent for. I also understand that I may call to speak with the nurse to discuss any medication concerns that I may have ...."
Review of closed medical record for patient #8 on 04/25/2017 revealed a [AGE] year old male admitted on [DATE] for thoughts of suicide. Patient was discharged AMA (against medical advice) by mother on 04/15/2017. Review of physician's orders dated 04/12/2017 at 1130 revealed "increase Celexa (antidepressant) to 15 mg (milligrams) po (by mouth) q am (every morning) for depression." Review of MAR (medication administration record) dated 04/13/2017 and 04/14/2017 revealed documentation of administration of Celexa 15 mg po at 0800. Further review revealed no evidence of notification of family member of medication changes.
Interview on 04/26/2017 at 1045 with RN #2 revealed family/legal guardians are given "a courtesy call" when doses are medications are changed. Further interview failed to provide documentation of family contact during medication changes.
2. Review of Nursing Service policy titled, "Verbal orders and test results" with revision date of 05/24/2016 revealed "...3. Staff shall take appropriate timely action when critical test results are received."
Review of closed medical record for patient #8 on 04/25/2017 revealed a [AGE] year old male admitted on [DATE] for thoughts of suicide. Patient was discharged AMA (against medical advice) by mother on 04/15/2017. Review of telephone admission orders dated 04/08/2017 at 0850 revealed "TORB (telephone order read back) (Attending psychiatrist)/RN. Hold Depakote for level." Further review revealed the Depakote level was collected on 04/12/2017 at 0539 and resulted at 0838, 4 days after the order. Further review revealed Patient#8 received the Depakote on 04/13/2017.
Interview on 04/26/2017 at 1045 with RN #2 revealed there is no policy available on timeliness of lab orders by the phlebotomist.
Interview on 04/27/2017 at 1140 with Phlebotomist revealed the physician orders are copied and placed in the phlebotomist's mailbox to be completed. "I do not look at the charts for the orders. The nurses signing off the orders makes a copy then brings the copied order to me or places it in my mailbox or places the order under my office door." Further interview revealed tracking of orders is done but no data was available.
Interview on 04/27/2017 at 1200 with MD #1 revealed there was not a notification of the delay in obtaining this Depakote level or the lab results. "The lab phlebotomist is here six days a week. There is no reason the lab should not have been drawn on the day it was ordered."