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|SOUTHEASTERN REGIONAL MEDICAL CENTER||300 W 27 ST PO BOX 1408 LUMBERTON, NC 28359||Aug. 23, 2018|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of hospital patient care standards, medical record reviews, and staff interviews, the hospital's nursing staff failed to perform alcohol withdrawal assessments as ordered by a physician for 2 of 3 sampled patients with a history of alcohol abuse (Patient #3 and #1).
Review on 08/22/2018 of hospital document "MEDICAL/SURGICAL PATIENT CARE STANDARDS" last reviewed/revised 02/01 revealed "Standard I: Patient's needs will be identified through the admission assessment... Interview patient and/or family and obtain information related to: a. Patient problems b. Past history of illness...j. Personal habits..."
1. Review on 08/22/2018 of the medical record for Patient #3 revealed a [AGE] year old male who was admitted on [DATE] after presenting to the emergency department for a chief complaint of "near syncope". Record review of history and physical revealed "Current Issues: Near syncope...- Patient's son in law reports that this is an ongoing condition that is believed to be tied to patient's alcohol abuse. Further review of the history and physical revealed "Physical Exam:... Psych: alert and oriented x 3 (person, place and time), normal affect..." Review of physician orders revealed "Alcohol and Drug Assessment" order placed on 07/22/2018 at 0115. Review of Alcohol and Drug Assessment order revealed "Comments a) Assess withdrawal symptoms now. b) If initial score is > (greater than) or = (equal to) 8, repeat q (every) 1 hour x 8 hours..... Indications for PRN (as needed) medications: 1) Total CIWA- AR (Clinical Institute Withdrawal Assessment for Alcohol) score of 8 or higher if needed PRN only .... " Review of nursing documentation revealed the first CIWA score documented on 07/23/2018 at 0300 of 30 (25 hours 45 minutes) after the order was placed.
Interview on 08/23/2018 at 0910 with RN #2 revealed she was the primary nurse for Patient #3 on 07/22/2018 on the 7am-7pm shift. Interview revealed she did not know Patient #3 had a history of alcohol abuse or the physician placed an order for "Alcohol and Drug Assessment" to be completed. Interview revealed she thought the patient had dementia. Interview revealed RN #3 stated "the last thing I am going to do is look at orders, I expect to get that in report. I don't have time to read the H&P (history and physical)." Interview confirmed the "Alcohol and Drug Assessment" was not initiated as per the physician orders.
2. Review of the medical record for Patient #1 revealed a [AGE] year-old male (MDS) dated [DATE] at 0932 with a chief complaint of left hip pain related to frequent falls. Further review revealed the patient was admitted at 1239 with a diagnosis of alcohol abuse, frequent falls and left hip pain. Review of the physician orders revealed an "Alcohol and or drug assessment" ordered on [DATE] at 1326 and canceled on 08/06/2018 at 1209. Further review of the record revealed an "Alcohol and or drug assessment" ordered on [DATE] at 0928 and discontinued on 08/21/2018 at 1449. Review of the "Alcohol and or drug assessment" order revealed "Comments: a) Assess withdrawal symptoms now. b) If initial score is >(greater than) or =(equal to) 8, repeat q1h (every hour) x(times) 8 hours, then if stable q2h (every 2 hours) x 8 hours, then if stable q4h (every 4 hours). c) If initial score is <(less than) 8, assess q4h x 72 hours. If score is < 8 for 72 hours, discontinue assessment. If score is > or = 8 at any time, go to (b)...." Review of the nursing flowsheet revealed documentation of an "Alcohol and or drug assessment" completed on 08/04/2018 at 1245 with a score of four (4), at 1645 - score four (4), at 2000 - score zero (0), on 08/05/2018 at 0000 - score one (1), at 0400 - score six (6), at 0600 - score two (2), at 0802 - score two (2), at 1237 - score one (1), at 1615 - score one (1), at 2000 - score six (6) and on 08/06/2018 at 0000 - score five (5) and 0400 - score five (5). Review of the record revealed no available documentation of an "Alcohol and or drug assessment" on 08/06/2018 at 0800, 1200, 1600 and 2000. Review of the medical record revealed Patient #1 was transferred to the Intensive Care Unit on 08/06/2018 at 1150 for alcohol withdrawal, fever, tachycardia (increased heart rate) and hypoxia (decreased oxygen levels).Continued review of the nursing flowsheet revealed documentation of alcohol assessment on 08/07/2018 at 0800 - score nine (9) [per alcohol assessment protocol begin assessments every hour for eight (8) hours for score equal to or above eight (8), then every two (2) hours for eight (8) hours, then every four (4) hours]. Review of the nursing flowsheet revealed the next available documentation was at 1200 - score eight (8) and at 1600 - score four (4). Review of the nursing flowsheet revealed no available documentation of an "Alcohol and or drug assessment" on 08/07/2018 at 0000, 0400, 0900, 1000, 1100,1300, 1400, 1500, 1800, 2000, 2200 and on 08/08/2018 at 0000.
Interview during medical record review on 08/23/2018 at 0942 with RN #1 revealed the staff failed to obtain alcohol withdrawal scores as ordered on the alcohol assessment protocol.