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|LAS PALMAS MEDICAL CENTER||1801 NORTH OREGON STREET EL PASO, TX 79902||Nov. 13, 2018|
|VIOLATION: ORGANIZATION OF NURSING SERVICES||Tag No: A0386|
|Based on a review of documentation, the director of nursing failed to be responsible for the operation of the nursing service, as nursing staff failed to follow facility policies and procedures.
Patient #1 had a rectal temperature of 101.8 degrees Fahrenheit at 11:32 am on 5-8-17. The patient was medicated with acetaminophen 650mg orally at 1:22 pm for fever, per doctor's order. The patient's temperature was reassessed at 3:32 pm and measured 100.0 Fahrenheit (orally). No other record of reassessment of patient #1's temperature was found.
The patient's vital signs were reassessed at the following times while in the emergency department:
* 5-8-17 at 12:00 pm
* 5-8-17 at 2:00 pm
* 5-8-17 at 3:00 pm
* 5-8-17 at 3:32 pm (including temperature)
* 5-8-17 at 4:32 pm
* 5-8-17 at 5:29 pm
* 5-8-17 at 7:30 pm
* 5-8-17 at 11:30 pm
* 5-9-17 at 3:30 am
* 5-9-17 at 6:15 am (and subsequently transferred from the ER to the Intensive Care Unit)
Facility policy titled "Documentation Policy" states, in part:
B. 3. Level II patients: vital signs to be done upon arrival, and then q1 hour [every hour] with temperature done every 4 hours or upon discharge if patient leaves in less than 4 hours. If patient is unstable and requires closer monitoring due to condition, medication administration or interventions/treatments vital signs to be documented every 15 minutes with temperatures every 4 hours of upon admission to hospital if in ED less than 4 hours.
C. Medication Administration:
2. Effects of medication should be assessed and documented in nurse's notes after administration.
3. The type of documentation required is related to the type of medication administered.
Antipyretics: patients' temperature to be documented in vital signs 30 minutes to 1 hour after administration of antipyretic."
The above was confirmed in an interview with the Chief Nursing Officer and Director of Clinical Informatics on the afternoon of