HospitalInspections.org

Based on interview and record review the Hospital failed to supervise the care of 1 of 11 patient files reviewed. Nursing services failed to hold blood pressure medication according to parameters established , failed to change central intravenous line dressings every 48 hours as ordered and failed to document Foley catheter care for patient ID# 1. (Patient ID#'s 1 to 11)

Findings include:

Blood Pressure Medication:

Record review of a History and Physical report for patient ID# 1 dated 7/16/10 stated "We will go ahead and optimize antihypertensive medications to maintain systolic blood pressure in the 120's. The Physician orders dated 7/16/10 stated " Atenolol tablet 25mg (for high blood pressure) to be administered every morning. The Medication Administration form said to " Hold for Systolic Blood Pressure less than 120. "

Upon review of the Medication administration forms it was determined that Mr. Holmes was given two doses of Atenolol on 7/26/10 and 7/27/10 with a Systolic blood pressure less than 120. The systolic blood pressure on 7/26/10 was 116 and the systolic blood pressure on 7/27/10 was 96. The blood pressure medication should not have been administered by nursing staff with a systolic reading less than 120 according to the medication administration record.

Central Venous Catheter IV:

Physician orders dated 7/16/10 stated " Sterile Dressing Changes every 48 hours. Central Line, triple lumen right femoral Central Venous Catheter. " Nursing notes reflected that only one dressing change was documented on 7/23/10 during the patient ' s 13 day stay at the hospital. The patient was admitted to the hospital on on 7/16/10 and discharged on 7/29/10.


Foley Catheter:

Nursing notes on 7/18/10 at 7 a.m. stated " Foley inserted. " No physician order for a Foley catheter was noted in the physician orders. Record review of the nursing notes and treatment records revealed no documentation of Foley catheter care provided for patient ID# 1 during his stay at Reliant Hospital.

Patient ID # 1 was care planned for Urinary function on 7/17/10 but the care plan did not list any interventions.

Record review of a policy titled " Nursing Guidelines for Patient Care Procedures " dated 8/2010 stated " To provide reference and guidelines for patient care procedures. Nurses shall reference Lippincott Manual of Nursing Practice for guidelines for patient care procedures. "

The Lippincott Manual reference stated the following:
" Indwelling Catheter: Clean around the area where catheter enters urethral meatus with soap and water during the daily bath to remove debris. "

The Risk Manager (ID# 53) acknowledged 8/30/10 at 2:30 p.m. that patient ID# 1 should not have been administered blood pressure medication with a systolic reading less than 120. The Risk Manager further stated that she could only locate one central line dressing change on 7/23/10 and that no Foley catheter care was documented in the medical record for patient ID# 1.

Based on interview and record review the Hospital failed to develop a care plan that addresses the patients needs for 1 of 11 patients files reviewed (Patient ID# 1).
(Patient ID#'s 1 to 11)

Findings include:

The Nursing Notes dated 7/16/10 stated patient ID# 1 had a central line, was incontinent of bowel and bladder, wore briefs, and required maximum assist with transfers and mobility.
Physician orders 7/16/10 stated " Sterile Dressing Changes every 48 hours. Central Line, triple lumen right femoral CVC. " The Hospital orders on 7/16/10 also stated " Needs assistance in feeding / please assign help to feed the patient at meal times. " The History and Physical dated 7/16/10 stated "We will monitor strict Intakes and Outputs and daily weights, and monitor his urine output."

Record review of the Care Plan for patient ID# 1 dated 7/16/10 to 7/29/10 revealed the patient was not Care Planned for Bowel Incontinence, Intake ' s and Output ' s, the Central intravenous line, the Foley catheter, assistance in feeding or requiring maximum assist with transfers and mobility.

The patient was Care Planned for Urinary function, Cognition, Alteration in Blood Pressure, and alteration in comfort. The Care Plans did not list any interventions for the problems identified.

The Risk Manager (ID# 53) acknowledged 8/30/10 at 2:30 p.m. that patient ID# 1's care plan did not list any interventions by nursing staff.