HospitalInspections.org

Based on review of documentation and interviews the facility failed to provide care in a safe setting. Physician order medication for patient #1 for critical lab value. Medication was not in the building. Medication was not given.

Findings were:
Review of nurse progress note 03/20/2019 22:00 per staff #5. Critical potassium of 5.5 orders to give calcium gluconate IV 1-gram. medication not available. Staff # 7 notified by staff # 4, charge nurse.

Review of progress note per staff #5, 3/20/19 2300. Staff #4 charge nurse called staff #6 physician about critical labs on pt and meds not available awaiting call back.

Review of progress note per staff #4 charge nurse 3/20/19 2300. Pt had critical INR 4.0 and CA 5.5 staff #7 notified, stated to notify internal medicine (IM) staff # 8. Text staff #8, no response. Spoke with staff #6 orders to hold Coumadin and to administer 1 Gram calcium gluconate, medication is not available in the building, after speaking with staff #2, pharmacist, paged staff #6 twice no response. Patient stable.

Patient Bill of Rights. "As a natural outgrowth of our beliefs, values and mission Methodist Rehabilitation Hospital recognizes the following PATIENT BILL OF RIGHTS. 1. A patient has the right to the hospital reasonable response to his or her requests and needs for treatment or service within the hospital capacity, its stated mission, and applicable law and regulation."

In an interview on 6/18/19 at 0940 with staff #2 pharmacist, staff #2 said Calcium gluconate has to be mixed by pharmacist. He remembers getting the call from staff #4, but never heard anything else after informing staff #4 the medication was not in the building. Staff #4 said when the physician doesn't order an alternative medication, arrangements are made for the medication to be picked up from the sister hospital. But he was never notified about alternative medication.

In an interview on 6/18/19 staff #1 agreed with the findings. Calcium gluconate was not in the building and was not given. The physician did not call staff #4 back.

Based on review of documentation and interviews the facility failed to ensure that patients were free from neglect as, 4 0f 10 patients were neglected. Position turn q2hrs. form 3/14/19 was not available for the surveyor to review. Multiple blanks were observed in the turn q2 hrs. forms. Indicating the patients were not turned every 2 hours. Causing potential for discomfort, compromise circulation, bedsores or lack of healing of bedsores.

Findings were:

4 (pt #1, 2, 3,4) of 10 medical records reviewed revealed the turn q2 hrs. forms had multiple blanks, indicating the patients had not been turned every two hours.
Pt #1
3/12/19, 0600-0800, 1400-1600, 1600-1800, 1800-2000.
3/13/19, 0600-0800, 0800-1000, 1000-1200, 1200-1400, 1400-1600, 1600-1800.
3/14/19, Not available for surveyor to review
3/15/19, 1200-1400, 0600-0800, 1400-1600, 1600-1800, 1800-2000.
3/16/19, 0600-0800, 2000-2200, 2200-2400
3/18/19, 2400-0200, 0200-0400, 0400-0600, 1800-2000.
3/19/19, 2400-0200, 0200-0400, 0400-0600, 0600-0800, 1800-2000, 2000-2200.
3/20/19, 1600-1800, 1800-2000.
3/21/19, 1800-2000.
3/22/19, 1800-2000, 2000-2200, 2200-2400.
3/23/19, 0200-0400.
3/24/19, 0600-0800, 1400-1600, 1600-1800.
Pt. #2.
3/27/19, 1200-1400, 1400-1600,1600-1800. 1800-2000.
3/28/19, 1400-1600,1600-1800. 1800-2000.
Pt. #3
6/17/19, 1200-1400, 1400-1600,1600-1800.
6/16/19, 1200-1400, 1400-1600,1600-1800.
6/15/19, 0200-0400
6/13/19, 1600-1800
6/11/19, 1600-1800
Pt. #4
6/15/19, 0200-0400, 0400-0600.

Policy POC 190, reviewed date: 10/2018. IV. The following criteria are used as a guide in identifying signs and symptoms of abuse or neglect of patient, elder, child by staff or others; A Physical Abuse. 1. Scratches, cuts, bruises, burns, welts, scalp injuries, gag marks, sprains, punctures, broken bones, bedsores, black eyes, passive/withdrawn/emotionless behavior, lack of reaction to pain, confinement.

Patient Bill of Rights. "As a natural outgrowth of our beliefs, values and mission Methodist Rehabilitation Hospital recognizes the following PATIENT BILL OF RIGHTS. 1. A patient has the right to the hospital reasonable response to his or her requests and needs for treatment or service within the hospital capacity, its stated mission, and applicable law and regulation."

In an interview at the facility on 6/18/19 staff #1 agreed with the findings.

Based on review documentation and interviews the facility fail to deliver care to patient #2. Multiple blanks were observed in the turn every two hours forms.

Findings were:

Review of medical record revealed multiple blanks in the turn every two hours forms indicating pt#2 was not turned every 2 hours. Causing potential for discomfort, compromise circulation, bedsores or lack of healing of bedsores.

The forms lack signatures of staff for 3/27/19, 1200-1400, 1400-1600,1600-1800. 1800-2000.
3/28/19, 1400-1600,1600-1800. 1800-2000.

In an interview with staff #1 at the facility on 6/18/19, staff #1 agreed with the findings.

Based on review of documentation the facility failed to ensure that orders were documented in the medical record when received by physicians. Calcium Gluconate was ordered for patient #1 for critical lab value. There were no orders in the medical record verifying the medication was ordered.

Findings were;
Review of nurse progress note 03/20/2019 22:00 per staff #5 LVN. Critical potassium of 5.5 orders to give calcium gluconate IV 1-gram. medication not available. Staff # 7 physician notified by staff # 4, charge nurse. There was no documentation the physician responded to calls and texts that the calcium gluconate was not in the building after staff #4 charge nurse spoke to staff #2 pharmacist.

Review of Policy MM 295. "1. B. The prescribing practitioner has determined that the patient is in need of medication in an urgent or emergency situation with verbal/telephone communication presenting the swiftest method of accomplishing the order."

Review of progress note per staff #5 LVN, 3/20/19 2300. Staff #4 charge nurse called staff #6 physician about critical labs for pt #1 and meds not available awaiting call back.

Review of progress note per staff #4 charge nurse 3/20/19 2300. Pt had critical INR 4.0 and CA 5.5 staff #7 physician notified, stated to notify internal medicine (IM) staff # 8. Text staff #8 physician no response. Spoke with staff #6 physician orders to hold Coumadin and to administer 1 Gram calcium gluconate.

In an interview 6/18/19 @ 0940 at the facility with staff #2 pharmacist stated calcium gluconate IV has to be mixed by the pharmacist. If the medication is not available, the nurse calls the physician for alternatives and notifies the pharmacist. If medication is still needed it can be borrowed from the sister hospital down the street. Staff #2 said he did not receive any more communication #4.

In an interview with staff #1 at the facility on 6/18/19, staff #1 agreed with the findings.

Based on review of documentation the governing body failed to ensure that the physician on call for patient #1 answer and respond to calls.

Findings were:
Review of nurse progress note 03/20/2019 22:00 per staff #5. Critical potassium of 5.5 orders to give calcium gluconate IV 1-gram. medication not available. Staff # 7 physician notified by staff # 4, charge nurse. There was no documentation the physician responded the calcium gluconate was not in the building after staff #4 and #5 spoke to staff #2 pharmacist; the medication was not given.

Review of progress note per staff #4 charge nurse 3/20/19 2300. Pt had critical INR 4.0 and CA 5.5 staff #7 physician notified, stated to notify internal medicine (IM) staff # 8. Text staff #8 physician no response. Spoke with staff #6 physician orders to hold Coumadin and to administer 1 Gram calcium gluconate.

In an interview with staff #1 at the facility on 6/18/19, staff #1 agreed with the findings.