HospitalInspections.org

Based on document review, observation, and interview nursing staff failed to ensure all patients in facility received an identification band on admission, failed to replace missing identification bands as a routine component of patients daily assessment process for 10 of 60 patients observed (Patient's 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21), failed to obtain lab tests, as ordered, in a timely manner, and failed to document laboratory results in the medical record in 1 of 11 patient MR's reviewed (Patient 4).

Findings include:
1. Facility policy titled: Patient Identification for Clinical Care and Treatment, PolicyStat ID: 12197172, last approved 08/2022, indicated under Patient Identification Policy: Hospital Wristband: A tamperproof, nontransferable identification band shall be prepared and affixed to the patient in the admitting department. The identification band will include the patient's name, hospital identification number, and medical record number, date of birth, age, sex, and attending physician. Before any procedure is carried out, the identification band shall be on the patient and will be checked by the responsible care provider for the follow two (2) identifiers to ensure that the right patient is involved: Patient name. Patient date of birth. Patient identification must be confirmed using the two (2) identifier system prior to conducting any healthcare procedures. Procedures may include, but are not limited to: Administration of medication. Defective or missing bands shall be replaced immediately with new bands. Each healthcare provider conducting assessments on the patient shall include a check of the patient's identification band to assure the band is present and legible, as a routine component of the patient assessment process. The daily nursing staff rounds shall include spot checking the patients to ensure they they are wearing identification bands and the information is legible.

2. Facility policy titled: Laboratory Process, PolicyStat ID: 12197196, last approved 08/2022, indicated under Policy: To obtain laboratory results and place them on the chart for provider review in a timely manner. Procedure: 1. Provider orders lab. 4. Nurses and/or phlebotomist obtains specimen for ordered tests. 8. Nurses/Unit Clerks obtain laboratory results from lab website and print results. 9. Nurses/Unit Clerks place printed results in the patient's medical record for the provider to review.

3. P4's MR documented the following lab orders on admission (6/02/25) as follows: CBC (complete blood count) with differential, CMP (complete metabolic panel), TSH (thyroid stimulating hormone), and U/A (urinalysis) with C & S (culture & sensitivity) test. On 6/3/25 at approximately 8:14 am, MD1 (Nurse Practitioner [NP]) note documented patients medical regimen and follow up based on pending labs. On 6/19/25 at approximately 10:30 pm, P4's MR documented patient cooperative for blood draw and was sent to lab for pick-up. P4's MR lacked any previous blood draw attempts and/or any further lab draws. P4's MR lacked documentation of lab results during facility stay or provider notification of missing labs. On 7/8/25, MD2's (Nurse Practitioner [NP]) note documented labs ordered on admission and pending. P4 was discharged on 7/08/25.

4. On 8/12/25 at approximately 11:43 am to 12:15 pm, this writer accompanied by A2 toured facility 100, 200, and 300 Unit specifically to count patient identifier armbands.
a. Unit 200 - Census 25, identification bands were missing from Patient's 14, 18, 19, 20, and 21.
c. Unit 300 - Census 13, identification bands were missing from Patient's 12, 13, 15, 16, and 17.

5. In interview on 8/11/25 at approximately 1:05 pm to 1:16 pm, N6 (RN, Unit 100) indicated that all labs are done on admission or within 2-3 days but did not recall a specific policy or timeframe. N6 indicated if labs were refused or unable to obtain would notify the provider and document in the patient's MR.

6. In interview on 8/12/25 at approximately 11:45 am, P12 (Current Patient, 300 Unit) indicated he/she did not have an identification band on and was not given one on admission.

7. In interview on 8/12/25 at approximately 11:46 am, P13 (Current Patient, 300 Unit) indicated he/she did not have an identification band on and was not given one on admission.

8. In interview on 8/12/25 at approximately 11:46 am, P15 (Current Patient, 300 Unit), confirmed an identification band was placed on admission but that he/she took it off and did not want to wear anything on the arms.

9. In interview on 8/12/25 at approximately 11:47 am, P16 (Current Patient 300 Unit) confirmed received an identification band on admission but since took it off and is in his/her pocket in room. P16 indicated did not want to wear the armband.

10. In interview on 8/12/25 at approximately 11:55 am, P14 (Current Patient, 200 Unit) indicated he/she did not have an identification band on and was not given one on admission.

11. In interview on 8/12/25 at approximately 12:20 pm, A1 (Director Clinical Services) confirmed there were 5 patients on the 200 Unit missing identification bands and 5 patients on the 300 Unit missing identification bands at the time of tour, on 8/12/25 at approximately 11:43 am to 12:15 pm.

Based on document review and interview nursing staff administered medications discontinued by the provider in 1 of 11 patient MR's reviewed (Patient 1).

Findings Include:

1. Facility policy titled: General Medication Administration, PolicyStat ID: 12386373, last approved 09/2022, indicated under Administration of Medication: The person administering the medication will verify that the selected medication is correct, based on the medication order and the medication product label.

2. MR review of P1 indicated on 3/24/25 at approximately 12:00 pm a provider order was documented in P1's MR to discontinue Xanax, 0.25 mg (milligrams), by mouth, twice daily. P1's MAR (Medication Administration Record) lacked documentation that the order had been discontinued. P1's MAR documented patient received the following doses of Xanax, 0.25 mg, by mouth, after the order had been discontinued as follows: 10:14 pm on 3/24/25, 8:37 am and 10:55 pm on 3/25/25, and at 7:48 am on 3/26/25.

3. Facility Incident Report dated 3/26/25, indicated P1 had a medication variance with no injury/adverse outcome to patient when a medication was discontinued by provider and the order was not transcribed appropriately on the patient's MAR. Patient received 4 doses of Xanax, 0.25 mg, by mouth, after the order was discontinued. The report noted physician/supervisor/patient family were notified, transcription error corrected, related causes and factors: policy/procedure not followed, and the resolution was reviewed by the CEO (Chief Executive Officer).