HospitalInspections.org

Based on interviews and records review, it was determined that the Governing Body was not effective in its oversight of the hospital.

Nursing Services failed to adequately supervise and evaluate the nursing care for 1 of 20 patients (Patient #2) who was hospitalized for rehabilitation from 02/08/13 through 02/20/13 at Hospital A after a 02/01/13 "Craniotomy" surgery. Patient #2 was transferred to Hospital B on 02/20/13 for treatment of an "Acute Abdomen" with diagnoses that included "acute renal failure...dehydration...hypotension...constipation."

A) The Nursing Staff did not follow physician orders regarding Strict I&O's (Intake & Output), and documentation of PVR's (post-void residuals) for Patient #2.

B) The Registered Nurse (RN) did not initiate the involvement of the Dietitian when evaluating the results of Patient' #2's oral intake.

C) Drugs and Biologicals were not administered to Patient #2 according to physician's orders.

Findings included:

A) The care performed by nurses' aides for Strict I&O's (Intake & Output), and documentation of PVR's (post-void residuals), did not follow the physician orders, and/or were not documented by the Nursing Staff.
(Cross refer to A0395)

B) The RN did not initiate the involvement of the Dietitian when evaluating the results of care regarding identified issues with Patient #2's decreased oral intake.
(Cross refer to A0395)

C) An anti-hypertensive drug (Lisinopril) was administered when Patient #2's blood pressure was below normal rate, Patient #2's intravenous (IV) fluid was discontinued without a physician's order, and Patient #2 was not administered a physician ordered suppository after not having a bowel movement in 8 days.
(Cross refer to A0405)

Based on interviews and records review, it was determined Nursing Services was not effective in its oversight of the Nursing Staff for the provision of care and services.

Nursing Services failed to adequately supervise and evaluate the nursing care for 1 of 20 patients (Patient #2) who was hospitalized for rehabilitation from 02/08/13 through 02/20/13 at Hospital A after a 02/01/13 "Craniotomy" surgery. Patient #2 was transferred to Hospital B on 02/20/13 for treatment of an "Acute Abdomen" with diagnoses that included "acute renal failure...dehydration...hypotension...constipation."

A) The Nursing Staff did not follow physician orders regarding Strict I&O's (Intake & Output), and documentation of PVR's (post-void residuals) for Patient #2. (Cross refer to A0395)

B) The Registered Nurse (RN) did not initiate the involvement of the Dietitian when evaluating the results of Patient' #2's oral intake. (Cross refer to A0395)

C) Drugs and Biologicals were not administered to Patient #2 according to physician's orders and standards of nursing practice. (Cross refer to A0405)

Based on interview, and record review, the hospital did not ensure that the registered nurse (RN), supervised and evaluated the nursing care for 1 of 20 patients (Patient #2), in that, care performed by nurses' aides for: A) Strict I&O's (Intake & Output), and documentation of PVR's (post-void residuals) did not follow physician orders, and/or were not documented, and B) the RN did not initiate the involvement of the Dietitian (Personnel #5) when evaluating the results of care regarding identified issues with Patient #2's decreased oral intake.

Findings included:

A) Patient #2's "Physician Orders" included the following:

The physician order dated 2/09/13 timed at 19:20 PM reflected, "Place ...(urinary) catheter...Strict I & O's." It was noted the order for "Strict I&O's" was never discontinued throughout Patient #2's hospitalization.

The physician order dated 2/14/13 timed at 14:45 PM reflected, "DC (discontinue)...(urinary) catheter... Intermittent cath if no void in 8 hours, or if PVR (post-void residual) is > 200 cc's."

There was no documentation in the medical record that the urinary catheter was discontinued as ordered by the physician on 02/14/13.

The 02/14/13 "Graphic Record Form" revealed, the strict urine output, measured in cc's, stopped being entered by the Day Shift Nurse Aide, and was changed to "number of times patient voided." There was no physician's order for this change in assessment.

The 02/08/13 through 02/20/13 "Graphic Record Form" revealed no documentation was found in the medical record that measured PVR's (post-void residuals) by using a bladder scanner, to determine whether Patient #2 needed to be catheterized. The "Intermittent cath if no void in 8 hours, or if PVR (post-void residual) is > 200 cc's," was still in effect.

On 02/19/13 the night shift record indicated Patient #2's urine measurement was 300 cc's, prior to being transferred to another acute care hospital (Hospital B) the next morning. There was a repeat physician order "In and Out cath every 8 hours, if no void for more than 6-8 hours, or if residual > 200."

In a telephone interview at 2:15 PM on 6/10/13 with the Chief Nursing Officer (CNO)(Personnel #2), he verified that he had reviewed Patient #2's medical record, and that "Strict I&O's" had stopped being done by nursing service staff on 2/14/13, even though there was no physician order to discontinue her "Strict I&O's."

B) Patient #2's "Graphic Record Form" dated 02/08/13 through 02/20/13 indicated 9 meals had 0% intake, and 17 meals had 30% or less intake, out of a total of 33 meals offered.

During an interview at 3:20 PM on 5/06/13 with the Dietitian (Personnel #5), she verified that Patient #2's dietary intake was poor, based on nurse aides' documentation on the "Graphic Record Form. Patient #2 was evaluated by the Dietitian (Personnel #5) on 02/11/13 and clarified the change in diet order to mechanical soft on 02/12/13 with a recommendation for 1-1 supervision with meals for safety. The Dietitian (Personnel #5) verified that she had no other dietary notes in the medical record between 2/12/13 and the date of discharge 2/20/13, regarding Patient #2's oral intake while she was to be on Strict I&O's. The Dietitian stated that she had participated in the two weekly Interdisciplinary Team Conferences held during Patient #2's stay, on 2/12/13 and 2/19/13, however there was no dietary input by the Dietitian noted for either of these meetings.

There was no documentation in the medical record that the RN supervising Patient #2's care, referred or initiated further dietary input from the Dietitian (Personnel #5).

The policy and procedure entitled, "Bladder Management Program" with a revised date of 01/31/12 reflected, "To assure standardized management of urinary retention and urinary incontinence...to establish consistent practices that supports the best patient outcomes...timed voiding...after voiding, the patient will be assessed for a Post Void Residual via ultrasound...patients will be hydrated...I&O's will be maintained..."

Based on interviews, and record reviews, the Rehab Hospital (Hospital A), did not ensure that drugs and biologicals were administered according to the orders of the physicians responsible for the care of 1 of 20 patients (Patient #2), or by accepted standards of nursing practice, in that: A) an anti-hypertensive drug (Lisinopril) was administered when Patient #2's blood pressure was below the normal rate; B) Patient #2's intravenous (IV) fluid was discontinued without a physician's order; and C) Patient #2 had no bowel movement for greater than 48 hours and was not administered a suppository according to the physician's 02/08/13 order. Patient #2 was transferred to Hospital B for treatment of an "Acute Abdomen."

Findings included:

A) Patient #2's admission "Physician Orders" dated 02/08/13 included medications that were being given at the previous hospital (Hospital B), and included: Lisinopril 10 mg. (milligrams) po (by mouth) daily for hypertension.

"Nursing Notes" at 7:00 AM on 2/09/13 recorded Patient #2's "blood pressure as 111/61. AM meds (medications) discussed and given, tolerated well, pills whole with water one-at-a-time." At 11:15 AM, "Patient up in wheelchair appears lethargic and difficult to arouse. Transferred to bed...vitals: 75/43 blood pressure..."

The "Medication Administration Record" (MAR) noted that Patient #2 received blood pressure medication, Zestril (Lisinopril) 10 mg. by mouth at 7:46 AM on 2/09/13.

At 11:30 AM, "blood pressure 73/48, heart rate 86. Bed is flat. Notified Charge RN (registered nurse) and physician (Personnel #8). Continue to monitor & perform neuro checks." At 12:30 PM, "blood pressure 77/56, heart rate 74. Opened eyes on command. Still lethargic. Notified Charge RN. Bed flat. Continue to monitor." At 13:00 (1:00) PM, "Patient too lethargic to participate in any therapy today. Contacted physician (Personnel #8). New order for Normal Saline at 80 ml/hr. via pump."

At 13:30 PM, the "Charge nurse wrote a verbal order from physician (Personnel #8) to Hold BP (blood pressure) med (Lisinopril)." At 14:30 (2:30) PM, "after multiple attempts patient has a 22 gauge IV (intravenous line) in left AC (antecubital) ..." At 19:30 PM, "blood pressure re-checked manually, 108/64."

B) Patient #2's "Physician's Orders" noted the following:
2/09/13 13:30 PM, "NS (normal saline) at 80 ml/hr," by physician (Personnel #8).
2/09/13 1720 PM, "Give bolus of 500 ml NS..." by physician (Personnel #8).
2/19/13 20:30 PM, "Start IV Sodium Chloride 0.9% at 80 cc/hr per TORB (telephone order read back) from physician (Personnel #6)."

The 02/09/13 13:00 PM "Nursing Notes" revealed, "Patient too lethargic to participate in any therapy today. Contacted physician (Personnel #8). New order for Normal Saline at 80 ml/hr. via pump."

At 17:20 PM, the RN wrote order from Personnel #8 to "give bolus of 500 ml NS (Normal Saline), please."

On 2/10/13 at 9:00 AM the RN (Personnel #13) wrote "Fluids stopped after one liter, IV (line) removed per physician order, will continue to monitor."

Review of Physician Orders, revealed there was no order to stop the IV fluid or to remove Patient #2's IV.

In an interview at 2:15 PM on 6/10/13 with the Chief Nursing Officer (Personnel #2), he verified that he had reviewed Patient #2's medical record, and that there was no order to stop IV fluids or to remove her IV on 2/10/13.

In a telephone interview at 3:45 PM on 6/11/13 with the RN (Personnel #13), she was asked if she remembered Patient #2, and she said "no." When asked if she remembered receiving a telephone or verbal order to stop an IV fluid bolus, and to remove the IV line, she said "she did not remember anything like that, and that she would not stop an ordered IV fluid or IV line without a doctor's order."

C) Patient #2's physician ordered a 10 mg. suppository daily PRN (as needed) for constipation on 02/08/13.

The medical record's "Graphic Record Form" revealed Patient #2 had no bowel movements from the evening of 02/09/13 to the day shift of 02/18/13 (8 days).

There was no indication in the medical record that the medication was administered as ordered.

Physician #6 was asked in a telephone interview on 06/10/13 at 2:45 PM if he knew Patient #2 had not had a bowel movement in 8 days. He said that he depends on the nurses to inform him of these types of things.

On 02/20/13, Patient #2 was admitted to Hospital B for "Abdominal Problem (distention), and Lethargy...blood pressure was 84/51 on admission..." Patient #2's active hospital diagnoses included "acute renal failure...dehydration...hypotension...constipation." Patient #2 was discharged home on 03/01/13 with home health care.

The policy entitled, "Vital Signs" with a revised date of 01/31/12 reflected, "Altered vital signs may be the first indication of life threatening pathological conditions..."

The policy entitled, "Bowel Program" with a revised date of 01/31/12 reflected, "The purpose of this policy is to establish standards of care for managing effective bowel elimination...at least one bowel movement every three days..."

The policy entitled, "Physician Orders" with a revised date of 01/31/12 reflected, "To ensure safety through accurate documentation and completion of physician patient care orders..."