HospitalInspections.org

A. Based on document review, observational tour, and interview, it was determined that for 1 of 2 (transport defibrillator) defibrillators on 8 west, the Hospital failed to ensure the defibrillator was checked every shift as required.

Findings include:

1. Hospital policy entitled, "Defibrillation; External, for Life-threatening Arrhythmias," (approval date April 1, 2014) required, "Policy...8. To ensure operability, at the beginning of each shift, defibrillators are checked for proper functioning.."

2. On 1/13/15 at approximately 12:00 PM during an observational tour of the 8 west nursing unit, the 2 unit defibrillators were observed. The transport defibrillator's testing printout was reviewed. The printout failed to include checks every shift as required from 1/6/15 at 10:23 AM to 1/10/15 at 9:12PM (3 days).

3. The Nurse Coordinator II of Medical-Surgical Nursing stated the defibrillator should have been checked every shift.

B. Based on document review and interview, it was determined that for 2 of 2 (Pt# 2 and 3) clinical records reviewed on 8 west for intake and output monitoring, the Hospital failed to ensure all patients' orders were followed as required.

Findings include:

1. The clinical record of Pt #2 was reviewed on 1/13/15. Pt #2 was a 45 year old female admitted on 12/23/14 with a diagnosis of Ascites. Pt #2's clinical record contained a physician's order dated 1/9/15 at 2:58 PM that required chest tube drainage to be measured every 4 hours. Pt #2's intake and output records for 1/9/15 to current lacked documentation of every 4 hour output monitoring from the chest tube as required. Examples include: 1/9/15 from 3:00 PM to 10:00 PM (7 hours); 1/10/15 from 5:00 AM to 2:00 PM (8 hours); 1/11/15 from 6:00 AM to 2:00 PM (8 hours); and 1/12/15 from 2:00 PM to 10:00 PM (8 hours).

2. The clinical record of Pt #3 was reviewed on 1/13/15. Pt #3 was a 35 year old female admitted on 1/12/15 with a diagnosis of anemia. Pt #3's clinical record contained a physician's order dated 1/13/15 at 1:39 AM that required strict I & O (intake and output) every 8 hours. Pt #3's intake and output record for 1/13/15 lacked documentation of Pt #3's I & O for the shift ending at 6:59 AM on 1/13/15.

3. The Nurse Clinician for 8 west stated during an interview on 1/13/15 at approximately 12:45 PM, that the patients' intake and outputs were not documented as ordered.

Based on record review and interview it was determined in 1 of 4 (Pt#1) clinical records reviewed for medication administration, the Hospital failed to ensure the nurse administered medication as indicated in the physician's orders.

Findings include:

1. The clinical record for Pt. #1 was reviewed on 1/13/15. Pt#1 was a 57 year old female admitted on 10/1/14 with a diagnosis of acute stroke. On 10/3/14 at 5:24 PM a physician documented "MRI head could not be done due to claustrophobia."

Pt#1's clinical record contained a physician's order dated 10/3/14 at 9:00 PM for Lorazepam 2 milligrams (mg) (anti-anxiety medication) to be administered intravenously "before being taken down for MRI (Magnetic Resonance Imaging) at 10:00 PM." Pt #1 went for an MRI on 10/3/14 at 10:00 PM, however, the clinical record lacked documentation of Lorazepam being administered as ordered, before the procedure.

2. On 1/14/15 at 1:00PM the Attending Physician (MD#1) stated it is unclear if Lorazepam was administered as ordered.