HospitalInspections.org

Based on record review, review of hospital regulations and interviews the hospital failed to meet the requirement because the hospital did not ensure that nurses administered Hydralazine prn (as needed) that was ordered by the nurse practitioner for Patient #1 identified during a complaint investigation for Patient #1.

Findings Include:

1. Medical Record Review:

The medical record for Patient #1 was reviewed in part on 02/25/20 beginning at 11:00 a.m. in a conference room. It revealed that on 06/29/19 an 85 year-old female with a history of chronic atrial fibrillation was admitted from the emergency department status post fall with a left hip fracture and left radial fracture to the telemetry unit to be monitored for rvr (rapid ventricular response). Her blood pressure at 13:08 at triage was 183/119. At 14:26 her blood pressure was 154/98.

An order was given by nurse practitioner #1 on 06/29/19 at 14:58 for Hydralazine 10 mg IV push q6hr PRN for blood pressure, sbp>150.

Vital signs records included the following blood pressures in which the patient had a systolic blood pressure greater than 150.

1. 06/29/19 at 16:32 BP 172/92
2. 06/30/19 at 00:00 BP 153/80
3. 07/01/19 at 00:00 BP 161/85
4. 07/02/19 at 00:00 BP 151/85
5. 07/02/19 at 04:00 BP 168/107
6. 07/03/19 at 16:44 BP 164/104
7. 07/03/19 at 20:00 BP 155/15
8. 07/04/19 at 05:33 BP 161/100
9. 07/04/19 at 14:00 BP 162/97
10. 07/04/19 at 18:00 BP 154/101
11. 07/04/19 at 20:18 BP 164/111

The Medication Administered Report indicated Hydralazine 10 mg IV push q6hr PRN for blood pressure, sbp>150 was given only once as ordered for a systolic blood pressure >150. It was given on 07/04/19 at 20:18 for a blood pressure of 164/111. There was no documentation to indicate that nurse practitioner #1 who ordered the Hydralazine or any other practitioner was contacted about the systolic blood pressures >150.

The Occupational Assessment Comment dated 07/04/19 at 12:23 stated in part, "Pt's activity tolerance limited today 2/2 BP inc with activity 157/102 and HR 98 while sitting on EOB. Pt returned to bed 2/2 BP and being symptomatic (e.g., diaphoretic, nausea). Pt's BP in supine increased to 164/110 with HR at 122. RN immediately notified."

2. The hospital "Medical Staff Rules and Regulations" with a last revised date of February 2020 was reviewed on 03/23/20 and stated the following in part:

Section 8.05 Allied Health Professional
4.0 Orders
Section 4.06 Drug Standards

Section 4.07 Dosage Time
Medications shall be given at designated administration times according to System policy or in accord with a practitioner's specific order ...

Section 4.08 Medication Orders
...All PRN (as needed) orders require an indication.

3. Interviews:

a. During a telephone interview of Nurse Practitioner #1 (NP#1) on 08/20/20 at 11:00 a.m., NP#1 confirmed her order in the medical record for Hydralazine 10 mg IV push q6hr PRN for blood pressure, sbp>150.

The vital signs records that included the following blood pressures in which the patient had a systolic blood pressure greater than 150 and Hydralazine was not given were reviewed with NP#1:

1. 06/29/19 at 16:32 BP 172/92
2. 06/30/19 at 00:00 BP 153/80
3. 07/01/19 at 00:00 BP 161/85
4. 07/02/19 at 00:00 BP 151/85
5. 07/02/19 at 04:00 BP 168/107
6. 07/03/19 at 16:44 BP 164/104
7. 07/03/19 at 20:00 BP 155/15
8. 07/04/19 at 05:33 BP 161/100
9. 07/04/19 at 14:00 BP 162/97
10. 07/04/19 at 18:00 BP 154/101

NP#1 confirmed that if the nurse was not going to give the Hydralazine for a sbp of >150, she would have expected the nurse to contact her, to page her to discuss any concerns or reasons as to why the nurse was not going to give it. NP#1 confirmed that no nurse ever contacted her to inform her that he/she would not be giving the Hydralazine as ordered.

b. During a telephone interview on 09/01/20 at 8:56 a.m., Staff #1 confirmed the following after her review of portions of the medical record including an order for Hydralazine, vital signs records and a medication administration record summary:

The medical record contained an order dated 06/29/19 at 14:58 by nurse practitioner #1 for Hydralazine 10 mg IV push q6hr PRN for blood pressure, sbp>150.

The vital signs records included the following blood pressures in which the patient had a systolic blood pressure greater than 150 and Hydralazine was not given:

1. 06/29/19 at 16:32 BP 172/92
2. 06/30/19 at 00:00 BP 153/80
3. 07/01/19 at 00:00 BP 161/85
4. 07/02/19 at 00:00 BP 151/85
5. 07/02/19 at 04:00 BP 168/107
6. 07/03/19 at 16:44 BP 164/104
7. 07/03/19 at 20:00 BP 155/15
8. 07/04/19 at 05:33 BP 161/100
9. 07/04/19 at 14:00 BP 162/97
10. 07/04/19 at 18:00 BP 154/101

The medication administration record summary indicated Hydralazine 10 mg IV push q6hr PRN for blood pressure, sbp>150 was given only once and that was on 07/04/19 at 20:18 for a BP of 164/111. The next documented blood pressure which was 139/97 was taken on 07/05/19 at 01:16 or about 5 hours after the Hydralazine was given.

c. During a telephone interview on 09/02/20 at 11:00 a.m., Staff #1 reviewed the Occupational Assessment Comment dated 07/04/19 at 12:23 that stated in part, "Pt's activity tolerance limited today 2/2 BP inc with activity 157/102 and HR 98 while sitting on EOB. Pt returned to bed 2/2 BP and being symptomatic (e.g., diaphoretic, nausea). Pt's BP in supine increased to 164/110 with HR at 122. RN immediately notified." Staff #1 confirmed she could not find any documentation under nursing notes text and could not provide documentation that a nurse assessed the patient or gave Hydralazine 10 mg IV push q6hr PRN for blood pressure, sbp>150 as ordered for the blood pressures documented in the Occupational Assessment Comment.