HospitalInspections.org

Based on medical record review, staff interview, and policy review, the facility failed to ensure bedfast patients were turned and repositioned every two hours. This affected three (Patients #1, #3, and #6) of ten patients reviewed. The facility census was 22.

Findings include:

1. Review of the medical record for Patient #1 revealed a diagnosis of quadriplegia and orders to turn and reposition the patient every two hours. The medical record contained documentation of repositioning every two hours with all positions listed as semi-fowlers on 02/19/25 from 12:00 AM through 8:00 AM, on 02/19/25 from 8:00 PM through 8:00 AM on 02/20/25, on 02/20/25 from 8:00 PM through 8:00 AM on 02/21/25, on 02/21/25 from 8:00 PM through 10:00 AM on 02/22/25, on 02/22/25 from 8:00 PM through 7:30 AM on 02/23/25, on 02/24/24 from 7:00 PM through 3:00 AM on 02/25/25, and on 03/03/24 from 2:00 PM through 7:46 AM on 03/04/25.

The medical record contained documentation of repositioning every two hours with all positions listed as right side on 03/02/25 from 4:00 PM through 8:00 PM. No repositioning was documented on 02/20/25 from 12:14 PM through 5:19 PM, on 02/22/25 from 2:00 PM from 7:00 PM, on 02/25/25 from 3:00 AM through 5:57 AM, and on 02/28/25 from 6:00 AM through 10:00 AM.

During an interview on 05/21/25 at 3:30 PM, Staff A and B verified the above information.

2. Review of the medical record for Patient #3 revealed immobility and orders for turning and repositioning every two hours. The medical record contained documentation of repositioning every two hours listed as right side from 5:38 AM through 10:00 AM.

During an interview on 05/22/25 at 1:15 PM, Staff A and B verified the above information.

3. Review of the medical record for Patient #6 revealed immobility and orders for turning and repositioning every two hours. The medical record contained lacked documentation of repositioning on 04/19/25 from 2:00 AM through 6:00 AM and from 1:00 PM through 8:00 PM. The medical record contained documentation of repositioning every two hours with all positions listed as semi-fowlers on 04/19/25 from 8:00 PM through 7:00 AM on 04/20/25.

During an interview on 05/22/25 at 1:50 PM, Staff A and B verified the above information.

Review of "Guidelines and Protocols, Clinical Policy", revised 01/01/25, stated bedfast patients are to be turned every two hours.

Based on medical record review and staff interview, the facility failed to ensure all medication and vital signs documentation were completed. This affected six (Patients #1, #2, #3, #5, #6, and #10) of ten patients reviewed. The facility census was 22.

Findings include:

1. Review of the medical record for Patient #1 revealed orders for continuous telemetry. Patient #1 had orders for Apresoline every eight hours with instructions to hold if systolic blood pressure is less than 110. Patient # 1 had orders for Isordil three times a day with orders to hold if systolic blood pressure is less than 90. Patient #1 had orders for Midodrine three times a day with orders to hold if systolic blood pressure is over 120. Patient #1 had orders for Lasix twice a day with instructions to hold if systolic blood pressure is under 95. Patient #1 had orders for Lopressor twice a day with orders to hold if heart rate is less than 65 or systolic blood pressure is less than 100. There were instances in which the medication was held due to not meeting parameters. Blood pressures and heart rates were not documented on the Medication Administration Record and blood pressures were not always documented on the Vital Signs Sheet for the times the medication was given.

During an interview on 05/21/25 at 3:30 PM, Staff A and B verified the above information.

2. Review of the medical record for Patient #2 revealed orders for continuous telemetry. Patient #2 had orders for Midodrine three times a day with instructions to hold if systolic blood pressure is over 100. There were 25 instances in which the medication was held due to not meeting parameters. Blood pressures were not documented on the Medication Administration Record and blood pressures were not always documented on the Vital Signs Sheet for the times the medication was given.

During an interview on 05/22/25 at 1:10 PM, Staff A and B verified the above information.

3. Review of the medical record for Patient #3 revealed orders for continuous telemetry. Patient #3 had orders for Midodrine three times a day with instructions to hold for systolic blood pressure greater than 120. There were instances in which the medication was held due to not meeting parameters. Blood pressures were not documented on the Medication Administration Record and blood pressures were not always documented on the Vital Signs Sheet for the times the medication was given.

During an interview on 05/22/25 at 1:15 PM, Staff A and B verified the above information.

4. Review of the medical record for Patient #5 revealed orders for continuous telemetry. Patient #5 had orders for Lopressor twice a day with orders to hold if heart rate is less than 60 or systolic blood pressure is less than 110. There were instances in which the medication was held due to not meeting parameters. Blood pressures and heart rate were not documented on the Medication Administration Record and blood pressures were not always documented on the Vital Signs Sheet for the times the medication was given.

During an interview on 05/22/25 at 1:40 PM, Staff A and B verified the above information

5. Review of the medical record for Patient #6 revealed orders for continuous telemetry. Patient #6 had orders for Norvasc daily with instructions to hold if systolic blood pressure is less than 100. Blood pressures were not documented on the Medication Administration Record and blood pressures were not always documented on the Vital Signs Sheet for the times the medication was given.

During an interview on 05/22/25 at 1:50 PM, Staff A and B verified the above information.

6. Review of the medical record for Patient #10 revealed orders for continuous telemetry. Patient #10 had orders for Coreg twice a day with instructions to hold if heart rate is less than 50 or systolic blood pressure is less than 100. Patient #10 had orders for Apresoline every eight hours with instructions to hold if systolic blood pressure is less than 100. Patient #10 had orders for Entresto twice a day with instructions to hold if systolic blood pressure is less than 100. There were instances in which the medication was held due to not meeting parameters. Blood pressures or heart rate were not documented on the Medication Administration Record and blood pressures were not always documented on the Vital Signs Sheet for the times the medication was given.

During an interview on 05/22/25 at 3:00 PM, Staff A and B verified the above information.

During an interview on 05/21/25 at 3:30 PM, Staff A and B stated the nurses would verify the vital signs on the telemetry monitor prior to administering medications. The telemetry readings do not transfer into the electronic medical record. The Medication Administration Record (MAR) does not require the nurse to enter the vital signs in the MAR. They verified that there were not vital signs documented in the electronic medical record for all of the medication administration times because of this. They did state that there were medications that were held due to not meeting parameters.