HospitalInspections.org

Based on document review and interview, the Registered Nurse failed to supervise and evaluate the care being provided to patients for 2 of 7 MR (medical records) reviewed (patients #1 & 4).

Findings include:

1. Review of the policy/procedure titled Fall Prevention Protocol (revised 12-17) indicated the following: "All patients admitted to [the facility] will be placed on fall prevention protocol...
Low Risk Fall Interventions...
b) Non-skid socks on when out of bed...
High Risk Fall Interventions / Identifiers:
All low risk interventions plus one or more of the following:
a) Yellow wrist band on patient
b) Patient placed in foam chair when needed
c) Chair alarm on the chair, wheelchair or recliner and clipped to the patient clothing..."

2. Review of the policy/procedure Content of the Medical Record (reviewed 7-17) indicated the following: "The medical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, and document the course and results accurately... The results of all reassessments are documented in the medical record along with actions and outcomes resulting from the reassessment, including revisions of the treatment plan..."

3. Review of the policy/procedure Assessment - Falls (revised 1-17) indicated the following: "Nursing Responsibility Post Fall... 6. Update plan of care with additional precautions."

4. Review of the MR for Patient #1 indicated the patient was admitted on 11-20-17 with orders for low fall risk precautions and indicated an initial Edmunson fall risk score of 77 (low risk).

5. The MR for Patient #1 on 11-23-17 indicated a fall risk score of 93 (high risk) and lacked documentation from 0700 to 1900 hours indicating fall prevention precautions including a yellow wrist band and chair alarm were implemented in response.

6. The Patient Care Observation Record for Patient #1 lacked documentation on 11-24-17 from 0700 to 1900 hours of fall prevention precautions including a yellow wrist band and use of a chair alarm.

7. The MR for Patient #1 indicated the patient experienced a fall on 11-26-17 at 1300 hours.

8. The Patient Care Observation Record for Patient #1 on 11-27-17 lacked documentation of fall prevention precautions including a yellow wrist band and use of a chair alarm.

9. The Patient Care Observation Record for Patient #1 lacked documentation on 12-3-17 from 0700 to 1900 hours of fall prevention precautions including a yellow wrist band and use of a chair alarm.

10. On 1-19-18 at 1230 hours, the Chief Clinical Officer, staff A4 confirmed the MR findings indicated above.

11. Review of the MR for Patient #4 indicated the patient was admitted on 1-2-18 with orders for low fall risk precautions and indicated an initial Edmunson fall risk score of 99 (high risk).

12. The MR for Patient #4 indicated the patient experienced a fall on 1-7-18 at 2230 hours.

13. The Patient Care Observation Record for Patient #4 lacked documentation on 1-9-18 and 1-10-18 from 0700 to 1900 hours of fall prevention precautions including a yellow wrist band and use of a chair alarm.

14. On 1-19-18 at 1620 hours, the Chief Clinical Officer, staff A4 confirmed the MR findings indicated above.

Based upon document review and interview, the facility failed to ensure medications were prepared and administered in accordance with written orders of the responsible practitioner and acceptable standards of practice for 3 of 7 medical records (MR) reviewed (Patients #1, 2 & 6).

Findings include:

1. The policy/procedure General Medication Administration (revised 7-17) indicated the following: "The Medication Administration Record (MAR) will be compared with the medication order prior to administration of any medication at least once every shift ...Prior to the administration of any high alert medications (i.e., anticoagulant or insulin) dose, two (2) licensed nurses will check the amount ordered and the amount prepared."

2. Review of the MR for Patient #1 indicated the following orders:
a) 11-21-17
Daily PT/INR
(Prothrombin time/International Normalized Ratio)
Hold Coumadin [for] INR > 3
b) 12-1-17
Increase Coumadin to 3.5 mg (milligrams) daily
Continue PT/INR M-W-F
(Monday, Wednesday, Friday
Hold Coumadin if INR > 3
c) 12-4-17 Decrease Coumadin to 3 mg po QHS
(by mouth at bedtime)

3. Review of the Coumadin Tracking - PT/INR - Interventions record for Patient #1 indicated the following entries:
a) 12-1-17 @ 0600 hrs ... INR = 1.5 ... Current Dose 3 mg Daily ... Staff N14 ... Intervention and next PT/INR Coumadin 3.5 mg daily. Continue PT/INR M-W-F Hold if INR > 3.
b) 12-4-17 @ 0600 hrs ... INR = 3.7 ... Current Dose 3.5 mg Daily ... Staff N14 ... Intervention and next PT/INR ... [no documentation to follow]
and no documentation indicated the daily Coumadin order and dose obtained for administration was checked and confirmed by two nursing staff from the first entry on 11-22-17 to the end of the hospital stay, or indicated 3 mg of Coumadin was administered or held on 12-4-17 or 12-5-17 in accordance with the standing Hold Order by the responsible nurse.

4. Review of the MAR for Patient #1 lacked documentation on 12-4-17 indicating 3 mg of Coumadin was administered or held for INR > 3 by the responsible nurse N10.

5. Review of the MAR for Patient #1 indicated 3 mg of Coumadin was administered on 12-5-17 at 1700 hours by the responsible nurse N19.

6. Review of administrative documentation regarding medication dispensing for Patient #1 confirmed that Coumadin was dispensed on 12-4-17 at 1656 hours to Registered Nurse N10 and on 12-5-17 at 1804 hours to Licensed Practical Nurse N19.

7. On 1-19-18 at 1230 hours, the Chief Clinical Officer, staff A4 confirmed the documentation indicated the Registered Nurse, staff N10 withdrew Coumadin for administration to Patient #1 on 12-4-17 and the Licensed Practical Nurse, staff N19 withdrew Coumadin for administration to Patient #1 on 12-5-17 in disregard for the standing order to hold Coumadin for INR > 3.

8. Review of the Coumadin Tracking - PT/INR - Interventions record for Patient #2 indicated the following entries:
a) 12-4-17 @ 0600 hrs ... INR = 2.3 ... Current Dose 4 mg T TR SAT + SUN (4 mg on Tuesday, Thursday, Saturday + Sunday) (and) 6 mg M,W,F (6 mg on Monday, Wednesday + Friday) ... Staff N9 ... Intervention and next PT/INR ... Continue current dose.
b) [no date entered] @ [no time entered] ... INR = 2.4 ... Current Dose [no dose entered] ... [no Staff entered] ... Intervention and next PT/INR ... [no documentation entry to follow]
c) 12-6-17 @ 1530 hrs ... INR = 2.2 ... [no dose entered] ... Staff N8 ... No new orders ...
and no documentation indicated the daily Coumadin order and dose obtained for administration was checked and confirmed by two nursing staff from the first entry on 12-04-17 to final entry on 12-8-17, or indicated 4 mg of Coumadin was administered on 12-5-17 by the responsible nurse.

9. Review of the MAR for Patient #2 lacked documentation indicating 4 mg of Coumadin was administered on 12-5-17 at 1700 hours by the responsible nurse N19.

10. Review of administrative documentation regarding medication dispensing for Patient #2 confirmed that no Coumadin was dispensed on 12-5-17 to the Licensed Practical Nurse N19 or other staff nurse.

11. On 1-19-18 at 1500 hours, the Chief Clinical Officer, staff A4 confirmed the MR lacked documentation on 12-5-17 indicating 4 mg of Coumadin was administered as ordered to patient #2.

12. Review of the policy/procedure Content of the Medical Record (reviewed 7-17) indicated the following: "Each Medical Record contains at least the following: ...20. Every dose of medication administered, including the strength, dose, and route ... 21. Any access site ... "

13. Review of the MR for Patient #1 lacked documentation of the sites of administration for IM (intramuscular) medications administered on 11-21-17 at 2245 hours, 11-23-17 at 2345 hours, 11-25-17 at 2100 hours, 11-28-17 at 2100 hours, and 12-3-17 at 1900 hours.

14. On 1-19-18 at 1425 hours, the Chief Clinical Officer, staff A4 confirmed the MR for Patient #1 lacked the documentation indicated above.

15. Review of the MR for Patient #6 lacked documentation of the site of administration for IM medication administered on 1-1-18 at 0115 hours.

16. On 1-19-18 at 1815 hours, the Administrator, staff A2 confirmed the MR for Patient #6 lacked the documentation indicated above.