HospitalInspections.org

Based on observation and interview the facility failed to ensure staff provided all patients with a safe environment when a staff member left one patient's (#20) room with the patient's bed in the high position. A total of three patients were observed for care. The facility census was 78.
Findings included:
Observation on 3/03/10 at 9:50 AM showed Staff J preparing to scan the bladder of Patient #20 (a bladder scan is a non-invasive method for determining bladder emptying). Staff J placed the patient's bed in the high position and then said he/she needed to get a different battery for the bladder scanner. Staff J left the patient's room to obtain the battery. Staff J left the patient's bed in high position when he/she left the room.
Observation on 3/03/10 at 10:05 AM showed Staff J pull the curtains around the bed of Patient #20 and then place the bed in high position. Staff J left the patient's bedside and went to the sink in the patient's room to fill a bath basin with water. Staff J left Patient #20's bed in the high position.
During an interview on 3/03/10 at 10:20 AM Staff J said he/she leaves the beds in the high position if he/she is still in the room with the patient and just going to the patient's sink to get water.
During an interview on 3/03/10 at 10:30 AM Staff J said he/she should put the bed in the low position if he/she is leaving the patient's bedside because the patient could fall out of bed and be injured.

Based on record review and interview, the facility failed to identify and/or update the nursing plan of care for each patient to include pertinent, individualized problems and/or interventions for two patients (#9 and #15) of 33 records reviewed. The facility census was 78.

Findings included:

1. Record review of current Patient #9's, medical record reveals the patient's lab value shows a hemoglobin (a protein in the blood that carries oxygen from the lungs to the body tissues) value of 6.7 (normal value is 13.8 - 17.2). Patient #9 received 2 units of blood on 2/24/10.

Record review of Patient #9's plan of care showed no care plan for low blood value related to patient #9's hemoglobin.

During an interview on 3/3/10 at 10:45 AM Staff C, registered nurse (RN), Risk manager confirmed lack of care plan for the Patient #9's low hemoglobin and blood administration. Staff C said would expect to find a care plan in the cardiovascular plan of care.





19957

2. Review of the lab values for discharged Patient #15 showed the patient's hemoglobin level was 8.3 (normal value is 13.8 - 17.2). Patient #15 received 2 units of blood on 2/18/10.

Record review of Patient #15's plan of care showed no care plan for low blood value related to his/her hemoglobin. Further review of the care plan showed no care plan for blood administration.

During an interview on 3/03/10 at 9:35 AM Staff B, the chief nursing officer said he/she would expect staff to develop a care plan for patients who are given a blood transfusion related to a low hemoglobin level.

Based on medication pass observation, facility policy review, record review and interview, the facility failed to ensure medications were administered as ordered by the physician for one current Patient #16 of eight patients observed during medication administration and failed to follow physician orders for one discharged patient (#1) of three closed record reviewed for medication administration. The facility census was 78.

Findings included:

1. Review of facility policy titled, Medication Administration, with a reviewed date of 12/08, showed the following (in part):

All medications transcribed to the medication administration record (MAR) are confirmed by a licensed nurse.

Procedures:
Nursing will review and correct each MAR prior to use. The MAR will be used to document medication administration.

If there is inconsistency between current MAR and new one, the pharmacy will be sent a copy of the MAR with changes with a copy of the order.

As PRN [as needed] medications are given on an as needed basis and not on a prescheduled basis, the nurse must include the actual time of administration of the PRN medication in the block. The effectiveness of the PRN will be recorded in the patient ' s clinical record on medication flow sheet for pain medication or nurse ' s notes for other PRN medications.

2. Observation of Licensed Practical Nurse (LPN), staff G, on 3/3/10 showed the following medication administered to current Patient #16 at 08:35 AM:
Urecholine (strengthen bladder contraction and prevent urine retention) 10 milligram (mg) times 3 (total of 30 mg)

3. Review of Patient #16's physician order sheet showed:
3/2/10 at 1:00 p.m.:
Change Urecholine to 25 mg PO (by mouth) BID (two times a day) X (times) 2 days
Then Urecholine 10 mg PO BID X 2 days then discontinue.

Review of Patient #16's MAR for 3/2/10 reveals Patient #16 received Urecholine 30 mg at 4 p.m. and 9 p.m., Patient #16 received Urecholine 30 mg at 9 a.m. on 3/3/10. Patient received 40 mg more of Urecholine than the physician ordered.

4. During an interview on 3/3/10 at 9:15 a.m., Staff G confirmed the medication error.




19957

5. Review of discharged Patient #1's physician's orders included the following orders:
8/07/09 Oxycontin 80 mg po (by mouth) BID (twice a day) for pain
Oxycodone 15 mg po q4h (every four hours) prn (as needed) for pain
8/10/09 increase Oxycodone to 20 mg po q4h

Review of the MAR dated 8/08/10 showed Patient #1 received Oxycodone 15 mg by mouth at 6:30 AM and again at 8:20 AM. The nurse administered the second dose of Oxycodone in less than two hours; the physician's order is every four hours.

Review of the MAR dated 8/09/09 showed Patient #1 received Oxycodone 15 mg at 2:45 PM and again at 6:00 PM. The nurse administered the second dose of Oxycodone within three hours and 15 minutes.

Review of the MAR dated 8/10/09 showed Patient #1 received Oxycodone 20 mg at 1:10 PM and again at 4:30 PM. The nurse administered the second dose of Oxycodone within three hours and 20 minutes.

Review of the MAR dated 8/11/09 showed registered nurse (RN) T administered Oxycontin 80 mg and Oxycodone 20 mg to Patient #1 at 9:00 AM.

6. During a telephone interview on 3/03/10 at 1:40 PM, Physician Staff U said it is not normal for the nursing staff to give a patient a prn pain medication at the same time as the routine pain medication. Physician U said, "That is strange that nurse gave the prn at the same time he/she gave the routine Oxycontin." Physician U said that staff usually give the routine medication and wait an hour to asses if the patient needs any additional pain medication.

Physician U said that he/she was not aware staff gave any of the prn pain medication to Patient #1 more frequently than every four hours as ordered.

During an interview on 3/04/10 at 1:20 PM RN Staff T said that he/she gave Patient #1 the prn pain medication, Oxycodone 20 mg along with the routine pain medication of Oxycontin 80 mg at 9:00 AM on 8/11/10. Staff T said, "It's normal to give the prn medication along with the long acting med, it's not out of the norm."

Based on policy review, observation and interview the facility failed to ensure staff provided proper urinary catheter (a sterile tube inserted through the urethra into the bladder to drain urine into a drainage bag) technique for one patient (#16) of two patients observed for urinary catheter insertion. The facility census was 78.

Findings included:

Review of Perry & Potter 4th Edition Catheter Care (the facility's policy) reveals in part for unexpected outcomes:
3. Catheter goes into vagina
a. Leave catheter in vagina
b. Recleanse urinary meatus. Using another catheter kit or another sterile catheter, insert catheter into meatus
c. Remove catheter in vagina after successful insertion of second catheter in bladder.
4. Sterility is broken during catheterization by nurse or client.
a. Replace gloves if contaminated and start over.
b. If client touches sterile field but equipment remains sterile, avoid touching that part of sterile field.
c. If equipment is contaminated, replace it with sterile items or start over again with new kit.

Observation of Staff I performing urinary catheter care for Patient #16 on 3/03/10 at 8:10 AM showed Staff I cleanse the urinary meatus and attempt to insert the urinary catheter. Staff I inserted the catheter into the vagina. Staff I left the catheter in the vagina. Staff I then left Patient #16's bedside with the sterile drape in place. Staff I returned to Patient #16's bedside with a second catheter and proceeded to insert the urinary catheter into the urinary meatus without recleansing the urinary meatus and without asking the patient if he/she had touched the sterile field.

During interview on 3/03/10 at 9:00 AM Staff I said he/she should have cleaned Patient
#16's urinary meatus before inserting the second catheter. Staff I said he/she should have asked Patient #16 if the patient had touched the sterile field.