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Based on record review and staff interview, the Hospital failed to follow their policy and procedure for initiating a Do Not Resuscitate (DNR) Order as evidenced by:
1) The RN implementing a DNR status without a physician's order for DNR for 1 of 1 (#2) sampled patients reviewed for DNR out of a total sample of 5 (#1-#5), and;
2) The physician failing to document in the progress notes the DNR discussion with the family, Power of Attorney and/or patient before DNR status was implemented for 1 of 1 (#2) of sampled patients reviewed for DNR status out of a total of 5 (#1-#5) sampled medical records.

Findings:

Review of the hospital policy titled, Code Status, policy number CL14 revealed in part the following: Patient are provided resuscitation services unless precluded by a legal advance directive and physician's order....It is the responsibility of the physician to ensure that any patient's written advance directive is considered prior to the Code Status being entered as the physician's order and that the physician considers the patient and/or decision maker wishes.


1) The RN implementing a DNR status without a physician's order:

Patient #2
Review of the medical record for Patient #2 on 02/13/17 at 2:30 p.m. revealed the patient was an 81 year old admitted to the hospital on 02/09/17 at 4:30 p.m. The patient's diagnoses included Chest Pain, Coronary Artery Disease, Coronary Artery Bypass, Biliary Disease with Laparoscopic Cholecystectomy, and Encephalopathy. Review of the initial nursing assessment dated 02/09/17 revealed the patient was a Full Code. Review of the outside binder of the patient's medical record revealed the patient's record contained stickers indicating the patient was a "DNR" status. Further review of the patient's record revealed the Resuscitation Declaration form indicating the patient was a DNR was signed by the patient's wife on 02/10/17 at 5:30 p.m. and the signature was witnessed by S3DON and S11RN. Review of the Resuscitation Orders form on 02/13/17 at 4:00 p.m. revealed no documented evidence that the patient's physician had signed the DNR order. Review of the Resuscitation Order form revealed the following: Do Not Resuscitate: No Code Blue (documentation and confirmation of communication with patient and/or family/responsible party must be written in the physician's progress notes).

In an interview on 02/14/17 at 10:20 a.m., S11RN confirmed she was assigned to Patient #2 when the patient was admitted. S11RN stated the patient was alert and oriented X2 on arrival but within the hour became combative and agitated. She stated she did not address the resuscitation status with the patient after he became confused. She stated the next day the patient's wife came in and signed the Resuscitation Declaration (2/10/17). S11RN stated the Resuscitation Declaration "Carries them for 24 hours until the physician comes in and signs the DNR." S11RN stated the chart would be flagged as a DNR once they obtained a signature on the Resuscitation Declaration form and knew the patient/family wishes. S11RN confirmed the DNR status was implemented on 02/10/17 and the DNR order was not signed by the physician until 02/13/17 at 7:00 p.m.


2) The physician failing to document in the progress notes the DNR discussion with the family, Power of Attorney and/or patient before DNR status was implemented:

Patient #2
Review of the medical record for Patient #2 on 02/13/17 at 2:30 p.m. revealed the patient was an 81 year old admitted to the hospital on 02/09/17 at 4:30 p.m. The patient's diagnoses included Chest Pain, Coronary Artery Disease, Coronary Artery Bypass, Biliary Disease with Laparoscopic Cholecystectomy, and Encephalopathy. Review of the initial nursing assessment dated 02/09/17 revealed the patient was a Full Code. Review of the outside binder of the patient's medical record revealed the patient's record contained stickers indicating the patient was a "DNR" status. Further review of the patient's record revealed the Resuscitation Declaration form indicating the patient was a DNR was signed by the patient's wife on 02/10/17 at 5:30 p.m. and the signature was witnessed by S3DON and S11RN. Review of the Resuscitation Orders form on 02/13/17 at 4:00 p.m. revealed no documented evidence that the patient's physician had signed the DNR order. Review of the Resuscitation Order form revealed the following: Do Not Resuscitate: No Code Blue (documentation and confirmation of communication with patient and/or family/responsible party must be written in the physician's progress notes). Review of the physician progress notes dated 02/11/17, 02/12/17, and 02/13/17 revealed no documentation related to the patient's DNR status or discussion with the patient's family regarding the DNR status.

In an interview on 02/14/17 at 3:30 p.m. S3DON reviewed above record and confirmed the DNR status for the patient had been implemented on 02/10/17 prior to the physician signing the order for the DNR. He confirmed the physician had signed the DNR order on 02/13/17 at 7:00 p.m. but had not documented confirmation of communication with the patient and/or family/responsible party of the DNR status. S2DQM also present for the interview confirmed the physician was required to document confirmation the DNR status had been discussed with the patient/family in the physician progress notes.

Based on record review and staff interview, the Hospital failed to ensure the use of restraints was in accordance with a written modification to the patient's plan of care for 1 of 1 (#2) sampled patients reviewed for the use of restraints out of a total sample of 5 (#1-#5). Findings:

Review of the hospital policy titled Restraints, revealed in part the following:
D. Documentation:
1. Modify the plan of care to include:
a. The safety issue that resulted in the need for restraints.
b. Desired measurable outcome-oriented goals.
c. Interventions to minimize restraint use, including attempts to use alternatives to restraints and to end-use at the earliest possible time.
d. Patient/family-education regarding the need for the restraint, alternatives attempted and the plan for safe removal.

Patient #2

Review of the medical record for Patient #2 revealed the patient was an 81 year old admitted to the hospital on 02/09/17 at 4:30 p.m. The patient's diagnoses included Chest Pain, Coronary Artery Disease, Coronary Artery Bypass, Biliary Disease with Laparoscopic Cholecystectomy, and Encephalopathy.
Review of the Critical Care Flowsheet dated 02/09/17 at 6:53 p.m. revealed the following: Bilateral soft wrist restraints placed on patient due to continuously climbing out of bed after being redirected multiple times and pulling at IV lines/Foley Catheter/Telemetry leads. MD made aware. Further review of the record revealed the patient remained in bilateral wrist restraints until 5:00 a.m. on 02/11/17.
Review of the Interdisciplinary Plan of Care revealed no documented evidence that the use of restraints was added to the patient's plan of care until 02/13/17. Further review of the plan of care revealed no documented evidence that patient/family education regarding the need for the restraints and the plan for safe removal of the restraints was included in the plan of care. There was no documented evidence that the safety issue that resulted in the need for restraints was included in the patient's plan of care.

In an interview on 02/14/17 at 3:30 p.m. S3DON reviewed the medical record for Patient #2 and confirmed the patient's plan of care was not updated until 02/13/17, 4 days after restraints were used on the patient. S3DON confirmed there was no documented evidence the plan of care was updated to include patient/family education regarding the need for the restraints and the plan for safe removal of the restraints and the safety issue that resulted in the need for restraints.

Based on policy review, record review and interview, the hospital failed to ensure the use of restraint or seclusion was in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient for 1 of 1 (#2) sampled patients with restraints out of a total sample of 5 (#1-#5).
Findings:

Review of the hospital policy titled, Restraints provided by S2DQM as current policy revealed in part the following: Restraint use requires an order by a physician or licensed independent practitioner (LIP) responsible for the patient's care and authorized by hospital policy or State law to order restraint use. A physician or other LIP responsible for the care of the patient must order the restraint prior to the application of the restraint except if the need for the restraint occurs so quickly that an order cannot be obtained prior to application. In these situations, the RN may oversee the application of restraints but then must obtain the order during the emergency application or within a few minutes after....Telephone orders may only be used for the first episode of restraint based on nursing assessment.


Patient #2

Review of the medical record for Patient #2 revealed the patient was an 81 year old admitted to the hospital on 02/09/17 at 4:30 p.m. The patient's diagnoses included Chest Pain, Coronary Artery Disease, Coronary Artery Bypass, Biliary Disease with Laparoscopic Cholecystectomy, and Encephalopathy.
Review of the Critical Care Flowsheet dated 02/09/17 at 6:53 p.m. revealed the following: Bilateral soft wrist restraints placed on patient due to continuously climbing out of bed after being redirected multiple times and pulling at IV lines/Foley Catheter/Telemetry leads. MD made aware. Further review of the record revealed the patient remained in bilateral wrist restraints until 5:00 a.m. on 02/11/17.

Review of the Critical Care Flow sheet and the Restraint Management Flowsheets revealed the bilateral wrist restraints were discontinued on 02/11/17 at 5:00 a.m. and restarted on 02/13/17 at 5:00 a.m.

Review of the Restraint Order form dated 02/10/17 at 6:53 p.m. revealed bilateral soft limb restraints were ordered to prevent disruption of life sustaining interventions. Review of the order revealed S19Physician signed the Restraint Order on 02/10/17 at 7:00 p.m. There was no documented evidence of a physician's order for restraints dated 02/09/17 at 6:53 p.m. when the restraints were initially applied. There was no documented evidence of a physician's order to discontinue the restraints on 02/11/17 at 5:00 a.m. There was no documented evidence of an order to place the patient back in restraints on 02/13/17 at 5:00 a.m.

In an interview on 02/14/17 at 10:20 a.m., S11RN confirmed wrist restraints were in use for Patient #2. When asked how they obtain orders for restraints, she stated the nurse calls the physician and they get verbal ok, then the physician signs when they come in. S11RN stated she was working on 02/09/17 when the restraints were first implemented for the patient and stated she called S19Physician and got a verbal order. When asked where the verbal order was documented, she reviewed the record and stated the nurse wrote the wrong date on the 02/10/17 order at 6:53 p.m. and stated this order should have been dated 02/09/17. S11RN confirmed there was no other order for restraints dated 02/10/17 or 02/09/17. S11RN stated the nurse fills out the restraint order form and signs/dates/times when the top of the order is filled out. S11RN confirmed there was no verbal order written for initiation of restraints. After reviewing the orders and nurse notes, she confirmed there was no documented evidence that restraints were used on 02/11/17 and 02/12/17. S11RN confirmed the restraints were initiated again on 02/13/17 at 5:00 p.m. and there was no verbal order to apply restraints at that time. S11RN stated there should have been an order to discontinue the restraints and stated the physician had reordered the restraints every day.

In an interview on 02/14/17 at 3:30 p.m., S3DON reviewed the medical record for Patient #2 and confirmed there was no physician's order for the restraints applied on 02/09/17, and there was no order to discontinue the restraints on 02/11/17 at 5:00 a.m. S3DON confirmed the restraints were discontinued for 2 days and reapplied on 02/13/17 at 5:00 a.m., but there was no physician's order to apply restraints on 02/13/17 at 5:00 a.m. S3DON confirmed verbal orders for restraints could only be used one time.

Based on record review and staff interview, the Hospital failed to ensure staff were trained and demonstrated competency in the application of restraints and providing care for patients in restraints as evidenced by 1 (S10RN) of 5 (S8LPN/WC, S10RN, S12LPN, S17RN, S18RN) sampled nursing personnel records with no documented evidence of restraint training or competency evaluation. Findings:

Review of the hospital policy titled, Restraints, revealed in part the following: All staff will be educated, trained and will demonstrate knowledge about caring for a patient in restraints before caring for a patient in restraints, as part of orientation, and yearly. This will include a return demonstration of proper application and removal of restraints.

Review of the personnel records for S10RN revealed a date of hire of 09/07/16. Review of the documented nursing competency evaluations done during orientation revealed no documented evidence of a competency in the use of restraints. There was no documented evidence of any education or training in the use of restraints.

In an interview on 02/15/17 at 10:30 a.m., S6HR reviewed the personnel record for S10RN and confirmed there was no documentation of restraint competency or training. S6HR stated it would have been spoken about in new hire orientation but there was no documentation of that.

Based on record reviews, observations, and interviews, the Hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:

1) Failing to ensure each patient was assessed at least every 24 hours by the RN as required by the hospital's policy and the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs without documented evidence of an RN assessment at a minimum of every 24 hours for 2 (#1, #3) of 5 (#1-#5) sampled patient medical records;

2) Failing to weigh patients as ordered by the physician for 1 (#4) of 5 (#1-#5) sampled patients, and;

3) Failing to use restraints as ordered by the physician for 1 of 1 (#2) sampled patients with restraints.


Findings:

1) Failing to ensure each patient was assessed at least every 24 hours by the RN as required by the hospital's policy and the Louisiana State Board of Nurse's Practice Act:

A review of the hospital policy titled "Assessment/Reassessment Nursing" , as provided by S2DQM as the most current policy, revealed in part: Reassessments will be performed by the RN or the LPN within their scope of practice when assuming responsibility for the patient's care. An RN reassesses the patient every 24 hours at a minimum. The assessments are recorded in the patient medical record.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a 68 year old to the hospital on 01/17/17 with diagnoses of Bilateral Lower Extremity Ulcerations, History of Peripheral Vascular Disease, End-stage Renal Disease, and Gangrene to the tips of fingers bilaterally.

Review of the nurse's notes revealed no documentation of an RN assessment on 2/06/17, 2/08/17, and 02/09/17. The nurse's notes revealed nursing assessments were done only by LPNS on these dates.

In an interview on 02/14/17 at 2:55 p.m., S3DON reviewed the medical record for Patient #1 and confirmed there was no documented evidence of an RN assessment of the patient on 02/06/17, 2/08/17, and 02/09/17.

Patient #3
A review of the medical record for Patient #3 revealed the patient was a 71 year old female admitted to the hospital on 12/23/16 with a diagnoses of multiple non-healing wounds and other medical conditions to include: Chronic Myeloid Leukemia, Congestive Heart Failure, Chronic Atrial Fibrillation, Hypothyroidism, Diabetes Mellitus Type 2, Chronic Kidney Disease, Cirrhosis, Coronary Artery Disease, Coumadin Necrosis, Peripheral Vascular Disease, Chronic Anemia, Malnutrition and Diabetic Neuropathy,

A review of the nurse's notes on 01/16/17 revealed no documented evidence that an RN reassessed the patient within 24 hours as per hospital policy. The nurse's notes on 01/16/17 further revealed that all nursing assessments were done by LPNs.

In an interview on 02/14/17 at 2:25 p.m. with S3DON he reviewed the medical record for Patient #3 and indicated there was no documented evidence of an RN reassessment on the patient on 01/16/17. S3DON indicated that an RN should have reassessed the patient within 24 hours as per hospital policy.




2) Failing to weigh patients as ordered by the physician:

Patient #4
Review of the medical record for Patient #4 revealed the patient was a 66 year old admitted to the hospital on 02/01/17 with diagnoses of Suspected Endocarditis, Diastolic Congestive Heart Failure, Chronic Atrial Fibrillation, Chronic IV Drug Abuse, and Chronic Obstructive Pulmonary Disease.
Review of the physician's admission orders dated 02/01/17 revealed daily weights were ordered. Further review of the physician's orders revealed daily weights were ordered again on 02/03/17, daily morning weights were ordered on 02/07/17 and twice a day (morning and evening) weights were ordered on 02/08/17.

Review of the nursing daily flowsheets, medications administration records, and the vital signs and intake & output records revealed no documented evidence of the patient's weight on admission on 02/01/17 or 02/02/17. There was no documented evidence of any weights done on 02/05/17, 02/10/17, and 02/11/17.

In an interview on 02/14/17 at 1:50 p.m., S2DQM reviewed the medical record for Patient #4 and confirmed the physician orders for daily weights and BID weights. S2DQM confirmed there was no documented evidence that the patient was weighed on admission to the hospital or on 02/02/17, 02/05/17, 02/10/17, and 02/11/17. S2DQM confirmed there was no documented evidence the patient was weighed twice a day on 02/10/17 and 02/11/17 as ordered by the physician.



3) Failing to use restraints as ordered by the physician:

Patient #2
Review of the medical record for Patient #2 revealed the patient was an 81 year old admitted to the hospital on 02/09/17 at 4:30 p.m. The patient's diagnoses included Chest Pain, Coronary Artery Disease, Coronary Artery Bypass, Biliary Disease with Laparoscopic Cholecystectomy, and Encephalopathy.
Review of the Critical Care Flowsheet dated 02/09/17 at 6:53 p.m. revealed the following: Bilateral soft wrist restraints placed on patient due to continuously climbing out of bed after being redirected multiple times and pulling at IV lines/Foley Catheter/Telemetry leads. MD made aware. Further review of the record revealed the patient remained in bilateral wrist restraints until 5:00 a.m. on 02/11/17.
There was no documented evidence that the bilateral wrist restraints were used from 02/11/17 at 5:00 a.m. to 02/13/17 at 5:00 a.m.
Review of the physician orders dated 2/10/17 at 6:53 p.m. revealed orders for soft limb restraints to bilateral upper extremities to prevent disruption of life sustaining interventions. Further review of the physician's orders revealed the restraints were ordered daily on 02/11/17, 02/12/17 and 02/13/17.

Further review of the Critical Care Flowsheet dated 02/12/17 revealed the following:
10:15 p.m. - Patient with one leg out of bed, bed alarm alarming. All telemetry leads off as well as dressing to biliary drain removed. Replaced leads and dressing to drain, assisted patient to comfortable position. Encouraged to call if assistance needed, verbalized understanding.
11:30 p.m. - Noise heard from room. Patient sitting on floor on buttocks beside bed. Bed alarm set but not alarming, patient with no injuries noted, able to perform AROM to all extremities without c/o pain, assisted back to bed. Bed alarm on, tested and working properly. Blinds to room opened for closer observations.

In an interview on 02/14/17 at 10:20 a.m., S11RN confirmed she was the nurse assigned to Patient #4 and stated she had admitted the patient on 02/09/17. After reviewing the orders and the Critical Care Flowsheets, she confirmed there was no documented evidence that restraints were used on 02/11/17 and 02/12/17. S11RN confirmed the patient sustained a fall on 02/12/17 and restraints were not used but were ordered. S11RN stated there should have been an order to discontinue the restraints and stated the physician had reordered the restraints every day.

In an interview on 02/14/17 at 3:30 p.m., S2DQM stated she had reviewed the patient's medical record after she was made aware of the fall on 02/12/17 and confirmed the restraints had been ordered daily by the physician and the restraints were not being used as ordered when the patient was found on the floor on 02/12/17.









30172

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed and kept current a comprehensive nursing care plan for each patient that included all the patient's medical diagnoses for which the patients were being treated and not solely those needs relating to the admitting diagnosis for 2 (#3, #5) of 5 (#1-#5) sampled patient medical records reviewed for nursing care plans.

Findings:
A review of the hospital policy titled, " Plan of Care", as provided by S2DQM as the most current, revealed in part: The care plan will include the identified patient problems, the goals to work toward, and the interventions to be used. The plan of care will be reviewed and updated daily if needed by the RN.


Patient #3
A review of the medical record for Patient #3 revealed the patient was a 71 year old female admitted to the hospital on 12/23/16 with a diagnosis of multiple non-healing wounds and other medical conditions to include: Chronic Myeloid Leukemia, Congestive Heart Failure, Chronic Atrial Fibrillation, Hypothyroidism, Diabetes Mellitus Type 2, Chronic Kidney Disease, Cirrhosis, Coronary Artery Disease, Coumadin Necrosis, Peripheral Vascular Disease, Chronic Anemia, Malnutrition and Diabetic Neuropathy. A review of the patient's care plan revealed no documented care plan for the following patient's medical conditions; Chronic Myeloid Leukemia, Diabetes Mellitus Type 2 and Congestive Heart Failure. A review of the patient's MAR revealed the patient was on daily Gleevac for Chronic Myeloid Leukemia and was on an insulin sliding scale before meals and at night for Diabetes Mellitus Type 2 and the patient was on daily Bumex for fluid retention for Congestive Heart Failure.

In an interview on 02/14/17 at 10:00 a.m. with S3DON, the patient's medical record was reviewed. S3DON indicated that the patient should have been care planned for Chronic Myeloid Leukemia, Diabetes Mellitus Type 2 and Congestive Heart Failure.


Patient #5
A review of the medical record for Patient #5 revealed the patient was a 82 year old female admitted to the hospital on 01/05/17 with a diagnosis of Malignant Pleural Effusion - Breast Cancer Stage IV and other medical conditions to include: Severe Malnutrition, Hypertension, and Physical Deconditioning. A review of the patient's care plan revealed no documented care plan for Hypertension. A review of the patient's MAR revealed the patient was on Metoprolol twice a day with blood pressure monitoring before each dose.

In an interview on 02/14/17 at 10:00 a.m. with S3DON, the patient's medical record was reviewed. S3DON indicated that the patient should have been care planned for Hypertension.

Based on record review and interview, the hospital:
1) Failed to ensure drugs and biologicals were administered in accordance with acceptable standards of practice as evidenced by failing to assess and document the patient's pulse and blood pressure prior to administration of Metoprolol for 3 (#1, #2, #5) of 5 (#1-#5) sampled patients, and;

2) Failed to ensure drugs and biologicals were administered to the patient as ordered by the practitioner for 2 (#1, #2) of 5 (#1-#5) sampled patients.

Findings:
1) Failed to ensure drugs and biologicals were administered in accordance with acceptable standards of practice as evidenced by failing to assess and document the patient's pulse and blood pressure prior to administration of Metoprolol:

Patient #1
Review of the medical record for Patient #1 revealed the patient was a 68 year old admitted to the hospital on 01/17/17 with diagnoses of Bilateral Lower Extremity Ulcerations, History of Peripheral Vascular Disease, End-stage Renal Disease, and Gangrene to the tips of fingers bilaterally.

Review of the physician's orders dated 02/02/17 revealed Metoprolol Tartrate (Medication for high blood pressure) 12.5 mg by mouth twice a day was ordered.

Review of the MARs revealed the following:
02/09/17 - Metoprolol Tartrate 12.5 mg administered by the nurse at 9:00 a.m. with no documented evidence the patient's blood pressure or heart rate was assessed prior to administering the medication. The section on the MAR for documentation of the blood pressure and heart rate was left blank.
02/12/17 - Metoprolol Tartrate 12.5 mg administered by the nurse at 9: 00 p.m. with no documented evidence the patient's blood pressure or heart rate was assessed by the nurse prior to administering the medication. The section on the MAR for documentation of the blood pressure and heart rate was left blank.

In an interview on 02/14/17 at 2:55 p.m., S3DON reviewed the medical record for Patient #1 and confirmed the nurse had failed to assess the patient's blood pressure and heart rate prior to administering the Metoprolol on 02/09/17 and 02/12/17.

In an interview on 02/15/17 at 10:30 a.m., S2DQM stated the hospital did not have a written policy related to parameters to assess for mediation administration. S2DQM stated they had a process for medication assessment that was developed and implemented after the last CMS survey in August, 2016. S2DQM provided a written description of the hospital's process for monitoring medications. Review of the form titled, Medications Necessitating Increased Monitoring, revealed in part the following: Metoprolol - Blood pressure and heart rate monitoring. The form also revealed, "These medications will be monitored by both nursing and pharmacy departments. The appropriate monitoring parameter will appear on the MAR for documentation. S2DQM confirmed the nurses should have documented the patient's blood pressure and heart rate prior to administering the Metoprolol.


Patient #2
Review of the medical record for Patient #2 revealed the patient was an 81 year old admitted to the hospital on 02/09/17 at 4:30 p.m. The patient's diagnoses included Chest Pain, Coronary Artery Disease, Coronary Artery Bypass, Biliary Disease with Laparoscopic Cholecystectomy, and Encephalopathy.

Review of the physician's orders revealed an order dated 02/09/17 to administer Metoprolol Tartrate 25 mg BID to Patient #2.

Review of the MARs revealed the following:
02/11/17 - Metoprolol Tartrate 25 mg administered by the nurse at 9:00 a.m. and 9:00 p.m. with no documented evidence the patient's blood pressure or heart rate was assessed prior to administering the medication. The section on the MAR for documentation of the blood pressure and heart rate was left blank.
02/12/17 - Metoprolol Tartrate 25 mg administered by the nurse at 9: 00 a.m. with no documented evidence the patient's blood pressure or heart rate was assessed by the nurse prior to administering the medication.

In an interview on 02/14/17 at 3:30 p.m., S3DON reviewed the medical record for Patient #2 and confirmed the nurse had failed to assess the patient's blood pressure and heart rate prior to administering the Metoprolol on 02/11/17 and 02/12/17.

Patient #5
A review of the medical record for Patient #5 revealed the patient was a 82 year old female admitted to the hospital on 01/05/17 with a diagnosis of Malignant Pleural Effusion - Breast Cancer Stage IV and other medical conditions to include: Severe Malnutrition, Hypertension, and Physical Deconditioning. A review of the patient's MAR revealed the patient was on Metoprolol twice a day with pulse and blood pressure monitoring before each dose. A further review of the medical record for the patient revealed the nurse administered the Metoprolol with no documented evidence of the patient's pulse and blood pressure being monitored prior to the prescribed dose of Metoprolol for the following days; 01/12/17, 01/13/17, 01/18/17, and 01/24/17. The sections on the MAR for documentation of the pulse and blood pressure was blank on those dates.

In an interview on 02/14/17 at 10:00 a.m. with S5RNMgr, the patient's medical record was reviewed. S5RNMgr indicated that the medical record revealed no documented evidence that the patient's pulse and blood pressure was taken and documented on the MAR prior to the administration of the Metoprolol. She indicated the pulse and blood pressure should have been taken and documented by the nurse in the space provided on the MAR prior to the administration of the Metoprolol.



2) Failed to ensure drugs and biologicals were administered to the patient as ordered by the practitioner:

Patient #1
Review of the medical record for Patient #1 revealed the patient was a 68 year old admitted to the hospital on 01/17/17 with diagnoses of Bilateral Lower Extremity Ulcerations, History of Peripheral Vascular Disease, End-stage Renal Disease, and Gangrene to the tips of fingers bilaterally.

Review of the physician's orders dated 02/02/17 revealed Metoprolol Tartrate 12.5 mg by mouth twice a day was ordered.

Review of the MAR dated 02/05/17 revealed do documented evidence that the Metoprolol was administered to the patient on 12/05/17 at 9:00 a.m.

In an interview on 02/14/17 at 2:55 p.m., S3DON reviewed the medical record for Patient #1 and confirmed there was no documented evidence that the Metoprolol was administered to the patient on 02/05/17 at 9:00 a.m.


Patient #2
Review of the medical record for Patient #2 revealed the patient was an 81 year old admitted to the hospital on 02/09/17 at 4:30 p.m. The patient's diagnoses included Chest Pain, Coronary Artery Disease, Coronary Artery Bypass, Biliary Disease with Laparoscopic Cholecystectomy, and Encephalopathy.

Review of the physician's orders dated 02/10/17 revealed Zosyn (Antibiotic) 3.375 Gm IV every 8 hours was ordered.

Review of the MAR dated 02/12/17 at 5:00 p.m. revealed Zosyn 3.375 Gm was scheduled to be administered, but there was no documentation that it was administered.

In an interview on 02/14/17 at 3:30 p.m., S3DON reviewed the medical record for Patient #2 and confirmed there was no documented evidence that the Zosyn had been administered to the patient on 02/12/17 at 5:00 p.m. S3DON also confirmed there was no documented evidence why the medication was not administered.







30172

Based on record reviews and interviews, the hospital failed to ensure all orders, including verbal orders, were dated, timed, and authenticated by the practitioner in accordance with state regulations for 1 (#1) of 5 (#1-5) sampled patient records and 1 of 1 (#R1) random records reviewed for authentication of physician orders.

Findings:

Review the Louisiana Hospital Licensing Standards, LAC 48:I.Chapter 93, revealed the following:
Subchapter H. Medical Records Services
9387. Organization and Staffing.
E. Written orders signed by a member of the medical staff shall be required for all medications and treatments administered to patients.... The bylaws may grant the medical staff up to ten days following the date an order is transmitted verbally or electronically to provide the signature or countersignature for such order.

Review of the Hospital's medical staff bylaws, rules & regulations revealed in part the following:
General Conduct of Care: All verbal or telephone orders shall be transcribed in the medical record and shall be countersigned by the practitioner in a time frame that complies with State regulations. Countersignature for medication or treatment orders must be obtained within 24 hours....Orders shall be communicated verbally only when it is not practical for the orders to be given in writing/entered into the medical record by the practitioner for an urgent care need....All clinical entries in the patient's medical record shall be accurately dated and authenticated....

Patient #1
Review of the medical record for Patient #1 revealed the patient was admitted to the hospital on 01/17/17.
Further review of the record revealed the following verbal orders had not been authenticated by the practitioner within 10 days of the order:
01/17/17 at 2:35 p.m. Admission orders given by S20MD.
01/19/17 at 1:00 p.m. Dialysis orders given by S21MD.
01/19/17 at 4:30 p.m. Wound care orders given by S22MD.
01/21/17 at 10:05 a.m. Dialysis orders given by S21MD.
01/22/17 at 11:30 p.m. PRN Physician orders protocol for Dyspepsia given by S20MD.
01/23/17 at 7:35 a.m. PRN Physician orders protocol for nausea given by S20MD.
01/24/17 at 6:45 a.m. Dialysis orders given by S21MD.
01/26/17 at 1:20 p.m. Dialysis orders given by S21MD.
01/28/17 at 9:00 a.m. Dialysis orders given by S21MD.

In an interview on 02/14/17 at 2:55 p.m., S3DON reviewed the medical record for Patient #1 and confirmed the above verbal orders had not been authenticated by the physician within 10 days of the date the verbal order was given.


Patient #R1
Review of the medical record for Patient #R1 revealed the patient was admitted to the hospital on 01/20/17.
Further review of the record revealed the following verbal orders had not been authenticated by the practitioner within 10 days of the order:
01/20/17 at 6:05 p.m. Admission orders given by S20MD.
01/20/17 at 9:35 p.m. High observation transfer orders given by S20MD.
01/20/17 at 10:38 p.m. Medication orders for IV Lopressor given by S20MD.
01/21/17 at 4:10 a.m. Orders for medications, labs, and x-rays given by S23NP.
01/21/17 at 3:55 p.m. Telemetry Status Transfer orders given by S20MD.
01/21/17 at 5:25 p.m. Diet orders and consult for Speech Therapy given by S20MD.
01/22/17 at 10:00 a.m. Medication orders given by S23NP.
01/22/17 at 10:30 a.m. Lab orders given by S23NP.
01/22/17 at 10:30 a.m. Medication orders given by S23NP.
01/25/17 at 6:10 p.m. PRN Physician Orders Protocol for agitation given by S20MD.

In an interview on 02/14/17 at 3:50 p.m., S3DON reviewed the medical record and confirmed the above verbal orders had not been authenticated by the physician or the nurse practitioner within 10 days of receipt of the verbal order.