HospitalInspections.org

Based on interviews, document review and during the course of a complaint investigation it was determined that hospital nursing staff failed to report changes in a patient's assessment, to the physician, for 1 of 7 patients in the sample selection.(Patient # 5)

The findings include:

Patient #5 was admitted on 5/3/17 with admission diagnoses of "1. intracranial hemorrhage, right temporal hemorrhage involving with extension to the ventricle compounded by obstructive hydrocephalus, status post placement of external ventricular drain 2. Respiratory failure, status post tracheostomy and PEG, on tracheostomy collar. The patient is here for weaning 3. Management of multiple comorbidities including encephalopathy, diabetes mellitus and hypertension along with rehabilitation." documented in the History and Physical by SM # 22 on 5/3/17 .

Review of the clinical record confirmed that nursing staff assessed the patient according to policy. Review of policy "Assessment and Reassessment" review date 1/18/17, states "The routine re-assessment of the patient's status includes a system review every shift (12 hours) in medical surgical unit. An RN is responsible for completing a head to toe assessment at a minimum of once in a 24 hour period. ICU/HOU will have full system review every (12 hours) by a RN..." Review of the clinical record found no missing assessments.

During review of the clinical record it was noted that as a part of the neurological nursing assessment Patient #5's pupil size in millimeters was documented as 3mm for the right and 3 mm for the left eye from admission on 5/3/17 each day until 5/23/17. The neurological nursing assessment on 5/23/17 at 7:31 AM documents the size of the right pupil was as being 4mm (millimeters) and the size of the left pupil at 3mm. The size of the right pupil was documented as being 4mm for the remainder of the Patient #5's stay in the hospital (with the exception of an assessment completed on 5/30/17 at 8:31 AM, when the right pupil size was documented as 3mm).The size of the left pupil remained at 3mm throughout the patient's stay in the hospital The clinical record failed to provide evidence the physician was notified of the change in the patient's assessment. Review of physicians' documentation for the corresponding time period failed to provide evidence the physician/s had been notified of this change in the patient's assessment.

On 8/23/17 at 1 PM, while reviewing Patient #5's clinical record, SM # 3 the CCO (Chief Clinical Officer and a registered nurse) was acting as navigator for the surveyor. Upon finding the change in pupil size and the apparent failure to notify the physician, SM #3 was asked what he/she would have expected of the nurse when the change in the patients assessment was noted. He/she stated that "changes should be reported to the MD, any change in pupil size or uneven pupil size should be reported." On 8/24/17, the expected actions of a nurse upon finding a change in the patient's assessment was discussed with SM # 7, the CEO. SM #7 stated the nurse should have notified the physician of the change.

The above findings were discussed with the management team for a final time on 8/24/17 at 4'45 PM. No further evidence was provided to the survey team.

Based on observations, interviews, and review of documents, it was determined the facility staff failed to ensure patient medications were administered as ordered by physicians for 4 of 7 patients (Patient #1, #2, #3, and #7).

The findings include:

1. Patient #3 had a medication administered late.

On the morning of 8/23/17, Staff Member (SM) #11 (a registered nurse) was observed while administering medications to Patient #3. Patient #3 had Klonopine 0.5 MG tablet ordered for 9:00AM. Patient #3's Klonopine was documented as being administered at 10:43AM. SM #11's comments about the late medication administration were that two patients had intravenous antibiotics that were not given on the night shift.

The following information was found in a facility policy entitled "Medication Administration Program and Computerized Process" (with an effective date of 6/2011 and a review date of 6/2016): "Medications should be given within the following guidelines: ... Routine: Given 30 minutes before or after at the next schedule administration time."

The following information was found in facility policy entitled "Medication: Administration and Documentation" (with an effective date of 4/2008 and an review date of 1/18/17): "Documentation of Scheduled Medications ... If the medication is given at a time greater than 1 hour before or 1 hour after the scheduled time, document in the medication administration record (MAR) as to why the medication was not given at the scheduled time."

2. Patient #1 had a medication administered late.

On the morning of 8/23/17, SM #11 was observed while administering medications to Patient #1. Patient #1 had Cipro 750MG (three 250MG tablets) ordered for 9:00AM. Patient #1's Cipro was documented as being administered at 11:01AM. SM #11's comment documented for the late medication administration was that he/she had left one medication (tablet) in the medication dispensing device. SM #11 reported to the surveyor at the time of the medication administration that the delay in medication administration was due to patients not being provided ordered antibiotics on the previous night shift.

3. Patient #7's medication administration documentation failed to have documentation to indicate the patient had received his/her antibiotics as ordered.

Patient #7 had an order for Zosyn 3.375GM to be administered intravenously every six (6) hours.

Patient #7 had an order for Vancomycin 1GM to be administered intravenously every twelve (12) hours.

Review of Patient #7's medication administration documentation, on 8/23/17 at 11:30AM, failed to provide documentation to show the previous two (2) dose of Zosyn and the previous two (2) doses of Vancomycin had been administered. During an interview with SM #11 on the morning of 8/23/17, SM #11 reported that he/she felt sure the 5:00AM dose of Vancomycin had been administered (but not documented) because that medication bag that had contained the dose of Vancomycin was still hanging on the IV pole at the beginning of the day shift. SM #11 acknowledged that Patient #7's previous two (2) doses of Zosyn and previous two (2) doses of Vancomycin had not been documented as being administered.

On 8/23/17 at 2:35PM, SM #12 (a pharmacist) confirmed that the aforementioned four (4) antibiotic doses had not been documented as being administered.

The aforementioned absence of documentation to indicate the four (4) doses of antibiotics had been given as ordered to Patient #7 was discussed with SM #2 (Senior Director of Quality Services). SM #2 stated he/she would expect the physician to be notified of the potentially missed medications. SM #2 stated Patient #7's missed Zosyn 6:00AM dose was discussed with the pharmacy and it was determined that since the dose would not be able to be administered until 9:00AM that it should not be given until the next schedule dose at 12:00NOON.

On 8/24/17 at 10:00AM, SM #2 provided the surveyor with copies of Vancomycin trough laboratory blood test. SM #2 stated that due to the elevated results that he/she felt as if the Vancomycin doses had been administered but not documented.


33117


4. On 08/23/17 at 2:44 PM a review of Patient #2's clinical record was conducted by the surveyor. On 08/22/17 the facility staff failed to give Patient #2's 10:00 PM medications as ordered by the physician. The document titled, "Medication Name Administration Record" read as follows:

· "Midodrine (used to treat low blood pressure) 10mg via feeding tube given at 1:21 AM.
· Keppra (used to treat seizures) 1500mg via feeding tube given at 1:19 AM.
· Valproate Sodium Syrp (used to treat seizure) 2000mg via feeding tube given at 1:20 AM.
· Vimpat (used to treat seizures) 200mg via feeding tube given at 1:22 AM.
· Pepcid (used to treat ulcers and excess stomach acid) 20mg via feeding tube given at 1:23 AM.
· Florinef (corticosteroid) 0.2mg via feeding tube given at 1:21 AM.
· Senna (used to treat constipation) 528mg via feeding tube given at 1:20 AM.
· Dilantin (used to treat seizure) 200mg IVP (intravenous push) given at 1:20 AM."

On 08/23/17 at 11:30 AM, SM #3 (the Chief Operating Officer), was interviewed about the medications that were given late. SM #3 stated he/she was unable to find out why the medications had been given late or why SM #15 (a Registered Nurse) failed to document a reason for the delay.