HospitalInspections.org

Based on medical record and document review, nursing services failed to notify medical staff of abnormal laboratory test results in a timely manner and delayed in administering medications as ordered by the physician for Patient #1.

Findings Include:

Review of Policy "Physician Notification Process" effective 2/11 revealed it is the policy of the hospital to notify attending physicians all matters requiring medical management of patient care. For situations requiring medical attention such as abnormal laboratory values, the attending physician will be notified by the charge nurse or designee. The time of notification and response will be documented.

Review of the Urinalysis obtained 10/17/11 at 1047 and reported 10/17/11 at 1215 revealed cloudy, amber colored urine with positive nitrites, 0-5 WBC & RBC, and many bacteria. There was no evidence in the medical record to indicate nursing staff notified the physician on 10/17/11 of the abnormal urinalysis.

Review of Physician Orders dated 10/18/11 at 1410 revealed Levaquin 250 mg daily for 7 days.

Review of the Medication Administration Record dated 10/18/11-10/26/11 revealed Levaquin 250 mg was administered on 10/19/11 at 1000. There was no evidence in the medical record why Patient #1 did not start antibiotic therapy on 10/18/11 when ordered by the physician.

Based on observation the facility did not maintain the physical environment to ensure the safety and well being of Patient #1.

Findings include:

Observation during the tour on 11/3/11 at 3:15 PM revealed mold and grime on the shower curtains and under the metal benches in the 2 shower stalls located on the fourth floor of the rehabilitation unit.

These findings were verified with the CCO on 11/3/11.

Based on medical record and document review, the facility did not ensure Patient #1 received proper post-hospital care.

Findings Include:

Review of Policy "Discharge of Patient/Client" last reviewed 4/11 revealed the charge nurse facilitates all patient/client discharges in collaboration with the medical staff, counseling staff, program manager, and the nursing supervisor. The discharge plan is reviewed by the clinical staff at the daily treatment team meeting or case conference to assure that the patient/client is ready for discharge and an appropriate referral has been made. The policy does not include guidance for documentation of discharge instructions including instruction for medication prescriptions/orders and instruction on medical issues and/or needed follow-up.

Review of the Urinalysis obtained 10/17/11 at 1047 and reported 10/17/11 at 1215 revealed cloudy, amber colored urine with positive nitrites, 0-5 WBC & RBC, and many bacteria. A handwritten note (no date, time, or author indicated) next to the test results lists "Interstitial cystitis; positive burning, frequent urination and no abnormal vaginal discharge."

Review of Physician Orders dated 10/18/11 at 1410 revealed Levaquin 250 mg daily for 7 days.

Review of the Medication Administration Record dated 10/18/11-10/26/11 revealed Levaquin 250 mg was administered on 10/19/11 at 1000.

Review of the Detox Care Plan dated 10/19/11 revealed a diagnosis of urinary tract infection and action to medicate as ordered and push fluids.

Review of the Detox Medicine Note dated 10/19/11 at 0710 revealed a plan for Levaquin 250 mg daily for 7 days for urinary tract infection and Paxil 20 mg for depression. Patient #1 may be discharged today, needs an appointment with Spectrum.

Review of the Discharge Instructions dated 10/19/11 revealed the medication section is blank. There was no evidence that Patient #1 was diagnosed with a urinary tract infection, instructions for Levaquin/antibiotics and instructions for Patient #1 to follow related to urinary tract infections.