HospitalInspections.org

Based on observations, review of facility policies and documents, review of medical records (MR) and interview with staff (EMP), it was determined that the facility failed to maintain a safe setting by ensuring that all emergency supplies were present and readily accessible on a code cart during one of one "code blue" observation for one patient (MR10).

Findings include:

Observation on December 3, 2015, from 10:38 AM to 11:00 AM, of a "code blue" called for MR10, revealed EMP7 stating "I am going to get pads" while leaving the patient's room.

Review on December 9, 2015, of policy "Code Blue Response," dated September 2013, revealed "... III. Procedure ... Maintenance of the Crash Cart/Code Cart 1. Code cart checked daily by RN: ... Check for correct pacer/defibrillator/monitor pads ..."

Review on December 9, 2015, of the third floor nursing unit's "Code Cart and Emergency Drug Box Daily Checklist," dated December 2015, revealed "Correct pads for hands free pacer/defibrillator on top of cart ... checked [by initials of the staff member who performed these daily checks]" for December 1, 2, and 3, 2015.

Review on December 9, 2015, of "SDS Adult Code Cart," dated August 11, 2015, revealed "... Top of Cart: 1st Floor and Lobby Code Cart only [the nursing units for this hospital are located on the 3rd and 4th floors of the building only] ... Pad Defib[rillator] Adult [brand name excluded]. Note All code carts that have defibrillators with the capability of doing external pacing must include these items on the top of the cart with the defibrillator." Correspondence received on December 9, 2015 from EMP5 confirmed the defibrillator is capable of doing external pacing.

Review on December 9, 2015, of MR10's "Cardiopulmonary Arrest Record" revealed "... Date/Time Event Recognized: 12/3/15 10:39 [AM] ..." Further review revealed "...11:09 ... External Pacer ..." This document was signed by EMP7.

Interview on December 3, 2015, at 12:40 PM, with EMP7, while in the presence of EMP8, confirmed "I looked on top [of the Crash Cart]. I didn't see them [defibrillator pads]. I had to go upstairs to get [defibrillator] pads." EMP7 confirmed that they left the room, during a patient's code blue event, to get defibrillator pads because they did not readily find the defibrillator pads on top of the crash cart. EMP7 confirmed that the defibrillator pads are normally stored on top of the Crash carts.

The facility failed to maintain a safe setting by ensuring that all emergency supplies were present and readily accessible on a code cart during one of one "code blue" observation.

Based on review of facility policy and procedures, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure that nursing reassessments were conducted following the administration of pain medications for 21 occurrences in five of 28 medical records reviewed for the administration of pain medication (MR12, MR13, MR17, MR22 and MR26).

Findings include:

Review on December 2, 2015, of the facility policy and procedures "Pain Management, Assessment," last reviewed March 2015, revealed "... II. ... Definition/Purpose/Practice Guidelines: ... If a patient experiences pain, the 'Pain Management Log' is used to document patient observations, assessments and responses to the management of pain prior to and after treatment. It is useful tool to see if the interventions are helping the patient [sic] obtain their pain goals. III. Procedure: Action ... 9. In the column, labeled 'Pain 1 hour post Intervention,' write the number of the patient's pain at that time ... "

1) Review on December 2, 2015, of the medication administration record (MAR) for MR12 revealed the patient received Morphine 15 mg per physician's order for left hip pain on August 22, 2015, at 6:40 PM. Further review of the MAR for MR12 revealed Oxycodone 5 mg was administered per physician's order for pain on September 8, 2015, at 8:40 AM. There was no documentation in MR12 of a nursing reassessment of the effectiveness of the pain medications given to the patient for the above dates and times.

2) Review on December 2, 2015, of the MAR for MR13 revealed that the patient received Oxycodone 5 mg per physician's order for pain, on September 3, 2015, at 3:15 PM, on September 5, 2015, at 4:20 PM, September 7, 2015, at 5:20 PM, on September 18, 2015, at 8:10 AM, and September 27, 2015, at 12:20 PM. There was no documentation in MR13 of a nursing reassessment of the effectiveness of the pain medication given.

3) Review on December 2, 2015, of the MAR for MR17 revealed the patient received Oxycodone 5 mg per physician's order for severe pain on June 25, 2015, at 6:00 AM, on June 27, 2015, at 10:30 PM, on June 29, 2015, at 3:00 AM, on June 30, 2015, at 5:30 PM, and on September 6, 2015, at 8:45 AM. Further review of the MAR for MR17 revealed Dilaudid 1 mg was administered per physician's order for severe pain on July 1, 2015 at 6:15 PM. There was no documentation in MR17 of a nursing reassessment of the effectiveness of the pain medications given for the above dates and times.

4) Review on December 2, 2015, of the MAR for MR22 revealed the patient received Tylenol 650 mg per physician's order for pain on February 21, 2015, at 12:45 PM, on February 27, 2015, at 6:40 PM, and on March 9, 2015, at 11:30 AM. There was no documentation in MR22 of a nursing reassessment of the effectiveness of the pain medications given for the above dates and times.

5) Review on December 2, 2015, of the MAR for MR26 revealed the patient received one tablet of Oxycodone 5/325 mg per physician's order for pain on October 27, 2015, at 6:35 PM, on October 29, 2015, at 5:30 PM, on November 3, 2015, at 5:15 PM, and on November 4, 2015, at 11:30 AM and 6:35 PM. There was no documentation in MR26 of a nursing reassessment of the effectiveness of the pain medications given for the above dates and times.

Interview on December 4, 2015, at 1:30 PM, with EMP5 confirmed there was no documentation of a nursing reassessment of the effectiveness of the pain medications given in MR12, MR13, MR17, MR22, and MR26. EMP5 also confirmed that pain reassessments should be documented within one hour of giving a pain medication.

Based on review of medical records, review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure all orders, including verbal orders, were dated and/or timed promptly by the practitioner or by any other practitioner who was responsible for the care of the patient for 38 occurrences in eight of eight medical records reviewed for signed, dated and timed orders (MR4, MR6, MR15, MR22, MR24, MR26, MR27 and MR28).

Findings include:

Review on December 3, 2015, of facility document "Medical Staff Rules and Regulation," approved May 28, 2013, " ... III. Patient Care ... 2. All orders for treatment and medication shall be written in the proper place in the medical record of the patient, and shall include the date, time, and full signature of the person writing the order .... 2) Verbal Orders/Telephone Verbal Orders: ... b) When a verbal order/telephone verbal order is taken, it must be counter-signed with date and time b a practitioner within twenty-dour (24 hours. If the practitioner is not the attending physician, he or she must be authorized by the attending physician and must be knowledgeable about the patient's condition."

1. Review on November 30, 2015, of MR4 revealed five verbal orders dated November 12, 2015, through November 19, 2015, with no documented evidence these verbal orders were dated and timed by a practitioner. Further review of MR4 revealed a restraint order dated November 20, 2015, with no documented evidence the order was timed by a practitioner.

2. Review on December 2, 2015, of MR6 revealed four verbal orders dated November 15, 2015, through November 16, 2015, with no documented evidence these verbal orders were timed by a practitioner.

3. Review on December 2, 2015, of MR15 revealed 12 verbal orders dated January 19, 2005, through March 25, 2015, with no documented evidence these verbal orders were dated and timed by a practitioner.

4. Review on December 2, 2015, of MR22 revealed seven restraint orders dated October 23, 24, 25, 26, 27, 28, and 29, 2015, with no documented evidence these orders were timed by a practitioner. Further review of MR22 revealed one verbal order dated October 28, 2015, with no documented evidence this order was dated and timed by a practitioner.

5. Review on December 2, 2015, of MR24 revealed two verbal orders dated July 20, 2015, with no documented evidence these verbal orders were dated and timed practitioner.

6. Review on December 2, 2015, of MR26 revealed three verbal orders dated October 22, 2015, through November 2, 2015, with no documented evidence these verbal orders were dated and timed by a practitioner.

7. Review on December 2, 2015, of MR27 revealed a verbal order dated October 26, 2016, with documented evidence this order was dated and timed by a practitioner.

8. Review on December 2, 2015, of MR28 revealed two restraint orders dated November 16, and 17, 2015, with no documented evidence these orders were timed by a practitioner.

Interview on December 3, 2015, with EMP5 confirmed the above findings for MR4, MR6, MR15, MR22, MR24, MR26, MR27 and MR28.