HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to ensure each patient's care and documentation of that care was completed according to facility policy and current standards of care for 9 of 10 patients of the hospital medical unit (Patients #1-4 and #6-10).

Findings were:

Facility policy entitled Pain Management Protocol, last revised 5/2016, included the following:
"Reassessment...
2. The patient will be reassessed for pain:...
b. Every shift and as needed...
Documentation...
Documentation of pain for all patients includes:
a. Type of pain
b. Location
c. Intensity scale
d. Any changes in level of consciousness, if applicable
e. Activity, if related
f. Side effects of treatment, if any
g. Medication..."

A review of facility medical records on 1/17/17 revealed 9 of 10 patients [Patients #1-4 and #6-10] had incomplete or missing pain assessments. Many nursing shifts included no documentation of a patient pain assessment having been performed during that shift. In addition, the response to pain medication administered was not documented in the records of Patients #1-4. For example, a nursing note in the record of Patient #2 on 1/16/17 at 1930 read, "Pt resting in bed. Shows s/s of discomfort/grimace on face. Will medicate with ordered pain med. No other needs assessed. Will continue to monitor." The next nursing note was at 0600 the next morning and did not address the patient's pain. The note at 1930 was the entire assessment and pain intervention documentation.

A review of facility Skin Care Guidelines, effective date 9/21/16, included the following:
"III. Prevention...
B. Positioning
1. Maintain the head of bed at or below 30 degrees or at lowest degree of elevation consistent with the patient's medical condition..."

The review of medical records on 1/17/17 revealed 7 of 7 patients with pressure wounds (Patients #1-3 and #6-9) each had a physician's order that read as follows: "May not have head of bed higher than 30 [degrees] when on his back longer than 30 minutes at a time..." Each of these records contained documentation of the beds being elevated higher than 30 degrees if the degree of elevation was noted at all. The daily nursing assessment forms included the following section: " HOB (head of bed) elevated - indicate degree." Thus, the degree of elevation was often not documented at all or was above the physician-ordered elevation in these patient records.

The above findings were all confirmed in an interview with the chief nursing officer in the facility conference room on the afternoon of 1/17/17.

Based on a review of facility documentation and staff interview, the facility failed to ensure that drugs and biologicals were administered in accordance with the orders of the practitioner responsible for the patient's care for 6 of 10 patients [Patients #1, #5, and #7-10].

Findings were:

The Cornerstone Hospital Medical Staff Rules & Regulations, effective July 2014, included the following:
"Medical Records and Orders
1. The attending physician will be responsible for the preparation of a complete and legible medical record for each patient...
3. The attending practitioner must sign or must read, edit and countersign all orders...
4. All clinical entries and summaries in the patient's medical record shall be accurately dated and authenticated...
8. Medical records that incomplete thirty (30) days after patient discharge are considered delinquent...
11. Telephone and verbal orders are to be used infrequently...All orders, including telephone orders, must be dated, timed, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and authorized to write orders by Hospital policy...Telephone orders must be authenticated in accordance with state laws or regulations..."

A review of the medical records of Patients #1, #5 and #7-10 revealed unsigned physician orders in excess of 48 hours, and some in excess of 30 days.

For example, the record of Patient #10 included the order: "Zofran 4mg IV q 6 [hours] for nausea/vomiting." The order was documented as T.O.R.B. (telephone order read back) by an RN on 12/13/16 at 6:30 p.m. The order was never authenticated by a physician.

The record of Patient #7 included the order: "Give additional 0.5 mg tab of Ativan p.o. for anxiety." The order was documented as T.O.R.B. by an RN on 12/3/16 at 4:47 p.m. The order was never authenticated by a physician.

The record of Patient #9 included the order: "Morphine 1mg IV q 4 [hours] PRN severe pain." The order was documented as T.O.R.B. by a licensed vocational nurse on 10/30/16 at 9:00 a.m. The order was never authenticated by a physician.

These findings were confirmed in an interview with the director of quality management and the chief nursing officer in an interview in the facility conference room on the afternoon of 1/17/17. The director of quality management stated they were aware of the problem and attempted to address it, but had thus far been unsuccessful.