HospitalInspections.org

Based on interview and record review the facility nursing staff failed to assess patient care needs by:
-Failing to perform a comprehensive physical assessment for injury after a fall for one of three (Patient #5) discharged patients medical records reviewed for falls.
-Failing to follow facility policy by documenting a report of a high serum potassium value to the physician caring for one (Patient #6) of eight current patient medical records reviewed.
-Failing to ensure the daily Medication Administration Record (MAR, a log of medication given to a patient) accurately reflected tube feeding administered to one of eight (Patient #6) current patients receiving tube feedings.

The facility census was 28.

Findings included:

1. Record review of discharged Patient #5's admission history and physical dated 10/05/11 showed the physician assessed the following:
-History of severe cognitive impairment.
-Had not lived independently for his/her entire adult life.
-Had aspiration pneumonitis (foreign materials in the lung, usually oral or gastric contents; such as food, saliva, or nasal secretions).
-Recent respiratory failure required a ventilator.
-Continued to have increased secretions.
-Failed a swallowing evaluation and continued on tube feeding (tube into the abdomen used to provide liquid nutrition when a person cannot swallow).
-Was non-verbal.

Review of Patient #5's nurse's Twenty Four Hour Flow sheet showed the following:
-Dated 10/05/11 at 11:00 PM restraints were applied due to patient trying to pull at oxygen tube and feeding tube.
-Dated 10/06/11 at 12:00 Midnight the patient tried to pull at tubes and get out of bed.
-Dated 10/06/11 at 4:00 AM the patient was restrained, pulled oxygen off and tried to pull at the feeding tube.
-Dated 10/06/11 at 6:05 AM the patient was found on the floor, without the restraint (restraint not tied), bed alarm not on and the bed was not in the low position. The nurse documented the patient had a cut above the left eye and the nose was bleeding.
-Dated 10/06/11 through 10/10/11 (on the 7:00 AM to 7:00 PM and the 7:00 PM to 7:00 PM shift) nursing staff failed to document any physical assessment of the patient's left eye and nose.
-Dated 10/11/11 on the 7:00 PM to 7:00 AM shift nursing staff documented an assessment of facial bruising and left shoulder bruising.

Review of Patient #5's physician's progress notes dated 10/11/11 at 2:00 PM showed the physician assessed the patient had pain, contusions to the left eye and jaw, pain on examination of the left arm, bruising to the face and left shoulder and ordered computer tomography (CT) of the face and x-ray of the left shoulder.

During an interview on 11/22/11 at approximately 2:00 PM Staff D, Nurse Manager stated the following:
-Patient #5 fell out of bed on 10/06/11 around 6:00 AM.
-The nursing staff Twenty Four Hour Flow sheets after 10/06/11 through 10/11/11 on the 7:00 PM to 7:00 AM do not show any physical assessment documentation of the patient's left eye and nose and fail to document any assessment of the patient's shoulder.
-Staff D confirmed there was no documentation of physical assessment after Patient #5 fell out of bed.
-Staff D stated she would expect nursing staff to document physical assessments of suspected injuries after a fall out of bed.

2. Record review of current Patient #6's laboratory values dated 11/03/11 showed a blood test result of 5.2 H (high) with normal values of 3.4-5.0 (Potassium regulates heart rate and rhythm, and controls muscle and nerve function in the body).

Record review of the patient's nurse's notes dated 11/03/11 showed nursing staff failed to document the high serum potassium and failed to document notification of the potassium to the physician.

During an interview on 11/21/11 at 2:25 PM, Staff D, Nurse Manager reviewed the patient's medical record and stated the following:
-Confirmed there were no nurse's notes on the 24 Hour Flow Sheet dated 11/03/11.
-Other possible documentation of the high blood potassium could be a sticker on the physician's order sheets.
-Confirmed there were no sticker's notifying the physician on the order sheets.
-Stated he/she would expect the nursing staff to write a nurse progress note regarding receipt of the high value.

During an interview on 11/21/11 at 2:25 PM, Staff B, Director of Quality Management stated he/she would expect nursing staff to place the preprinted sticker on the physician's order sheets which notified the physician of a high value found on any tests.

3. Record review of the facility's policy titled, "Pharmacy Services Medication Administration Record", dated 09/09 showed the following direction:
-The Medication Administration Record will be generated daily by Pharmacy.
-The purpose was to minimize the potential errors involved in recopying MAR and to serve as a further double check in the interpretation of the Physician's Orders.
-The procedure included obtaining the physician's order nursing staff would forward a copy of the order sheet to Pharmacy.
-The procedure also directed evening/night shift nursing staff to verify the accuracy of the MAR.
-The procedure directed the MAR will contain tube feeding orders.

Record review of current Patient #6's Nutrition Services Notes dated 11/14/11 showed the following:
-The Registered Dietitian (RD) documented the patient's current diet order included tube feeding (tube into the abdomen used to provide liquid nutrition when a person cannot swallow or eat enough food to meet their nutritional needs).
-The RD also noted the patient had not been receiving tube feeding since 11/07/11.
-The RD documented the physician had ordered seventy milliliters per hour (about two and a half ounces) of a canned commercially prepared feeding, Jevity through the jejunostomy tube.
-The tube feeding had not been on the MAR since 11/06/11.

Review of Patient #6's Graphic Sheets dated 11/05/11 through 11/15/11 showed no tube feeding was administered to the patient.

During an interview on 11/21/11 at 3:20 PM Staff K, Pharmacist reviewed Patient #6's Nutrition Note and Physician's orders and stated the Pharmacist enters the physician's orders, including tube feeding orders, into the computer. The MAR were printed from the computer and the midnight nurse should check the MAR for accuracy.

During an interview on 11/21/11 at 3:20 PM Staff D, Nurse Manager reviewed Patient #6's medical records and confirmed the following:
-There were no orders to discontinue tube feeding.
-The last time the nursing staff documented that the patient received tube feeding was on 11/04/11.
-There were no nursing notes documenting the tube feeding was discontinued.
-The patient should have received tube feeding from 11/04/11 through 11/15/11.