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PAM HEALTH REHABILIATION HOSPTIAL OF KYLE
ORGANIZATION OF NURSING SERVICES
Tag No.: A0386
Based on interviews and record reviews, the facility failed to ensure organized nursing services were provided in that, Patient #1's STAT (immediately) lab orders were not completed, and physician was not notified in a timely manner.
Findings included:
Review of Physician Orders on 3/3/20, at 09:07, reflected STAT orders for CMP and CBC.
Review of Staff #4's Patient Care Notes dated 3/3/20, at 09:45, reflected, "Patient received order for stat CBC, CMP ... this nurse attempted blood draw to Rt arm with not [sic] success. Charge nurse aware."
Review of Staff #4's Patient Care Notes dated 3/3/20, at 10:15, reflected, "Assisted by (Staff #7) with Stat blood draw. Attempted to draw blood multiple times without success. Charge nurse notified."
Review of Staff #4's Patient Care Notes dated 3/3/20, at 12:18, reflected, " ... Patient appearing to have mild shaking. 1230- notified charge nurse and MD, awaiting response."
Medical records reflected no other documentation that a physician and/or other licensed practitioner was notified of incomplete STAT order until 1230.
In an interview with Staff #13 on 3/9/20, at 2:50 p.m., she stated her shift was from 6 am to 6 pm. She stated she was notified of STAT lab orders not being completed around 1 p.m., which was over 2 hours after last STAT lab order draw attempt. She stated she expected nursing staff to notify the physician immediately if STAT orders are not being completed.
In an interview with Staff #2 on 3/9/20, at 3:25 p.m., she stated when STAT orders cannot be completed, she expected staff to immediately notify the physician. She further stated facility does not have a policy specifically mentioning incomplete STAT order communications.
Review of policy titled Critical Value Notification, NSG #19, with last revision date of July 19,2019, stated in part, " ... To ensure that life-threatening or 'critical' diagnostic or laboratory result are effectively and accurately communicated to the appropriate ordering physician and/or licensed practitioner in a timely manner."