HospitalInspections.org

Based on policy review, record review and interviews, the hospital failed to ensure all licensed nurses who provide services in the hospital adhered to the policies and procedures of the hospital. This deficient practice was evidenced by: 1) failing to ensure the physician was notified for medications not administered for 1 (Patient 2) of 5 patient records reviewed; 2) failing to ensure telephone orders were input into the electronic medical record and signed by the physician for 1 (Patient 1) of 5 of 5 patient records reviewed; and, 3) failing to ensure wound measurements were performed on admission for 1 (Patient 5) out of 5 patient records reviewed.
Findings:

1) Review of the hospital policy NS-27 titled, "Medication Administration revealed in part: II Documentation of Medication Administration part G Recording of medication not given - When regularly scheduled medication is not administered, the nurse or respiratory therapist will record the dose as omitted and indicate the reason why the medication was not given. The nurse or respiratory therapist should communicate with the physician when a medication is held due to clinical judgement.

Review of Patient 2's medical record revealed in part: Physician order 06/06/2023 Metoprolol 50 mg PO QD start 6/7/23 9:00 a.m. EMAR (electronic medication administration record) review revealed in part: Metoprolol 50 mg PO QD with an administration time of 9:00 a.m. Metoprolol parameters - Blood pressure to be monitored prior to administration of medication. RN's are to notify the physician if patient's HR <60 and SBP BP <100 prior to administration of the medication. Further review of the EMAR failed to reveal the physician was notified on 06/07/2023 for the Metoprolol which was not administered for a documented BP of 101/57 and HR of 57.

Interview on 08/32/31 at 3:30 p.m., S1DON reviewed the EMAR and acknowledged the physician was not notified according to policy.

2) Review of the hospital policy 19.5 titled, "Planning Care, Treatments and Services revealed in part: B. Verbal/Telephone Orders shall be issued by a member of the Medical Staff or allied health practitioner to licensed nursing personnel. 2 Verbal orders must be signed, dated and timed ...by the prescribing practitioner or other credentialed practitioner involved in the patient's care.

Review of Patient 1's medical record revealed in part: Nursing note 03/12/2023 telephone order for Foley catheter placement for urine retention verified by bladder ultrasound performed by S2RN. Foley catheter placed by S2RN. Review of Patient 1's physician orders failed to reveal an order for placement of a Foley catheter.

Interview on 08/01/2023 at 12:10 p.m., S2RN stated she called the physician regarding the urine retention and received a telephone order for the Foley but failed to enter the order into the CERNER (an electronic medical record system) to be signed by the physician.

3) Review of the hospital policy NS-15 titled, "Photo Documentation of Wounds" revealed in part: 6. Photos will be taken to accurately document the size of the wound upon presentation to this hospital or initial discovery while a patient is in the hospital.

Review of the hospital policy NS-08 titled, "Nursing Assessment" revealed in part: 7. The admitting RN will screen each patient during the initial assessment process to identify patients at risk, who require further specialized assessments. Screening is completed within 24 hours and includes:...Wound Care.

Review of Patient 5's medical record revealed and admit date of 07/20/2023 with physician orders to monitor the right foot dressing daily. Further review failed to reveal initial photo documentation or wound measurements for the patient's right foot was performed on admission.

Interview on 08/02/2023 at 9:00 a.m., S1DON stated a photo and wound care measurements should have been completed on admission for Patient 5.