HospitalInspections.org

Based on observations, interviews and document review, it was determined that the facility failed to ensure staff provide nursing care per nursing standards for two (2) of six (6) Patients (Patients # 1 and # 2).

Please see Tags # 392, # 397 and # 405 for specific findings.

Based on document review and interviews, it was determined that the facility failed to provide patient care by nurses per standard practice by not monitoring blood pressure (BP) and not calling report for transport for two (2) of six (6) Patients (Patients # 1 and # 2).

The findings include:

On July 26, 2022, a review of the Clinical record and adverse events revealed the following:

Patient # 1-
On July 13, 2022 at 9:30 a.m., the Patient was transported (to another facility) for a thoracentesis (procedure). The clinical record did not contain documentation of the receiving facility receiving report from the sending facility for the procedure.

The facility policy titled "Patients traveling off the unit" reads in part "the day of the medical procedure or treatment off the unit: the hospital nurse assigned to this patient will call the facility or physician's office for a nurse to nurse hand off prior to sending the patient on the day of the medical procedure or treatment."

Patient # 2-
On May 24, 2022 at 4:23 p.m., the Patient's BP was documented as 196/84. At 5:23 p.m., BP was 173/81, IV Labetalol (BP medication) was given per Physician orders. There was no follow up BP documented until 3:00 a.m. (over nine (9) hours after medication was given).

On May 26, 2022 at 7:32 p.m. the Patient's BP was documented as 184/82. IV Labetalol and Amoldipine (BP medication) 5mg was given at 8:32 p.m. There was no follow up BP documented until 4:44 a.m. (over eight (8) hours after medication was given). There was no Physician order for IV Labetalol.

Interview with Staff Member # 3 on 7/26/22 at 3:00 p.m. confirmed upon (Staff Member #'s) review of the clinical record, the staff failed to monitor vital signs to include BP related to medications. The Patient had two (2) elevated BP outside of parameters and staff failed to notify the Physician.

Interview with Staff Member # 2 on 7/27/22 at 9:20 a.m. revealed Staff failed to monitor BP and notify Physician of BP out of parameters per Policy. According to Staff Member # 2, staff were re-educated on BP monitoring and parameters and no further incidents have occurred.
Staff Member # 2 was unable to provide evidence of education provided.

Interview with Staff Member # 4 on 7/27/2022 at 10:05 a.m. revealed "Agency staff get one (1) day on orientation on the treatment floor with a preceptor; hospital Staff get two (2) days. Staff Member # 4 stated "It's not enough". Staff Member # 4 did not recall any specific information about medication administration in orientation."

The facility policy titled "Medication Administration" reads in part "Monitoring effects of Medication: Monitor patient clinical response as appropriate for medication given. Any administration parameters will be noted (BP). "
The parameters included to notify the Physician for Systolic BP greater than 160.

The findings were discussed on July 27, 2022 with Staff Members # 1, # 2 and # 3 during the exit interview on 7/27/22.

Based on document review and interviews, it was determined that the facility failed to provide patient care by not administering tube feedings as ordered by the Physician as for one (1) of six (6) Patients (Patient # 1).

The findings include:

On July 26, 2022, a review of the Clinical record and adverse events revealed the following:

Patient # 1-
On June 28, 2022 at 6:05 p.m., Rapid Response Team (RRT) was called due to Patient being cold, clammy and unresponsive. Patient's blood sugar was 22. Physician's order for Dextrose 50% given. Repeat blood sugar 109.

Interview with Staff Member # 3 on 7/26/22 at 3:00 p.m. revealed there were new orders for the tube feeding (TF) on June 28, 2022 at 10:45 a.m. Staff Member # 4 failed to program the TF correctly to deliver the TF as ordered by the Physician.

A review of adverse events reports confirmed the TF was programmed incorrectly.
There were no other TF programming error identified on the adverse events report.

Interview with Staff Member # 2 on 7/27/22 at 9:20 a.m. confirmed Staff Member # 4 programmed the TF incorrectly. According to Staff Member # 2, Staff Member # 4 was re-educated on the TF machine and no further incidents have occurred.
Staff Member # 2 was unable to provide evidence of education provided.

There was no TF policy related to programing of the machine provided.

The findings were discussed on July 27, 2022 with Staff Members # 1, # 2 and # 3 during the exit interview on 7/27/22.

Based on document review and interview, it was determined that the facility staff failed to administer medications as ordered by the Physician for one (1) of six (6) Patients (Patient # 1).

The findings include:

On July 26, 2022, a review of the Clinical record and adverse events revealed the following:

Patient # 1-
On June 12, 2022 at 9:25 p.m., Patient's blood sugar (BS) was 64. A recheck of the BS was 69. (According to ADA (American Diabetes Association) normal BS range is 70 - 99). The Physician was notified and orders received. The Patient was given D 10 (10% dextrose solution) twice along with the glucose gel.

Interview with Staff Member # 3 on 7/26/22 at 3:00 p.m. revealed the Patient's insulin was 25 units daily due to being on dextrose fluids. On June 11, 2022, the dextrose fluids were changed to normal saline. The insulin was not adjusted. The evening insulin dose on June 11, 2022 was held. The morning insulin on June 12, 2022 was given resulting in low BS that evening.

On July 1, 2022, Patient's BS was 59. The Physician gave orders to adjust the insulin.
On July 3, 2022, Patient's BS was 54.
On July 4, 2022, Patient's BS was 64.

Interview with Staff Member # 3 on 7/26/22 at 3:00 p.m. revealed the Patient's insulin order was adjusted on July 1, 2022 but staff failed to adjust the insulin as ordered.

A review of adverse events reports confirmed the insulin was not given per Physician orders. No other insulin error were identified on review of the adverse events report.

The facility policy titled "Medication Administration" reads in part "Monitor Patient clinical response as appropriate for the medication given. Any administration parameters will be noted (BP, Blood sugar, heart rate, etc)."

The findings were discussed on July 27, 2022 with Staff Members # 1, # 2 and # 3 during the exit interview on 7/27/22.