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Based on hospital policy and procedure review, medical record reviews and staff interviews, the nursing staff failed to ensure vital signs were obtained as ordered by the physician for 3 of 10 sampled records (#5, #6 and #2).

Findings included:

Review on 10/09/2018 of the hospital policy and procedure titled "Nursing Assessment, Daily" revised January, 2018 revealed "Vital Signs Documentation 1. Vital signs ... will be obtained ... routinely thereafter per physician order. 2 ...a. Vital Signs ...the vital signs, to include patient temperature, blood pressure, respiratory rate and heart rate will be obtained ..."

1. Review on 10/09/2018 of the open medical record for Patient #5 revealed a 65-year-old female admitted on 09/28/2018 at 1054 with a diagnosis of Acute Respiratory Failure with Ventilator. Review of the physician orders revealed an order dated 09/28/2018 at 1000 for vital signs every four (4) hours. Review of the Vital Signs Monitoring Sheet from 09/28/2018 through 10/10/2018 revealed no available documentation of vital signs on 10/01/2018 at 1200, on 10/02/2018 at 0000 (temperature only documented), 0400, 1200 and 2000, on 10/03/2018 at 0400 and 1200, on 10/05/2018 at 1200, on 10/06/2018 at 1200, on 10/07/2018 at 1200 and 1600, on 10/08/2018 at 2000 and on 10/09/2018 at 0400. Review of the medical record revealed evidence that the nursing staff failed to follow the physician order to obtain vital signs every four (4) hours.

Interview on 10/10/2018 at 1215 with the Director of Quality Management revealed the nursing staff were expected to follow the physician orders. Interview confirmed the nursing staff failed to follow the hospital policy for obtaining vital signs per the physician orders.

2. Review on 10/09/2018 of the open medical record for Patient #6 revealed a 48-year-old male admitted on 09/20/2018 at 1437 with a diagnosis of Acute Respiratory Failure with Ventilator. Review of the physician orders revealed an order dated 09/20/2018 at 1215 for vital signs every two (2) hours. Review of the Vital Signs Monitoring Sheet from 09/20/2018 through 10/10/2018 revealed no available documentation of a temperature on 09/20/2018 at 2000, on 09/23/2018 at 0000, on 09/24/2018 at 2000 and 2200, on 09/25/2018 at 0000, 0200, 0400 and 0600, on 09/26/2018 at 0200 and 1800, on 09/30/2018 a 1000, 1200 and 1800, on 10/01/2018 at 1200, on 10/05/2018 at 1200, on 10/06/2018 at 0600 and on 10/08/2018 at 1800. Review of the medical record revealed evidence that the nursing staff failed to follow the physician order to obtain a temperature with the vital signs every two (2) hours.

Interview on 10/10/2018 at 1215 with the Director of Quality Management revealed the nursing staff were expected to follow the physician orders. Interview confirmed the nursing staff failed to follow the hospital policy for obtaining vital signs per the physician orders.


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3. Review on 10/09/2018 of closed medical record for patient # 2 revealed a 54 year old female patient admitted on 06/07/2018 with a diagnosis of Intravenous antibiotic treatment for multi drug resistant organism and urinary tract infection and discharged on 06/22/2018. Review of the physician orders on 06/07/2018 revealed an order for vital signs every four (4) hours. Review of the Frequent Monitoring Vital Signs Sheet from 06/17/2018 through 06/22/2018 revealed no available documentation of vital signs on 06/17/2018 at 0000, on 06/19/2018 at 0000 and on 06/21/2018 at 0000. Review of the medical record revealed evidence that the nursing staff failed to follow the physician order to obtain vital signs every four (4) hours.

Interview on 10/10/2018 at 1215 with the Director of Quality Management revealed the nursing staff were expected to follow the physician orders. Interview confirmed the nursing staff failed to follow the hospital policy for obtaining vital signs per the physician orders.

Based on hospital policy and procedure review, medical record review, incident report review and staff interviews, the nursing staff failed to follow the hospital drug administration procedure to ensure the right patient received the right drug for 1 of 10 sampled records (Patient # 7).

Review on 10/10/2018 of the hospital policy and procedure titled "Administration of Drugs" revised January 2018 revealed, "...Drugs to be administered should be compared with the MAR (medication administration record) to ensure that the dose and label is correct and that the drug is not contraindicated by allergy, sensitivity, or diagnosis. ... The drug label should be read at least three times: a. when picking up the drug, b. Just prior to administration, c. just after administration. ...Before administration of any drug, the five rights should be reviewed: a. Right patient, b. Right drug, c. Right dose, d. Right route, e. Right time... The patient must be identified before drugs are administered according to institution policy using 2 patient identifiers."

Open medical record review on 10/10/2018 for Patient #7 revealed, a 44 year old female patient admitted on 10/05/2018 for basilar artery thrombus, multiple infarcts (Stroke). Review of the physician orders revealed an order on 10/05/2018 at 1456 for Zosyn 3.375grams to infuse over four hours every eight hours. Review of the Medication Administration Record revealed RN (registered nurse) #1 (primary nurse) documented she administered Zosyn (antibiotic) on 10/09/2018 at 1330. Review of the nursing notes on 10/09/2018 by RN # 1 at 1420 revealed, "Nurse noticed med error and stop IV (intravenous) abx (antibiotic). Merrem (antibiotic) 1g (gram) IV was hanging and should have been Zosyn 3.375g." Review of the nurses' note written by RN#1 revealed the antibiotic had infused approximately 50 minutes prior to RN #1 recognizing the error and stopping the infusion. Review of the nursing notes at 1428 revealed, the pharmacy was notified of the medication error. Review of nursing notes at 1433 revealed, "Spoke with PA (physician assistant) about med (medication) error. PA and pharmacy states that there should not be a problem."

Review on 10/10/2018 of the incident report on 10/09/2018 revealed, RN #1 (primary nurse) stated, "I had two scheduled antibiotics on different patients. I primed both lines in the med room and took to floor. I got stopped in the middle of going into the room and when I resumed I picked the wrong IV antibiotic up."

Interview on 10/10/2018 at 1600 with RN # 1 revealed, she had been in the room for a long time doing "a lot of tasks". She stated family was in the room and very talkative. She stated the family was distracting, but she did not want to be rude, so she did not ask them to stop to give her a moment to work. She stated patient had several IV lines and she did not look at the antibiotic once she hung it. She stated she was very backed up and running late with care. She stated she discovered the medication error when she went to hang the second antibiotic she had removed simultaneously from the medication room for another patient. She stated she did not hang the wrong antibiotic on second patient. She stated she stopped the medication and called the physician and pharmacist for direction. She stated pharmacy reviewed allergies and potential interactions and told her patient should be ok.

Interview on 10/10/2018 at 1645 with the Director of Quality Management revealed the nursing staff were expected to follow the policy and procedures for administration of drugs. Interview confirmed the nursing staff failed to follow the hospital policy for administration of drugs.

NC00142549