HospitalInspections.org

Based on review of medical records and staff interviews, facility staff failed to provide wound care as ordered by the physician for 2 of 2 records reviewed of patients with wounds requiring wound care (#3, #2).

Findings included:

1. Closed record review on 5/10/2012 of Patient #3 revealed a 66 year old admitted 10/20/2011 and discharged 11/24/2011 for acute respiratory failure and end stage renal disease requiring hemodialysis. Review of Wound Treatment Orders dated 10/21/2011 revealed "Wound Location: Perineum...Frequency...Daily...PRN (as needed)...Creams...Extra Protective Cream". Review revealed on the following dates there was no documented evidence the wound treatment was provided as ordered: 10/27/2011, 10/29/2011, 11/13/2011, 11/14/2011, 11/15/2011, 11/17/2011 and 11/18/2011 (7 of 35 total days hospitalized or not performed 20% of the time).

Interview on 5/10/2012 at 1000 with a facility wound care nurse revealed the order for Patient #3's wound care was to apply the protective cream at least daily. Interview failed to reveal any documented evidence staff provided the daily wound care as ordered.

2. Closed record review on 5/09/2012 of Patient #2 revealed an 86 year old admitted 10/11/2011 and discharged 10/31/2011 for respiratory failure. Review of Wound Treatment Orders dated 10/18/2011 revealed "Wound Location: Sacral/Gluteus...Apply Skin Prep to periwound, Frequency...Every 3 days...PRN...Cover Dressing...Tegaderm Adhesive Foam...Specialty Dressing...Vaseline Gauze". Review revealed the sacral/gluteal dressing was applied on 10/18/2011, 10/21/2011, 10/24/2011 and not again until 10/28/2011 (four [4] days).

Interview on 5/10/2012 at 1000 with a facility wound care nurse revealed the order for Patient #2's wound care was to perform wound care with dressing change at least every three (3) days. Interview failed to reveal any documented evidence staff changed the dressing from 10/21/2011 through 10/28/2011. Interview revealed staff "should have changed the dressing on 10/27/2011".

Based on review of medical records and staff interview, pharmacy staff failed to profile a medication as ordered by the physician for 1 of 3 records reviewed (#3).

Findings included:

Closed record review on 5/10/2012 for Patient #3 revealed a 66 year old admitted 10/20/2011 and discharged 11/24/2011 for respiratory failure and end stage renal disease requiring hemodialysis. Review revealed a physician's order written 11/04/2011 at 1005 "give Ativan 0.5mg IV only prior to each dialysis tx (treatment)". Review of the Medication Administration Record (MAR) for 11/05/2011 revealed electronic transcription of the physician's order written 11/04/2011 at 1005 for the pre-dialysis Ativan was transcribed onto the electronic MAR as "Lorazepam (Ativan) 0.5mg IV (intravenous) Tuesday, Thursday, Saturday @ 1000...prn anxiety." Further review of MARs from 11/05/2011 through 11/08/2011 revealed the Ativan was scheduled for 1000 on 11/05/11 (Saturday) and on 11/08/2011 (Tuesday). Review of nursing documentation for 11/05/2012 at 1230 revealed "Pt (Patient) returned from dialysis pt upset refused scheduled Ativan Daughter at BS (bedside)..." Review of the 11/05/2012 MAR revealed documentation by the pre-dialysis Ativan "Pt refused". Review revealed nursing staff attempted to administer the pre-dialysis Ativan at 1230, after the patient had finished the dialysis treatment, however, the patient refused the Ativan.

Interview on 5/10/2012 at 1225 with the hospital's pharmacy director revealed all medication orders are reviewed by the pharmacist and profiled onto the MAR by the pharmacist. Review revealed the Ativan ordered to be a pre-dialysis dose on 11/04/2012 at 1005 should not be administered after the dialysis treatment had ended. Interview revealed the way the Ativan was profiled on the MAR as a scheduled medication"is a glitch in this (MAR) system." Interview revealed "I am afraid if I put it (the medication) on the MAR as an unscheduled dose, it would be missed." Interview revealed "I can see how the way it is transcribed on the MAR could be confusing."

Based on review of facility policies and procedures, review of medical records and staff interview respiratory therapy (RT) staff failed to provide services per physician's order and per medical staff policies and procedures for 1 of 3 records reviewed of patients receiving RT services (#3).

Findings included:

Review on 5/10/2012 of facility policy "Policy: Oxygen will be administered for the treatment of tissue hypoxia by order of a physician...The nurse or respiratory therapist will contact the physician to notify changes in patient status."

Closed record review on 5/10/2012 for Patient #3 revealed a 66 year old admitted 10/20/2011 and discharged 11/24/2011 for respiratory failure and end-stage renal disease requiring hemodialysis. Review of pre-printed physician admission orders written 10/20/2011 at 1006 revealed "17. Respiratory...(check mark) CPAP (continuous positive airway pressure oxygen therapy) nightly..." Record review for the patient's entire stay at the hospital failed to reveal any documentation the patient was on CPAP during the hospital stay and failed to reveal any documentation the physician discontinued the CPAP at any time during the hospital stay.

Interview on 5/10/2012 at 1310 with the hospitalist physician who ordered the CPAP on 10/20/2011 for Patient #3 revealed the patient needed CPAP at night related to her obstructive sleep apnea. Interview revealed the patient was on CPAP at home related to the condition. Interview revealed "I thought she was getting the CPAP." Interview revealed "I would not have discontinued the CPAP since she was on it prior to the hospitalization."

Interview on 5/10/2012 at 1200 with the respiratory therapy services director revealed "I do not see any documentation the patient was ever on CPAP while a patient here." Interview revealed there was a physician's order for the CPAP at night. Interview failed to reveal any further documentation the patient was on CPAP during the hospital stay or any documentation by staff to note a conversation with the physician about the CPAP order. Interview revealed staff failed to implement a physician's order for CPAP respiratory therapy.

Review on 5/10/2012 of facility policy "Pulse Oximetry" dated 3/08/2006 revealed "Responsibility: Respiratory Care Staff, Procedure:...VII...D. Patients on Low flow nasal cannula - 1. Chart SpO2 on treatment flow sheet under the spot check SpO2 section once per shift and PRN."

Further record review for Patient #3 revealed the patient was receiving oxygen therapy by nasal cannula. Review revealed pulse oximetry (SpO2) checks were performed at 2134 on 11/16/2011 and not again until 2245 on 11/17/2011 (25 hours and 11 minutes between checks) and not again until 1618 on 11/18/2011 (17 hours and 33 minutes between checks).

Interview on 5/10/2012 at 1245 with administrative staff revealed the spot checks should be performed every shift, or at least every 12 hours. Interview revealed from 11/16/2011 through 11/18/2011 respiratory therapy staff failed to monitor the patient's oxygen levels by pulse oximetry as defined by hospital policy. Interview failed to reveal any further documentation the SpO2 checks were performed as per hospital policy.

NC00076505 and NC00077543

Based on review of facility policies and procedures, review of medical records and staff interviews, nursing staff failed to administer "as needed" (PRN) medications as per facility policy and procedure and failed to document injection sites for injectable medications for 3 of 3 records reviewed (#5, #3, #2).

Findings included:

Review on 5/10/2012 of facility policy "Pain Management, Assessment and Intervention Protocol" dated 10/01/2010 revealed "Procedure...3. Progression of Pain Management...B. For moderate to severe pain, management may progress in the following manner: 1) Acetaminophen or NSAIDS or ordered PO (oral) pain med, 2) IM or IV analgesic medications..."

Review on 5/10/2012 of facility policy "Medication Administration" dated 12/15/2011 revealed "Policy...21. Follow the '6 Rights' of medication administration. Administer...6. In the right circumstance...Documentation...D. Location of subcutaneous (SC) and intramuscular (IM) injections will be documented on MAR (Medication Administration Record)".

1. Open record review on 5/09/2012 for Patient #5 revealed a 48 year old admitted 3/08/2012 for respiratory failure. Review of nursing documentation on 5/06/2012 at 1000 revealed "Patient complains of pain 10/10 PRN given ..." Review of Medication Administration Records (MAR) revealed on 5/06/2012 at 1000 the patient was administered Oxycodone 5mg (milligrams) orally and Morphine Sulfate 2mg IV (intravenously) also at 1000. Review revealed Morphine Sulfate 1mg IV was available as a minimum dose, but the patient was given the maximum dose of 2mg.

Further review of MARs for Patient #5 revealed on the following dates and times, the patient was administered subcutaneous (SC) insulin with no injection sites documented:
- on 5/07/2012 at 2100 received 75 Units of Levamir insulin with no injection site documented.
- on 5/08/2012 at 2400 received 4 Units and at 0600 received 1 Unit of Humalog insulin with no injection sites documented.

Interview on 5/10/2012 at 1140 nursing administrative staff revealed unless otherwise ordered by the physician, the nurse should first administer oral pain medications and assess for effectiveness and if ineffective administer any ordered IM or IV medications at the lowest dose first and assess for effectiveness. Interview failed to reveal any documented reason why Patient #5 was administered the oral pain medication Oxycodone and the IV medication Morphine Sulfate at the maximum ordered dose at the same time for the patient's complaint of pain. Further interview revealed staff must document injection sites when SC or IM medications are administered. Interview revealed on the dates listed the patient received SC Humalog insulin and staff failed to document injection sites. Interview revealed staff failed to follow medication administration policy and procedure for PRN pain medication administration and failed to document injection sites with SC medication administration.

2. Closed record review on 5/10/2012 for Patient #3 revealed a 66 year old admitted 10/20/2011 and discharged 11/24/2011 for respiratory failure and end stage renal disease requiring hemodialysis. Review revealed pre-printed physician's orders authenticated by the physician on 10/20/2011 at 1450 which had an order for the medication Lorazepam (Ativan) 0.5mg PO/PT (per gastric tube)/IM/IV as needed for anxiety and an order for the medication Diphenhydramine (Benadryl) 12.5-25mg PO/PT/IV every 6 hours as needed for itching. Review of documentation on the MAR revealed on 10/22/2011 at 0720 and 1625 and on 10/23/2011 at 0140 the patient was administered Ativan 0.5mg with no route of administration documented and no indication as to why the medication was administered. Review of the MAR revealed on 10/29/2011 at 1930, on 10/31/2011 at 2200 and on 11/01/2011 at 2145 the patient was administered Diphenhydramine 25mg IV with no documentation of a reason why the patient was administered the medication. Review of the MAR revealed on 10/31/2011 at 1130 the patient was administered Diphenhydramine 12.5mg IV with no documented reason why the patient was administered the medication. Review revealed on 11/04/2011 at 0400 the patient was administered Ativan 0.5mg IV with no documented reason why the medication was administered.

Further review of MARs for Patient #3 revealed on the following dates and times, the patient was administered SC insulin with no injection sites documented:
- on 10/23/2011 at 2400 received 1 Unit of Humalog insulin with no injection site documented.
- on 10/29/2011 at 1800 received 1 Unit of Humalog insulin with no injection site documented.
- on 11/04/2011 at 2400 received 1 Unit of Humalog insulin with no injection site documented.
- on 11/06/2011 at 1200 and on 11/07/2011 at 2400, 0600, 1200 and 1800 received 1 Unit of Humalog insulin with no injection sites documented.
- on 11/11/2011 at 2200 received 1 Unit of Humalog insulin with no injection site documented.
- on 11/13/2011 at 2400, 1200 and 1800 received 1 Unit of Humalog insulin with no injection site documented.

Interview on 5/10/2012 at 1130 nursing administrative staff revealed PRN medications should have a reason documented as to why the medication was administered. Interview failed to reveal any documented evidence why the Ativan was administered to Patient #3 on 10/22/2011 at 0720 and 1625, on 10/23/2011 at 0140 and on 11/04/2011 at 0400. Interview failed to reveal any documented evidence why the Diphenhydramine was administered to Patient #3 on 10/29/2011 at 1930, on 10/31/2011 at 2200, on 11/01/2011 at 2145, and on 10/31/2011 at 1130. Interview revealed staff must document the route a medication is administered and specific injection sites when injectable medications are administered. Interview revealed on 10/23/2011 at 0140 staff failed to indicate if the Ativan 0.5mg was administered IM or IV and on the dates listed where the patient received SC Humalog insulin, staff failed to document specific injection sites. Interview revealed staff failed to follow medication administration policy and procedure by failing to indicate why a PRN pain medication was administered and failed to document the route of administration and specific injection sites with SC medication administration.

3. Closed record review on 5/09/2012 for Patient #2 revealed an 86 year old admitted 10/11/2011 and discharged 10/31/2011 for respiratory failure. Review revealed a physician's order written 10/11/2011 at 1354 for the oral pain medication Oxycodone 5mg (milligrams) every six hours as needed. Review revealed the patient was administered Oxycodone 5mg orally on 10/22/2011 at 2215. Review of documentation failed to reveal any reason as to why the medication was administered. Review of nursing documentation of the most recent pain assessment prior to the Oxycodone administration on 10/22/2011 at 2215 revealed at 2200 the patient's pain level was "0" (no pain). Review revealed the patient was administered Oxycodone 5 mg orally on 10/27/2011 at 2230. Review of documentation failed to reveal any reason as to why the medication was administered. Review of nursing documentation of the most recent pain assessment prior to the Oxycodone administration on 10/27/2011 at 2040 revealed "...Pt A&Ox3 (fully alert and oriented) with periods of confusion...Denied...pain."

Further review of medication administration for Patient #2 revealed on the following dates and times, the patient was administered SC medications with no injection sites documented:

- on 10/14/2011 at 2200 received 4 Units of Humalog insulin with no injection site documented.
- on 10/15/2011 at 2200 received 4 Units of Humalog insulin with no injection site documented.
- on 10/17/2011 at 2200 received 8 Units of Humalog insulin with no injection site documented.
- on 10/18/2011 at 2200 received 6 Units of Humalog insulin with no injection site documented.
- on 10/27/2011 at 2200 received 10 Units of Humalog insulin with no injection site documented.

Interview on 5/10/2012 at 1130 nursing administrative staff revealed PRN medications should have a reason documented as to why the medication was administered. Interview failed to reveal any documented evidence why the Oxycodone was administered to Patient #2 on 10/22/2011 at 2215 or on 10/27/2011 at 2230. Interview revealed staff must document injection sites when SC or IM medications are administered. Interview revealed on the dates listed the patient received SC Humalog insulin and staff failed to document injection sites. Interview revealed staff failed to follow medication administration policy and procedure by failing to indicate why a PRN pain medication was administered and failed to document injection sites with SC medication administration.