Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 530033	(X3) Date Survey Completed 10/23/2013
Name of Provider or Supplier Mountain View Regional Hospital	Street Address, City, State 6550 East 2nd Street, Casper, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag

Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)

A0395

RN SUPERVISION OF NURSING CARE
CFR(s): 482.23(b)(3)

A registered nurse must supervise and evaluate the nursing care for each patient.

This STANDARD is not met as evidenced by:
Based on staff interview, medical record review, and review of the nursing facility death records, the hospital failed to ensure nursing assessment, monitoring, and implementation of nursing measures were provided for 1 of 7 sample patients (#3). The findings were: Review of the medical record showed patient #3 was admitted on 5/21/13 with diagnoses including lumbar spinal stenosis, lumbar radiculopathy, lumbar spondylosis, and neurogenic claudication. Review of the operative report showed the patient had a complete L4 decompressive lumbar laminectomy with bilateral open facet rhizotomies, medial facetectomies, and foraminotomies performed on 5/21/13. On 5/25/13 the patient had an unplanned additional surgical procedure which included exploration of the lumbar wound and L3 decompression with L2-L3 diskectomy. The following concern was identified: Review of the physician's post-operative orders dated 5/21/13 and timed at 10:15 AM showed bowel management orders included Colace 100 mg twice daily when able to take oral fluids. In addition, there was an order that "If no BM [bowel movement] by 2nd day post-op start bisacodyl suppository 1 per rectum BID [twice daily] until patient has results." Review of the 5/21/13 physician's standing orders, also timed at 10:15 AM, showed bowel management orders for Colace 100 mg twice daily as needed and could use liquid if the patient was unable to swallow a tablet. Also ordered was MOM (milk of magnesia) 30 ml (milliliters) daily as needed, bisacodyl 10 mg rectal suppository as needed, magnesium citrate 1/2 to 1 bottle daily as needed, and finally a Fleets enema per rectum every 2nd day as needed. Review of the nursing notes showed the patient had a BM on the day of admission but not again for 7 days; the patient had no BM as of the time of discharge on 5/28/13. Review of the May 2013 MAR showed the patient was administered Colace and a bisacodyl suppository at 2:56 PM on 5/21/13 and MOM on that same day at 8:13 PM. The patient was administered the Colace twice daily as ordered. The patient received MOM on 5/26/13, 5/27/13 and on 5/28/13. However, none of these medications were effective in producing a BM. Review of the 5/27/13 nursing notes timed at 7 AM showed the patient was bloated and constipated. Review of the physician's orders dated 5/27/13 showed the nurse activated the standing order for magnesium citrate (previously ordered) at 6:57 AM. Review of the 5/27/13 nursing notes timed at 7:26 PM showed the patient remained bloated and constipated and had no flatus. On 5/28/13 at 7:45 AM the nursing notes indicated the patient was nauseous, had a distended and firm abdomen, and was constipated. Review of the 5/28/13 physical therapy notes timed at 9:25 AM showed "unable to fit brace at this time d/t [due to] abd [abdominal] distention." There was no evidence any interventions other than the routine Colace and the PRN MOM and magnesium citrate were provided despite having other physician orders available if these medications were ineffective. Review of the physician's post-operative orders showed a specific order for the patient to have bowel treatments until there were results after the 2nd post-operative day, including a Fleets enema if necessary. The patient was discharged on 5/28/13 at 10:23 AM to a nursing home without having had a BM for 7 days and had experienced bloating, nausea, abdominal distention and firmness significant enough to make it impossible for the physical therapist to place the lumbar brace on the patient. Interview with the DON on 10/23/13 at 10:20 AM revealed it was unacceptable to allow a patient to go 7 days without a BM, especially when there were physician orders available for use. The DON further stated it should not have happened and he was unsure why the patient was discharged without having had a BM post-operatively. Review of the nursing facility death record showed the patient's abdomen was distended and tender upon admission. The nursing facility physician ordered a double Fleets enema "now" on 5/28/13, the day of admission. According to the nursing facility nursing notes, the patient was found dead at 4:20 AM on the morning of 5/29/13, less than 24 hours after transfer from the hospital.