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UNIVERSITY OF MD CAPITAL REGION MEDICAL CENTER
PATIENT RIGHTS: NOTICE OF RIGHTS
Tag No.: A0117
Based on record review of 4 open medical records and 8 closed medical records it was determined that two Medicare recipients had unsigned or were missing the Important Message (IM) from Medicare.
Patient #2 had been in hospital for 5 days at time of survey with an unsigned initial Important Message in chart. Patient #1 was admitted for 23 days and had missing second IM from Medicare.
ORGANIZATION OF NURSING SERVICES
Tag No.: A0386
Based on review of 4 registered nurse (RN) personnel files and it was determined that two RN's did not have an updated clinical evaluation. RN #2 last performance evaluation was in June of 2015. RN #4 last performance evaluation was in May 2015.
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based on record review of 4 open medical records and 8 closed medical records it was determined that patient #1's care lacked sufficient evidence that care was provided according to accepted nursing standards.
Patient #1 was an elderly obese patient with numerous co-morbidities who presented to the Emergency Department (ED) by Emergency Medical Services (EMS) in November 2016 after falling down stairs. His work up revealed a right hip fracture. Patient #1 was admitted to the hospital for further evaluation and management. He had surgical reconstruction done to his hip. Status post-surgery he was transferred to the post-anesthesia care unit (PACU) under the services of the critical care team because of critical care bed shortages. He was in the PACU for 7 days and later transferred to the Critical Care Center (CCC). The patient was in the CCC for longer than expected due to an inability to be weaned off mechanical ventilation support. He was extubated (removal of the endotracheal tube) 12 days post-surgery and discharged to sub-acute rehab.
Patient #1 developed loose stools shortly after being started on tube feeding. Placement of a rectal tube for fecal management and skin protection was ordered. Per chart review patient #1 had first bowel movement on 11/19 of loose stool and consistently thereafter of watery or liquid stool up till 11/23.
No bed bath or perineal care was documented between 11/17 at 4: 00 PM to 11/21 at 12 am. Specialty bed was ordered on 11/17. Interview with PACU manager on 2/9/17 revealed that a Hoyer lift was not in unit during the time patient was there.
The nursing staff failed to document patient's hygiene care for some days during patients PACU stay.