HospitalInspections.org

Based on review of hospital policies and procedures, medical record review, observations and staff interview, the nursing staff failed to assess and monitor patients per physician orders for 4 of 7 sampled post-operative patients (Patient #1, #2, #3 and #4).

Findings Included:

Review on 09/26/2018 of the hospital policy and procedure titled "Nursing Process and Physical Assessment Standards" approved 10/09/2015 revealed "Policy: ...Assessment of additional physical parameters ...should be performed as appropriated based on the patient's clinical condition, presence of abnormal findings, suspected problems, and/or as ordered by the physician."

Review of a policy and procedure titled, "Nursing Process and Physical Assessment Standards", approved by Council October 9,2015 revealed, ..."Assessment: refers to the nurses` assessment of the patient on admission to include the Health History and physical assessment as well as ongoing assessments the nurse performs throughout the patient`s stay. ...A full assessment will be documented at least once during a standard 12-hour shift. Focused assessments will be performed and documented as dictated by patient condition and /or physician order."

Review of a policy and procedure titled, "Scope of Service 5 North Orthopedic Department", revised 7/13/2013 revealed, " ...Routine vital signs every 8 hours."

1. Review on 09/25/2018 of the open medical record for Patient #1 revealed a seventy-six year old female admitted on 09/24/2018 at 0509 with a diagnosis of fall with right hip fracture. Review of the medical record revealed Patient #1 underwent a Right Total Hip Arthroplasty on 09/25/2018. Review of the physician orders dated 09/25/2018 at 1858 revealed a post-operative order to assess vital signs (Temperature, Heart Rate, Respiratory Rate and Blood Pressure) every hour times four (4), then every four (4) hours. Review of the nursing notes revealed Patient #1 returned to the Orthopedic Unit from the Operating Room (OR) on 09/25/2018 at 1821. Review of the nursing vital signs flowsheet revealed documentation of vital signs (Heart Rate, Respiratory Rate and Blood Pressure) on 09/25/2018 at 1814 (no documented temperature). Further review of the nursing vital signs flowsheet revealed the next available documentation of vital signs was on 09/25/2018 at 2141 (3 hours and 25 minutes later). Further review of the nursing vital signs flowsheet revealed the next available documentation of vital signs was on 09/26/2018 at 0450 (7 hours and 9 minutes later). Review of the medical record revealed no evidence of vital signs documentation on 09/26/2018 from 0450 through 1000. Review of the medical record revealed no available documentation of hourly vital signs post-operatively times four (4) and no documentation of every four hours vital signs following the completion of the hourly vital signs.

Review of the physician orders dated 09/25/2018 at 1858 revealed a post-operative order for neurovascular checks every hour times four (4), then every four (4) hours. Review of the nursing flowsheet revealed documentation of a neurovascular assessment on 09/25/2018 at 1814. Further review of the nursing flowsheet revealed the next available documentation of a neurovascular assessment was on 09/25/2018 at 2008 (1hour and 54 minutes later). Review of the medical record revealed no further available documentation of the post-operative neurovascular assessments.

Review of the physician orders dated 09/25/2018 at 1858 revealed a post-operative order for a bed with an overhead patient helper or overhead frame with a trapeze bar with nursing instructions to page/call orthopedic technician with new orders. Review of the nursing flowsheet revealed documentation of a musculoskeletal assessment on 09/25/2018 at 1814 with documentation of right lower extremity with limited movement with no documentation of assistive devices. Further review of the nursing flowsheet revealed documentation of a musculoskeletal assessment on 09/25/2018 at 2008 with documentation of limited movement of right lower extremity, weight bearing restrictions and assistive devices documented as "None". Continued review of the nursing flowsheet revealed documentation of a musculoskeletal assessment on 09/26/2018 at 1000 with assistive devices documented as "None".

Observations during tour of the orthopedic unit on 09/26/2018 at 1300 revealed Patient #1 did not have an assistive device (overhead patient helper or overhead frame with a trapeze bar) as ordered by the physician on 09/25/2018 at 1858.

Interview on 09/26/2018 at 1500 with NM #1 revealed staff are expected to assess and monitor patients as per the physicians' orders. She stated staff are expected to document assessments in the electronic medical record per hospital policy. Interview confirmed the nursing staff failed to document vital signs assistive devices and neurovascular assessments per the physicians' orders.

2. Review on 09/25/2018 of the open medical record for Patient #2 revealed an eighty-six year old female admitted on 09/22/2018 at 1241 with a diagnosis of displaced left femoral neck fracture. Review of the medical record revealed Patient #2 underwent a Left Hip Hemiarthroplasty on 09/24/2018. Review of the physician orders dated 09/24/2018 at 2100 revealed a post-operative order to assess vital signs (Temperature, Heart Rate, Respiratory Rate and Blood Pressure) every fifteen (15) minutes times one (1) hour, then every hour times four (4), then routine (every eight [8] hours). Review of the nursing notes revealed Patient #2 returned to the Orthopedic Unit from the Operating Room (OR) on 09/24/2018 at 2025. Review of the nursing vital signs flowsheet revealed documentation of vital signs (Heart Rate, Respiratory Rate and Blood Pressure) on 09/24/2018 at 2030. Further review of the nursing vital signs flowsheet revealed the next available documentation of temperature, heart rate, respiratory rate and blood pressure was on 09/25/2018 at 0527 (8 hours and 57 minutes later). Review of the medical record revealed no available documentation of every 15 minutes vital signs post-operatively times one hour and no documentation of vital signs every hour times four (4) per physician orders.

Review of the physician orders dated 09/24/2018 at 2100 revealed a post-operative order for neurovascular checks every fifteen (15) minutes times one (1) hour, then every hour times four (4), then routine (every eight [8] hours). Review of the nursing flowsheet revealed documentation of a neurovascular assessment on 09/24/2018 at 2030. Further review of the nursing flowsheet revealed the next available documentation of a neurovascular assessment was on 09/25/2018 at 0923 (12 hours and 53 minutes later).

Review of the physician orders dated 09/24/2018 at 2100 revealed a post-operative order for a bed with an overhead patient helper or overhead frame with a trapeze bar with nursing instructions to page/call orthopedic technician with new orders. Review of the nursing flowsheet revealed documentation of a musculoskeletal assessment on 09/24/2018 at 2130 with documentation of bedside commode and front wheel walker assistive devices. Further review of the nursing flowsheet revealed no available documentation of an overhead patient helper or overhead frame with a trapeze bar as ordered by the physician on 09/24/2018 at 2100.

Observations during tour of the orthopedic unit on 09/26/2018 at 1300 revealed Patient #2 did not have an assistive device (overhead patient helper or overhead frame with a trapeze bar) as ordered by the physician on 09/25/2018 at 1858.

Review of the physician orders dated 09/24/2018 at 1746 revealed an order for ice to the operative site times twenty-four (24) hours and as needed for pain. Review of the nursing flowsheet revealed no available documentation of ice applied to the operative site as ordered by the physician on 09/24/2018 at 1746.

Interview on 09/26/2018 at 1500 with NM #1 revealed staff are expected to assess and monitor patients as per the physicians' orders. She stated staff are expected to document assessments in the electronic medical record per hospital policy. Interview confirmed the nursing staff failed to document vital signs, assistive devices and neurovascular assessments per the physicians' orders.


40284

3. Closed medical record review on 09/25/2018 of Patient #4 revealed a 72 year old female was admitted on 08/20/2018 at 1505 for right hip arthroplasty. Review of the medical record revealed patient underwent a Right Hip Arthroplasty on 08/20/2018.
Review of the physician orders dated 08/20/2018 at 1637 post surgery revealed neurovascular checks every 1 hour times 4, then every 4 hours times 24 hours, then every 8 hours. Review of the nursing assessments on 08/20/2018 at 1645 revealed an initial assessment on the orthopedic unit was performed. Subsequent assessments were documented on 08/21/2018 at 1033 (17 hours and 45 minutes later) and 08/22/2018 at 1200 (22 hours and 30 minutes later). Review of the medical record revealed no further available documentation of post-operative neurovascular assessments.

Review of the physician orders dated 08/20/2018 at 1637 post surgery revealed and vital signs every 1 hour times 4, then every four 4 hours times 24 hours then every 8 hours. Review revealed on 08/20/2018 prior to arrival to orthopedic unit vital signs documented at 1616, then at 2100 (3 hours and 44 minutes later) on orthopedic unit. Subsequent vital signs documented on 08/21/2018 at 0544 (8 hours and 44 minutes later), 1934 (13 hours and 50 minutes later), 2053 (1 hour and 20 minutes later) and 08/22/2018 at 0523 (7 hours and 30 minutes later). Review revealed no further available documentation of vital signs as ordered on the orthopedic unit.

Review of the physician orders dated 08/20/2018 at 1637 post surgery revealed apply cold therapy to the operative site for 24 hours and as needed for pain. Record review revealed cold therapy documented once on 08/21/2018 at 1000 (17 hours and 30 minutes later). Review revealed no further documentation of cold therapy available.

Review of the physician orders dated 08/20/2018 at 1637 post surgery revealed overhead frame and bar with trapeze. Further review revealed no documentation of overhead frame and bar with trapeze.

Interview on 09/26/2018 at 1500 with NM #1 revealed staff are expected to assess and monitor patients as per the physicians' orders. She stated staff are expected to document assessments in the electronic medical record per hospital policy. Interview confirmed the nursing staff failed to document vital signs assistive devices and neurovascular assessments per the physicians' orders.

Telephone Interview on 09/26/2018 at 1525 with the 5 North Department Director revealed, the work list for equipment such as overhead frame and bar for trapeze are generated by physician orders. It is ultimately the nurse's responsibility for any orders written by physicians.

4. Closed medical record review on 09/26/2018 of patient #3 revealed a 58 year old male admitted for right hip arthroplasty. Review of the medical record revealed patient underwent a Right Hip Arthroplasty on 08/20/2018. Patient was discharged on 08/21/2018 at 1738.
Review of the physician orders dated 08/20/2018 at 1557 revealed a post-operative order for neurovascular checks every 1 hour times 4, then every 4 hours times 24 hours, then every 8 hours. Patient handed off to orthopedic unit at 1613. Review of nursing assessments revealed documentation of neurovascular checks on 08/20/2018 at 1932 (3 hours and 35 minutes later), then 08/21/2018 at 0815 (12 hours and 43 minutes later). Review of the medical record revealed no further available documentation of post-operative neurovascular assessments.

Review of the physician orders dated 08/20/2018 at 1557 post surgery revealed and vital signs every 1 hour times 4, then every four 4 hours times 24 hours then every 8 hours. Review of vital signs revealed no documentation between 0513 and 1416 on 08/21/2018 (9 hours and 3 minutes).

Review of the physician orders dated 08/20/2018 at 1557 post surgery revealed apply cold therapy to the operative site for 24 hours and as needed for pain. Review revealed no documentation of cold therapy applied.

Review of the physician orders dated 08/20/2018 at 1557 post surgery revealed overhead frame and bar with trapeze. Further review revealed no documentation of overhead frame and bar with trapeze.

Interview on 09/26/2018 at 1500 with NM #1 revealed staff are expected to assess and monitor patients as per the physicians' orders. She stated staff are expected to document assessments in the electronic medical record per hospital policy. Interview confirmed the nursing staff failed to document vital signs assistive devices and neurovascular assessments per the physicians' orders.

Phone Interview on 09/26/2018 at 1525 with Orthopedic Department Director revealed, the work list for equipment such as overhead frame and bar for trapeze generated for the Orthopedic Technicians from physician orders are not monitored. If it is not done the Registered Nurse should be calling the Orthopedic Technicians.