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Based on clinical record review and staff interview, it was determined the facility failed to ensure the medical record adequately documented treatment and services provided and the patient's response. Findings:

1. Patient #3 was treated with intravenous fluids. The electronic intake and output record did not allow for documentation of a shift total or of 24 hour totals of IV fluids administered. The intake and output record did not document oral intake. When staff were asked to review the intake and output record, they could not determine if the documentation of intake was oral or intravenous fluid. Upon further review, the staff determined the form documented IV fluids administered only. There was no documentation of oral intake.

The staff agreed there was also no documentation of shift or daily totals for any forms of intake and output.

2. Patient #3 was provided with an electronic form that documented discharge instructions. The form populated data from the clinical record and provided information and instructions in medical language and abbreviations the patient was not likely to understand. Staff stated the form was generated automatically based on data included in the clinical record and through "built-in" choices of discharge instructions. The staff agreed the discharge instructions were not provided in a manner the patient could understand.




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Based on clinical record review and staff interview, it was determined the facility failed to ensure the medical record adequately documented treatment and services provided and the patient's response. Findings:

1. Patient #3 was treated with intravenous fluids. The electronic intake and output record did not allow for documentation of a shift total or of 24 hour totals of IV fluids administered. The intake and output record did not document oral intake. When staff were asked to review the intake and output record, they could not determine if the documentation of intake was oral or intravenous fluid. Upon further review, the staff determined the form documented IV fluids administered only. They agreed there was no documentation of oral intake.

The staff agreed there was also no documentation of shift or daily totals for any forms of intake and output.

2. Patient #1 was treated with oxygen therapy. The electronic vital signs record at times, documented "O2" and nothing else. Staff were asked if the record should document how much oxygen was administered (flow rate) and the method of administration, i.e. mask, nasal cannula, etc. They stated it should.

This patient's clinical record documented the patient received discharge instructions on oxygen therapy. There was no documentation in the electronic record of a physician's order for oxygen therapy at home. There was no consistent documentation of oxygen therapy administered during the hospitalization and no documentation of the patient's oxygen present or not, at the time of discharge.

3. Patient #5 - on 09/09/2012, the patient was discharged from the acute care medical unit and admitted to the geriatric psychiatric (gero psych) unit. The physician's admission orders did not include all the medications charted as given to the patient while on the gero psych unit. The admission order contained a notation to see the discharge medication orders. The discharge orders contained in this section were generated on 09/12/2012, the date of the patient's discharge from the gero psych stay. The computer generated physician authenticated acute care discharge medication orders for 09/09/2012 were filed in the discharge order section for gero psych stay. This finding was reviewed and confirmed with Staff A, B and C at the time of review on 09/18/2012.




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