HospitalInspections.org

Based on document review, and interview it was determined that for 1 of 1 (Pt. #1) clinical record reviewed of a patient requiring a surgical procedure, the Hospital failed to ensure the patient was informed prior to the procedure.

Findings include;

1. The clinical record for Pt. #1 was reviewed on 5/15/2018 at approximately 1:00 PM. Pt. #1 was a 54 year old female, who was admitted on 3/8/2018, for exploratory laparotomy [procedure to open abdomen] for colostomy takedown and correction of colorectal anastomosis (procedure in which the colon is attached to remainder of colon). On 5/23/18, Pt #1 was scheduled for the placement of a Quinton Catheter (central line used for dialysis). Pt #1's clinical record contained a consent form dated 3/23/2018 for insertion of the Quinton Catheter (central line used for dialysis). The consent lacked a signature by the surgeon performing the procedure, that would have indicated, "The matters set forth in Paragraph 2 above have been explained by me to the patient."

2. The Hospital's policy titled "Patient Rights and Organizational Ethics/Informed Consent" (reviewed 3/2017) was reviewed on 5/17/2018 and required, "Any treatment or procedure...should be authorized in writing after the risks and complications have been explained..."

3. The above findings were discussed with an Operating Room Registered Nurse (E #27) during an interview on 5/17/2018 at approximately 10:30 AM. E #27 stated, "We normally obtain an informed consent prior to the surgery or procedure from the patient or family with a witness."

Based on document review and interview, it was determined that for 1 of 6 (Pt #4) clinical records reviewed of a patient with restraint device usage, the Hospital failed to ensure the restraint order was written for a specific time frame and event.

Findings include:

1. The Hospital's policy entitled, "Use of Restraints and Seclusion," (dated 2/17) required, "Policy: Restraints or seclusion may only be imposed to protect the patient, a staff member, or others...Addendum A - Restraint for the non-violent, non-self-destructive patient..." The policy for non-violent non-self-destructive patient did not include that the order for restraints may not be as a PRN (as needed).

2. The clinical record of Pt #4 was reviewed on 5/15/18 at approximately 11:15 AM. Pt #4 was a 79 year old male who was admitted to the Hospital on 5/8/18 with diagnoses of congestive heart failure and chronic obstructive pulmonary disease. Pt #4's clinical record contained a signed Restraint/Seclusion Physician Order dated 5/11/18 at 9:30 AM. The order failed to include: type of intervention; mechanical restraint; medications; rationale for restrictive measure; and maximum duration of intervention. Pt #4's clinical record lacked documentation that Pt #4 had been placed in restraints during his hospitalization.

3. The physician who signed the restraint order was unavailable for interview.

4. The Nurse Practitioner (E #9) stated, during an interview on 5/15/18 at approximately 11:30 AM, that the physician probably signed the order in case it was needed.

A. Based on document review and interview it was determined that for 1 of 1 (Pt. #7) clinical record reviewed for a patient requiring blood sugar monitoring, the Hospital failed to ensure the physician's order was followed, as required.

Findings include:

1. The Hospital's policy titled, "Blood Glucose Monitoring: Using the Precision Xceed Pro Blood Glucose Testing System" (reviewed 1/2017) reviewed on 5/15/2018, required, "...Blood Glucose monitoring shall be performed on those patients who require...Procedure: 1. Confirm physician order. 14. Document the blood glucose in the electronic medical record."

2. The clinical record for Pt. #7 was reviewed on 5/15/2018 at approximately 11:15 AM. Pt. #7 was a 46 year old male who was admitted to the Hospital on 5/5/2018 with a diagnosis of acute pancreatitis. The clinical record for Pt. #7 contained a physician's order dated 5/12/2018 that required, "Accucheck [blood glucose monitoiring] every 6 hours." Pt. #7's clinical record lacked documentation of accuchecks for the following dates: 5/8/2018 at 4:00 AM to 5/8/2018 at 11:06 AM (7 hours 6 minutes); 5/8/2018 at 4:00 PM to 5/9/2018 at 12:30 PM (20 hours 30 minutes); and 5/9/2018 at 12:30 PM to 5/10/2018 at 11:00 AM (23 hours 30 minutes).

3. An interview was conducted on 5/15/2018 at approximately 11:40 AM with the Nurse Practitioner (E #9). E #9 stated, "The tech's are supposed to do the accuchecks and document them in the electronic health record. If it's not showing up here, then we have to assume it was not done."

B. Based on document review and interview it was determined that for 1 of 1 (Pt. #1) clinical record reviewed for patient with an unusual occurrence, the Hospital failed to ensure that an occurrence report was completed as required.

Findings include:

1. The clinical record for Pt. #1 was reviewed on 5/15/2018 at approximately 1:00 PM. Pt. #1 was a 54 year old female, who was admitted on 3/8/2018, for exploratory laparotomy [procedure to open abdomen] for colostomy takedown and correction of colorectal anastomosis (procedure in which the colon is attached to remainder of colon). The clinical record indicated that Pt #1 came out of surgery on 3/8/18, with an endotracheal tube (used to assist in breathing) in place.

2. On 5/16/18 at approximately 11:30 AM, an interview was conducted with E #16 (Registered Nurse, CCU). E #16 stated, "If a patient pulls out a tube such as a central line or chest tube, we have to notify the doctor and document the incident. The only documentation I see in this chart is the NG (nasogastric tube in the nose, stomach, and throat) being pulled out by the patient (Pt. #1)."

3. On 5/17/2018 at approximately 10:30 AM, an interview was conducted with MD #3 (Surgeon). MD #3 stated, "She (Pt #1) pulled out endotracheal tube ...I don't know when she pulled out the endotracheal tube. I was made aware the next day, when I came to see her."

4. The Hospital's policy titled, "Improving Organizational Performances/Unusual Occurrence Reporting: Patient and Visitor (revised 1/2017)" was reviewed on 5/17/2018, required, "An unusual occurrence will be entered into the Clarity...in a timely manner...Process: 2. When any occurrence...inconsistent with the care and treatment of a patient..."

Based on document review and interview it was determined that for 2 of 2 (Pt. #4 and #7) clinical records reviewed for patients requiring subcutaneous [under skin] medications, the Hospital failed to ensure the medications were administered and documented, as required.

Findings include:

1. The Hospital's policy entitled, "Heparin Subcutaneous Administration," (dated 12/2016) required, "Procedure...8. Select injection site...14. Document the medication on the MAR (Medication Administration Record) sheet...16. Injection sites should be rotated..."

2. The Patient Education document titled, "Enoxaparin (blood thinner injection)" (undated) reviewed on 5/17/2017 required, "...Use a different body area each time...Keep track of where you give each shot...rotate body areas."

3. The clinical record for Pt. #7 was reviewed on 5/15/2018 at approximately 11:15 AM. Pt. #7 was a 46 year old male who was admitted to the Hospital on 5/5/2018, with a diagnosis of acute pancreatitis. The clinical record for Pt. #7 contained a physician's order dated 5/6/2018, that required Enoxaparin (blood thinner) 40 mg (milligrams) subcutaneous daily. Pt. #7's clinical record included documentation that the Enoxaparin was administered as required, however the site of administration was not documented.


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4. The clinical record of Pt #4 was reviewed on 5/15/18 at approximately 11:25 AM. Pt #4 was a 79 year old male who was admitted to the Hospital on 5/8/18 with diagnoses of congestive heart failure and chronic obstructive pulmonary disease. Pt #4's clinical record contained a physician's order, dated 5/9/18, that required 5,000 units of Heparin (blood thinner) subcutaneous every 12 hours. Pt #4's clinical record included documentation that the Heparin was administered, as required; however, the site of the administration was not documented.

5. During an interview with the Nurse Practitioner (E #9) on 5/15/19, at approximately 11:30 AM , E #9 stated, "Our computer system does not allow for the nurse to document the site of injection."