HospitalInspections.org

Based on document review and staff interviews the administrative staff failed to ensure registration staff documented they offered patient rights and responsibilities brochure for 6 of 16 patients (Patients # 5, # 7, # 9, # 10, #15 and #18). The administrative staff identified an average daily census of 69 inpatients.

Failure to ensure registration staff documented they provided the patients with a copy of their patient rights and responsibilities on admission could potentially result in patients not knowing and exercising their patient rights.

Findings included:

1. Review of the policy, "Patient Rights and Responsibilities," revised 5/2017, revealed in part, "Mercy respects, protects, and promotes patient rights: ... Informs the patient of his or her rights in all settings ..." and "Patient Rights and Responsibilities Procedures ... Patient initials the General Consent for Service ... and the Registration Record indicating Patient Rights and Responsibilities information was offered."

2. Interview with Registration Representative N on 5/24/2017 at 3:50PM revealed the patients sign the consent to treat form and the patients initial the form to indicate they received the patient rights brochure.

3. Review of closed medical records revealed:

a. Patient #5 was admitted on 5/12/2017 to the hospital. Patient #5's medical record lacked documentation Patient #5 received their patient rights and responsibilities.
b. Patient #7 was admitted on 5/17/2017 to the hospital. Patient #7's medical record lacked documentation Patient # 7 received their patient rights and responsibilities.
c. Patient #9 was admitted on 5/19/2017 to the hospital. Patient #9's medical record lacked documentation Patient # 9 received their patient rights and responsibilities.
d. Patient #10 was admitted on 3/24/2017 to the hospital. Patient #10's medical record lacked documentation Patient #10 received their patient rights and responsibilities.
e. Patient #15 was admitted on 6/27/2016 to the hospital. Patient #15's medical record lacked documentation Patient # 15 received their patient rights and responsibilities.
f. Patient #18 was admitted on 5/4/2017 to the hospital. Patient #18's medical record lacked documentation Patient #18 received their patient rights and responsibilities.

4. During an interview on 5/24/2017 at 9:00 AM, the Director of Quality, Patient Safety and Compliance acknowledged the registration failed to ensure patients #5, #7, #9, #10, #15 and #18 initialed the forms to acknowledge they received patient rights and responsibilities brochures.

Based on review of documentation, staff interviews, and policy the acute hospital staff failed to ensure patient care plans accurately reflected nursing care and kept current for three (3) of fifteen (15) sampled closed records (Patients #4, #12, and #13). The hospital reported a daily average of 69 patients.

Failure to update care plans could potentially result in the facility's inability to ensure the provision of quality health care in a safe environment.


Findings included:

1. Review of the policy titled "Nursing Process/Interdisciplinary Care Planning" revised 9/16, revealed in part,"the RN will plan care by prioritizing patient problems establishing patient outcomes and specifying nursing interventions for each goal." The policy reflected care plan interventions be developed that will facilitate the medical care prescribed" and, "will be individualized to achieve patient goals and be specific directions for individualized care..."


2. Review of the closed medical record revealed Patient #12, was admitted to the hospital on 3/5/17 with chief complaint of abdominal pain. The patient reported a diagnosis of Influenza A on 3/4/17. Influenza A is a viral infection which, per the Centers for Disease Control and Prevention (CDC), requires specific isolation precautions to prevent transmission. Patient #12's medical record reflected information regarding isolation precautions related to a diagnosis of Influenza A.

Review of the policy titled "Infection Control Manual," reviewed 4/17, revealed in part, "Use Droplet Precautions...for a patient known or suspected to be infected with...influenza..."

Patient #12's Care Plan failed to update the Care Plan to include interventions related to isolation precautions.

3. Review of the closed medical record revealed Patient #13 was admitted on 3/6/17 at 4:22 AM with a diagnosis of right foot pain.
The admission nursing assessment, dated 3/6/17 at 6:46 AM revealed nursing staff placed Patient #13 in contact isolation.

Review of the policy titled "Infection Control Manual," reviewed 4/17, revealed in part, "Use Contact Precautions...for a patient known or suspected to be infected or colonized with epidemiologically important micro-organisms that can be transmitted by direct contact with the patient..."

Patient #13's Care Plan failed to update the Care Plan to include interventions related to contact isolation.


On 5/23/17 at 2:55 PM Director of Quality, Patient Safety and Compliance, the Director of Nursing Services, and the Director of Inpatient Services, stated isolation is not part of the patient's care plan, instead is a physician's order. The Director of Inpatient Services stated nursing staff changes in Care Plans are updated by nurse

4. Review of the closed medical record revealed Patient #4 was admitted on 5/10/17 at 12:27 PM with a diagnosis of possible TIA (tranischemic attack).

On 5/11/17 at 12:26 PM nursing notes reflected the Enterostomal/Wound Nurse (ET nurse) assessed the skin ulceration. The assessment reflected the 10 centimeter (cm) x 9 cm x 0.1 cm eccomyotic area with open red base on nonblancable erythema in an irregular shape. Pressure reducing interventions included, but not limited to, an air mattress, reposition every 2 hours, a waffle cushion and topical medication.

Patient #4's Care Plan failed to update the Care Plan to include interventions related to identification of skin ulceration or pressure reducing interventions.

On 5/24/17 at 9:00 AM Staff M, Director of Nursing Professional Practice, confirmed the patient's Care Plan did not reflect the alteration in skin integrity or ET consult/interventions and should be implemented in 24 hours.