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Based on documentation review it was determined the Hospital failed to ensure all medical records contained complete information regarding each staff members evalaution and reevaluation of epidural catheter sites in one of one applicable medical record reviewed.

Findings included:

The Hospital policy that addressed epidural analgesia infusion was reviewed. The policy stated check dressing every shift.

Medical record documentation indicated the Pateint had had knee replacement surgery on 2/17/10. An epidural catheter remained in place following surgery and an infusion pump was utilized for adminstration of medications for pain control. The epidural catheter remained in place until 2/19/10 when it was removed at 5:20 PM, as ordered.

Review of 2/17/10, 4:00 PM-2/19/10, 5:20 PM nursing documentation indicated on 2/18/10 at 8:00 it was noted the epidural catheter was in place and on 2/19/10, documentation written at 12:43 AM indicated the epidural catheter was noted to be intact and the dressing clean at the insertion site. With the exception of these two entries documentation did not indicated the epidural cathter was assessed/checked.

Based on documentation review it was determined the Hospital failed to ensure all medical record were accurately and clearly timed in one of one applicable medical record reviewed.

Findings included:

Review of 2/18/10 nursing clinical documentation indicated the documentation entry was written at 11:58 PM on the computerized analgesic flowsheet. The time entered as the time the assessment was performed was 6:40 PM, however a second time was also associated with the note that indicated on 2/18/10 at 7:30 PM the activity occurred.


Review of 2/19/10 nursing clinical documentation indicated the documentation was written at 12:00 AM on the computerized analgesic flowsheet. The entry was for an assessment performed on 2/18/10 at 9:00 PM , however a second time was also associated with the note that indicated on 2/18/10 at 8:00 PM the activity occurred.