HospitalInspections.org

Based on interviews and record reviews, it was determined that the facility staff failed to document that care was provided as planned/directed by physicians for 1 of 4 sampled patients (Patient #2).

The findings include:

Patient #2's clinical record contained the following physician orders:
- On 2/27/15 at 1:50AM, an order for incentive spirometry to be used every hour while awake. (Incentive spirometry is a device used to improve lung function.)
- On 2/27/15 at 3:49PM, an order for foot pumps to be used while in bed. (Foot pumps are medical devices used to prevent blood clots after surgery.)
- On 2/27/15 at 3:49PM, an order for ice to be applied to the affected limb or extremity as tolerated.
These three aforementioned orders were not discontinued during Patient #2's stay in the facility; the patient was transferred to a long term care facility on 3/6/15.

Review of Patient #2's clinical record failed to reveal evidence of the implementation of the incentive spirometry order and the foot pump order. No evidence was found of discontinuation or clarification of the incentive spirometry and/or the foot pump orders.

During an interview with the facility's Director of Quality (DoQ) on 5/6/15 at 9:35AM, the DoQ reported that no documentation was found to indicate the incentive spirometry order had been implemented.

During an interview with the facility's Compliance Coordinator on 5/5/15, the Compliance Coordinator reported that foot pumps would not be used at the same time as SCDs (Sequential Compression Devices); Patient #2's documentation indicated that the patient had SCDs ordered and in use during his/her hospital stay. On 5/6/15 at 11:25AM, the Compliance Coordinator reported that a clarification order for the foot pumps was not found.

Documentation indicating an ice application was used for Patient #2 was found only once in the clinical documentation. The following documentation was found in a nurse's note dated 2/28/15 at 5:22AM: "... ICE APPLIED TO RIGHT HIP AS MD (medical doctor) ORDERED ..." The facility staff provided the survey team with the following information found in a Lippincott Procedures document entitled 'Cold Application'; it included the following information: "Documentation ... Record the time, date, and duration of cold applications; type of device used (ice bag or collar, K pad, or chemical cold pack); site of applications; temperature or temperature setting; the patient ' s temperature, pulse, and respirations before and after application; skin appearance before, during, and after application; signs of complications; and the patient ' s tolerance of the treatment." Neither this nurse's note nor the physician's order identified how long the ice was to be applied. The nurse's note did not document the patient's response to the application of the ice.