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Based on medical record review and interview, the facility failed to ensure medical records contain supporting documentation to justify the care and treatment of patients.

Findings:

On 12/19/2011, a 70 year old patient was admitted to the telemetry unit with shortness of breath, fluctuating blood sugars, tachycardia and possible sepsis. The patient had a history of chronic obstructive pulmonary disease (COPD) and Type II Diabetes Mellitus. On 12/20/2011 at 1940 a rapid response team (RRT) was activated because the patient was having increased shortness of breath. The patient's respirations were 30 and labored. Her oxygen saturation was 82% and her heart rate was 130-150. According to the Situation Background Assessment Response (SBAR) sheet, the patient was given 1mg of epinephrine intravenously. The patient was then intubated, given Adenosine 6mg/12mg and transferred to the intensive care unit (ICU) with improved heart rate. The patient was then placed on a ventilator.

The medical record does not contain documented evidence as to why the patient was medicated with epinephrine. A physician board certified in internal medicine reviewed the medical record and opined that epinephrine is contraindicated with tachycardia. Documentation by the RRT physician was clear that Adenosine was given for the tachycardia.

On 5/9/13 at 0915, on interview with the physician who responded with the RRT revealed that he had ordered and administered the epinephrine in the event the patient was experiencing a delayed anaphylactic reaction to new antibiotics or having a possible bronchospasm. The physician indicated that his documentation surrounding the RRT was lacking.

Further review of the medical record revealed that the Discharge Summary lacked any documentation of the patient's tachycardia, cardiac consult, intubation and/or time spent on a ventilator in ICU.