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Based on medical record review, policy review and interview, the facility failed to ensure the medical record contained information that described the patient's response to services for one of ten medical records reviewed (Patient #5). The facility's active census was 360.

Findings include:

Review of the facility policy titled, Ambulatory Nursing Documentation Guideline (Version 1, Effective 04/04/22) revealed the guidelines are to define ambulatory nursing best practice documentation standards and to describe the Registered Nurse (RN)/Licensed Practical Nurse (LPN)/Medical Assistant (MA)/Ambulatory Clinical Technician (ACT) roles in the development of safe, clear, accurate and timely documentation. Nursing notes can be written to address nursing specific care provided and patient response. Flowsheets are an acceptable tool for documenting and information should not be repeated in a note. Registered Nurses chart nursing interventions, advice given, and patient's response.

According to the Journal of Infusion Nursing, Infusion Nursing Standards of Practice, developed by Infusion Nurses Society (Volume 34, Number 1S, Revised 2011): Standard 14.1 Documentation shall contain accurate, factual, and complete information in the patient's permanent medical record regarding the patient's infusion therapy and vascular access. B. Documentation should include, but not be limited to, the following: 4. Date and time of insertion, number and location of attempts, functionality of device, local anesthetic (if used), and the insertion methodology, including visualization and guidance technologies.

Review of the medical record for Patient #5 revealed the patient presented to the facility's emergency department on 04/28/22 for right shoulder pain. The medical record contained two documented successful intravenous attempts. A narrative in the medical record by Staff P on 04/28/22 at 7:45 PM referenced a missed attempt at establishing IV access. The medical record did not contain documentation regarding the time, location and date of a missed attempt at establishing intravenous access by Staff J.

On 06/16/22 at 10:27 AM, Staff Z reported Staff J did not document a missed attempt at establishing intravenous access for Patient #5 on 04/28/22. Staff Z confirmed that Staff J did attempt to start an IV site for Patient #5 on 04/28/22 and the medical record did not contain documentation regarding the failed attempt.