HospitalInspections.org

Based on document review, observation, and interview nursing services failed to evaluate patient care by applying a known allergen to a patient during a procedure on 1 of 10 patient medical records (MR) reviewed (P2); and by not documenting all hourly rounding from 0700 hours to 2200 hours, and every 2 hours from 2200 hours to 0600 hours per policy on 7 of 10 patient's MRs reviewed (P2, P5, P6, P7, P8, P9 and P10).

Findings include:

1. Facility policy titled, Hourly Rounding, PolicyStat ID: 12250635, last revised 8/22/22, indicated nursing staff will perform formal hourly rounding for each patient from 0700-2200. From 2200-0600, nursing staff will round every 2 hours; Hourly Rounding: address the 4 P's - Pain, Potty, Position, and Possessions; document rounding in the EMR or patient Rounding Log if on downtime.

2. P2 MR indiccated the following:
a. Patient allergy listed as iodine.
b. Straight catheterization (cath) completed and documented on 3/1/24 at 1421 hours by N3 (Emergency Room Technician [ERT]), and indicated an 8 french straight cath kit was used.
c. MR lacked documentation of staff excluding iodine packet from cath procedure.
d. MR lacked documentation of hourly rounding completed every hour from 0700 hours to 2200 hours and every 2 hours from 2200 hours to 0600 hours including but not limited to: 3/3/24 at 0300 hours through 3/3/24 at 0700 hours.

3. MR for P5 lacked documentation of hourly rounding completed every hour from 0700 hours to 2200 hours and every 2 hours from 2200 hours to 0600 hours including but not limited to: 1/25/24 at 1500 hours through 1/25/24 at 2000 hours.

4. MR for P6 lacked documentation of hourly rounding completed every hour from 0700 hours to 2200 hours and every 2 hours from 2200 hours to 0600 hours including but not limited to: 4/16/24 at 2100 hours through 4/17/24 at 0700 hours.

5. MR for P7 lacked documentation of hourly rounding completed every hour from 0700 hours to 2200 hours and every 2 hours from 2200 hours to 0600 hours including but not limited to: 4/16/24 at 2100 hours through 4/17/24 at 0700 hours.

6. MR for P8 lacked documentation of hourly rounding completed every hour from 0700 hours to 2200 hours and every 2 hours from 2200 hours to 0600 hours including but not limited to: 4/15/24 at 1000 hours through 4/15/24 at 2000 hours.

7. MR for P9 lacked documentation of hourly rounding completed every hour from 0700 hours to 2200 hours and every 2 hours from 2200 hours to 0600 hours including but not limited to: 4/16/24 at 1949 hours through 4/17/24 at 0700 hours.

8. MR for P10 lacked documentation of hourly rounding completed every hour from 0700 hours to 2200 hours and every 2 hours from 2200 hours to 0600 hours including but not limited to: 4/13/24 at 1900 hour through 4/13/24 at 2300 hours.

9. In interview, on 4/17/24 at approximately 1430 hours, A1 (Quality Director) and A6 (Manager Medical Surgical Unit) verified the MRs as detailed above.

4. On 4/17/24 at approximately 1438 hours, this writer observed the in/out cath kits in the emergency department. The 8 french in/out cath kit list iodine as a supply within the kit.