HospitalInspections.org

Based on review of policy and procedures, closed medical record review, and physician interview, the nursing staff failed to follow a physician order for1 of 3 sampled patient's with surgical drains (Patient #2).

The findings include:

Review of the hospital's policy titled, "Standards of Care--Adult Med-Surg" with revision date of November 2014, revealed "....Shift reports: A. The patient's response to care, changing needs and interventions will be communicated to the oncoming shift to assure continuity of care...."

Closed medical record review of Patient #2 on 08/01/2017 revealed a 51 year old female admitted on 05/31/2017 for a planned surgery. Review of a physician's progress note dated 06/03/2017 at 0916 revealed procedures performed were Cystoscopy (procedure to examine lining of the bladder and the tube carrying urine to outside of body), Sigmoid Colectomy (Removal of the left side of the colon), and insertion of bilateral ureteral stents (tubes to prevent or treat obstruction of the urine flow from the kidneys) with drains from surgical site. Review of the attending physician's order (MD #1) dated 06/02/2017 at 0855 revealed "Discontinue Drain (Jackson Pratt--tube to drain fluid from a surgical site). Scheduled for 06/03/2017 at 0000." Review of MD #1 progress note dated 06/02/2017 at 0849 revealed "DC JP drain 6/3/2017..." Patient was discharged home on 06/08/2017.

Interview on 08/02/2017 at 1300 with MD #1 revealed an order was written to remove the JP drain. "I had written the order for the drain to be removed because it was not draining much. I was made aware that the drain was not removed during the hospital stay." Further interview revealed patient did go home with the drain and the order was not done.

NC00129530