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Based on interview and record review the hospital failed to maintain complete and consistent information for 1 of 30 sampled patients (31). Patient's 31's refusal of a planned renal hemodialysis treatment (a procedure used to remove toxins in the blood for the treatment of kidney failure), had not been documented in the patient's medical record. Patient 31's medical record had not reflected the description of an occurrence which had the potential to affect the patient's health and well being. In addition, a handwritten date, on a paper Hemodialysis Order form had been transposed with another date, which made the dates illegible. The handwritten error had not been corrected in a manner that clarified the intended date and posed the potential for confusion and/or error.

Findings:

Patient 31 was admitted to Hospital A on 12/30 15 with diagnoses which included end stage renal disease (chronic progressive kidney failure) per the admission History and Physical Examination report. The same report indicated that the patient had received renal hemodialysis as an outpatient prior to this hospital admission and that a Nephrology (physician specialist for the treatment of kidney disease) consultation was planned.

During a joint interview and record review on 1/5/16 at 11:15 A.M., Patient 31's medical record was reviewed with the Director of Telemetry (DT). The DT stated that nursing staff had informed her that the patient had refused a scheduled "dialysis" treatment. The record indicated that the patient had received renal hemodialysis since admission to the hospital, however there was no documentation in the record of the patient's refusal of a planned procedure. The DT acknowledged that Patient 31's refusal of the renal hemodialysis treatment was an occurrence that should have been documented in the patient's medical record.

In addition, Patient 31's medical record included a paper version of the contracted agency's Hemodialysis Orders form, which also reviewed with the DT. The same form included an area which indicated "Schedule the next treatment for [date]" The handwritten date was illegible, as it had been transposed or overwritten by another date. The error had not been corrected, clarified or authenticated by the writer.

The DT acknowledged that the reviewed handwritten date, on the Hemodialysis Orders form, was not legible and that the record had not been maintained in a concise manner.

Based on interview and record review the facility failed to develop a nursing care plan that reflected the care needs for 1 of 30 sampled patients (31). A nursing care plan had not been developed for Patient 31's ongoing renal hemodialysis treatment (a procedure used to remove toxins in the blood for the treatment of kidney failure). This deficient practice had the potential to interfere with the communication, coordination and implementation of interventions related to the patient's renal hemodialysis procedures.

Findings:

Patient 31 was admitted to Hospital A on 12/30/15 with diagnoses which included end stage renal disease (chronic progressive kidney failure) per the admission History and Physical Examination report. The same report indicated that the patient had received renal hemodialysis as an outpatient prior to this hospital admission and that a Nephrology (physician specialist for the treatment of kidney disease) consultation was planned.

During a joint interview and record review on 1/5/16 at 11:15 A.M., Patient 31's medical record was reviewed with the Director of Telemetry (DT). The record indicated that the patient had received renal hemodialysis since admission to the hospital. The medical record included that the patient had a vascular access site (vein/artery catheter used for hemodialysis) located in the right subclavein (neck area) which required scheduled observations and dressing changes. The DT stated that the patient's renal dialysis treatments were performed at the hospital by a contracted agency. The DT stated the expectation that hospital staff and the contract agency were expected to coordinate that patient's renal hemodialysis treatment and procedures.

During a joint interview and record review on 1/5/16 at 2:00 P.M., the Chief Operating Officer of Renal Dialysis [name of contracted dialysis provider] (COORD) stated the expectation that a plan of care, for renal hemodialysis, was to be developed and coordinated between the hospital nursing staff and the dialysis staff. The COORD acknowledged that a plan of care for Patient 31's hemodialysis had not been developed, which created a potential for inconsistent coordination of the patient's renal hemodialysis treatments.

A review of the hospital policy and procedure entitled Plan of Care, Interdisciplinary, dated "May 2014" included "Inpatients will have a POC [plan of correction] developed that includes assessment based on comprehensive patient needs, treatments and goals. The RN [registered nurse] is ultimately responsible and accountable for the POC, however, all members of the health care team are responsible for contributing to the plan of care and documenting whenever a need is identified."

Based on interview and record review, the hospital failed to ensure the rate of infusion for an intravenous (IV, directly into a vein) insulin infusion was ordered by the physician. The hospital administered an insulin infusion at a rate that was not ordered by the physician. This failure resulted in the potential for patients to be exposed to avoidable medication errors.

Findings:

During a concurrent interview and medical record review, on 1/7/16 at 11:20 am, Nurse Director of Intensive Care (NDIC 21) identified Patient 21's electronic medical record (EMR, computer medical chart). Inspection of the EMR showed Patient 21 was admitted to the hospital on 12/3/15. A physician's order dated "12/3/15 at 22:25 (10:25 P.M.) for Rx (prescription) number U000690475 (100 units insulin (drug for the control of blood sugar) regular in 99 ml (milliliter) sodium chloride (salt water) 0.9%) IV sliding scale (insulin rate dependent on blood glucose) protocol (orders)". NDIC 21 reviewed the EMR and identified the IV insulin was started on 12/3/15 at 11:41 P.M. at an infusion rate of 7.7 units per hour. The IV insulin infusion rate was changed on 12/4/15 at 1:30 A.M. to 9 units per hour. Continued review of the EMR did not show a physician order to change the rate from 7.7 to 9 units per hour on 12/4/15 at 1:30 A.M.. NDIC 21 acknowledged the EMR did not contain a physician order to change the insulin infusion rate from 7.7 to 9 units per hour on 12/4/15 at 1:30 A.M.