HospitalInspections.org

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.