HospitalInspections.org

Based on document review, interview and stated practice, it was determined in 1 of 10 (Pt. #8) patient's records reviewed, the Hospital failed to ensure a code sepsis and septic shock flow sheet were documented. This has the potential to affect all patients with sepsis admitted in the Emergency Department.

Findings include:

1. The clinical record for Pt #8 was reviewed on 8/29/17 at 2:30 PM. Pt #8 was admitted to the ED on 8/29/17 with a Diagnosis of Cellulitis in Lower Legs. The code sepsis log was reviewed on 8/29/17 at 1:00 PM. Pt. #8 was listed on the log on 8/1/17 at 2230 (10:30 PM) for code sepsis in the ED. The nurses note dated 8/1/17 at 2229 (10:29 PM) included sepsis screen, actions taken-provider notified and treatment in progress. The record lacked documentation of the septic code being done and lacked the flowsheet "Severe Sepsis/ Septic Shock Flowsheet."

2. During an interview with E#2 (Director of Critical Care) on 8/31/17 at approximately 2:30 PM, it was verified that there was no documentation of the code sepsis in the record and no documentation of the severe sepsis/shock flowsheet and there should have been. E#2 included the practice/process is whenever there is code sepsis done it should be documented in the record and on the flowsheet. E#2 stated the flowsheet is new and was initiated on 7/5/17 and staff may not be used to using it yet. E#2 verified that the "Severe Sepsis/ Septic Shock Flowsheet" hasn't been incorporated into the policy.