HospitalInspections.org

Based on document review and interview, the registered nurse failed to follow the facility policy and procedure for event reporting for 1 of 10 medical records (MR) reviewed (P3).

Findings include:

1. Review of the policy titled Patient, Volunteer, Visitor Event Reporting, Last Revised 02/2017, indicated the following:
A. It is the policy of (The Hospital) that all patient, volunteer, or visitor events, unusual or untoward, or disruption of services within the hospital, grounds and/or buildings will be reported to the Director of Quality Services for review... An event is any occurrence or situation which is not consistent with the care and treatment of a particular patient...Such events include, but are not limited to: 1. Patient or visitor injuries and any unanticipated/unexpected circumstances.
B. Guidelines: All events occurring on hospital property, including those apparently minor in nature, shall be reported on-line through the Healthcare Safety Zone portal.
C. It is the responsibility of the involved hospital department director/designee to review the patient, volunteer or visitor event and assure that the event report is completed appropriately, that internal review is completed, and that appropriate corrective action is taken.

2. Review of MRs indicated the following for patient P3:
A. Admission date 8/21/17 to discharge 8/28/17. Operative report 8/21/17 indicated the patient underwent "Bilateral internal and external double-J ureteral stent placement and Cope loop catheter placement over a guidewire".
B. Progress Note dated 8/23/17 indicated the following: I think the best plan is to keep him/her here in the hospital for 1 to 2 weeks or however long it takes for everything to completely heal together, for the catheter and stents to be removed...he/she needs very close supervision until the anastomosis heals.
C. Physician Progress Note dated 8/24/17 indicated the following: SUBJECTIVE: called at 0400 hours this am...patient in 15/10 pain. ureteral stents were pulled all the way out during a transfer...When I came to see the patient both stents were hanging out of his/her body save the proximal 1-2 inches. His/her "stat lock" was on the left leg and the drainage bag, catheters and stents were draped over the right leg, crossing his/her body.

3. Review of hospital event reports from 7/1/17 to 9/27/17 lacked documentation of an event having been reported for the unusual occurrence of patient P3 during the 8/21/17 to 8/28/17 hospitalization.

4. On 9/28/17 at approximately 4:45pm, A1, Directory of Quality Services, indicated the event(s) of the catheter and stents being abruptly removed from patient P3 was an unusual occurrence and verified lack of documentation of an incident report or internal review of the occurrence.

Based on document review and interview, the registered nurse (RN) assigning patient care failed to ensure care of 1 patient (P3) was assigned to personnel with competence in accordance with patient's needs for 2 nursing staff members (N5 and N7).

Findings include:

1. Review of hospital policies indicated the following:
A. The policy titled Staffing Guidelines, Last Revised 07/2017, indicated the following: B. The charge nurse is responsible to assign the patient load for RNs...while considering the following: 1. The complexity of the patient's condition. 3. Competency of the nursing staff. 5. Relevant infection control and safety issues.
B. The policy titled Orientation, Last Reviewed/Approved 12/2016, indicated the following: The employee's department will conduct Departmental Orientation. All areas discussed in orientation will be documented on the general orientation checklist.
C. The policy titled Competency Assessment, Last Reviewed/Approved 04/2016, indicated the following: 4. clinical competencies are completed on an annual basis...Skills identified as necessary for job competence will be observed by a supervisor or competent designee in a simulated or actual work environment.

2. Review of the medical record (MR) for patient P3 indicated the patient had bilateral ureteral stents, placed 8/21/17, draining to a Foley catheter bag. The MR indicated patient assignment & stent care was provided by the following nursing staff during the hospital admission of 8/21/17 to 8/28/17: N5 and N7.

3. Review of nursing assignment(s) for 8/22/17 at 22:42 hours on the form titled Census Report indicated that N5 was assigned to patient P3 on that date.

4. Review of personnel files lacked documentation of orientation or competency in the care of ureteral stents for nurses N5 and N7.

5. On 9/28/17 at approximately 6:00pm A1 indicated that N5's personnel file had a 2013 certificate of competency in Foley Catheter insertion and care, but lacked documentation of orientation. A1 verified the competency did not include stent care. A1 also verified lack of documentation of orientation and/or stent competency for nurse N7 and verified his/her date of hire was 3/21/16.

Based on document review and interview, the hospital failed to ensure that the medical record (MR) for 1 of 10 patients (P3) contained information to support and describe patient condition and response to care in accordance with hospital policy.

Findings include:

1. Review of the policy titled Communication - Collaboration With Physicians/Providers, Last Revised 06/2016, indicated the following: Purpose: To provide guidelines for accurate and timely communication and collaboration with the physician/provider. A. Effective Physician/Provider and Nurse Collaboration. 1. Nurses and physicians/providers create an environment of collaborative communication among healthcare providers, and collaborative communication is associated with positive patient, nurse, and physician/provider outcomes. B. Communicating Information to Physicians/Providers. C. Providing Necessary Information: SBAR (situation, Background, Assessment, Recommendation)...1. Use the SBAR method to deliver information. 2. Document who you spoke with, time of call, and summary of conversation.

2. Review of medical records (MR) indicated the following for patient P3:
A. Admission date 8/21/17 to discharge 8/28/17. Operative report 8/21/17 indicated the patient underwent Bilateral internal and external double-J ureteral stent placement and Cope loop catheter placement over a guidewire.
B. Physician Progress Note dated 8/24/17 indicated the following: called at 0400 hours this am...patient in 15/10 pain. ureteral stents were pulled all the way out during a transfer...
C. The MR lacked description of patient care or response to care or treatment related to the ureteral stents being pulled out and lacked documentation of who contacted the physician, the time of the call or summary of the conversation.

3. On 9/28/17 at approximately 3:30 pm, A5, Clinical Manager of Post Surgical, verified lack of MR documentation of patient care related to the stent/catheter event and lacked nursing documentation of communication to the physician for the occurrence with P3 noted in physician Progress Note dated 8/24/17.

Based on document review and interview, the hospital failed to ensure medical records (MR) contained pertinent nursing notes and entries of procedures performed for 4 of 10 MRs (P3, P6, P7 and P8) reviewed.

Findings include:

1. Review of hospital policies and procedures (P&P) indicated the following: Catheter (Urinary), Last Revised 01/2017: PURPOSE: To provide guidelines for staff regarding the insertion, care, and specimen collection of urinary catheters...D. Indwelling catheter: Document pertinent information.

2. Review of MRs indicated the following:
A. Patient P3 - Admission date 8/21/17 to discharge 8/28/17. Operative report 8/21/17 indicated the patient underwent "Bilateral internal and external double-J ureteral stent placement and Cope loop catheter placement over a guidewire". Genitourinary Assessments indicated the following: On 8/21/17 at 16:00 hours: Bladder Scan Urinary Output #1 Indwelling Catheter Urinary Output Type: Indwelling Catheter. 19:10 hours - Bladder Scan Urinary Output #1 Indwelling Catheter Urinary Output Type: Indwelling Catheter. Bladder Scan Urinary Output #2 Indwelling Catheter Urinary Output Type: Left Nephrostomy. Genitourinary Assessment Comment: Nephrostomy output is bilateral stents to a F/C (Foley catheter) bag. On 8/22/17 at 16:00 hours Ureteral Stent(s) in Place documentation was blank and the entry lacked documentation of the stent(s) assessment. On 8/23/17 at 09:00 hours Ureteral Stent(s) in Place documentation indicated Bilateral internal and external stents connected to F/C bag. On 8/23/17 at 15:30 hours documentation lacked indication of Ureteral Stent(s) in Place. On 8/24/17 at 08:45 hours, 16:30 hours and 20:45 hours documentation lacked indication of Ureteral Stent(s) in Place. Physician Progress Note dated 8/24/17 indicated the following: SUBJECTIVE: called at 0400 hours this am...patient in 15/10 pain. ureteral stents were pulled all the way out during a transfer...When I came to see the patient both stents were hanging out of his/her body save the proximal 1-2 inches. His/her "stat lock" was on the left leg and the drainage bag, catheters and stents were draped over the right leg, crossing his/her body. The MR lacked documentation of when the ureteral stents were "pulled out", by whom or how.
B. Patient P6 - Admission date 8/19/17 to discharge date 8/22/17. Operative documentation dated 8/19/17 indicated the patient underwent an I&D (incision and drainage) of a peritoneal abscess and had drains placed. The MR indicated left and right penrose drains were placed. MR discharge information lacked documentation of the patient being discharged with the drains in place. The MR lacked drain removal documentation. The MR lacked indication if the drains were to be left in place or removed at discharge.
C. Patient P7 - Admission date 8/23/17 to discharge date 9/1/17. On 8/24/17 placement of a F/C was ordered. MR documentation indicated that on 8/24/17 between 09:03 hours, verification of the order and 16:05 hours, F/C assessment documentation, a F/C was placed. MR documentation dated 8/26/17 at 0650 hours indicated F/C discontinued. F/C removed at this time... The MR lacked documentation of pertinent details of the F/C on 8/24/17, 8/25/17 or 8/26/17.
D. Patient P8 - Admission date 8/14/17 to discharge date 8/15/17. MR documentation indicated the patient had a JP (Jackson Pratt) drain placed 8/14/17. Discharge information lacked documentation of the patient being discharged with the JP drain in place. The MR lacked documentation of an order for the JP drain to remain in place or be removed at discharge. The MR lacked pertinent documentation of the JP removal or when/if it was removed.

3. On 9/28/17 between 3:15 and 6:00 pm A5, Clinical Manager Post Surgical, indicated that all procedures, including insertion, care and/or removal of a device such as F/Cs or drain lines/tubes is to be documented with pertinent details of the procedure process, date, time and person completing the task. A5 also verified lack of pertinent documentation in the MRs of patients P3, P6 and P7.

4. On 9/28/17 at approximately 6:15 pm A6, Regulatory Compliance Coordinator, verified lack of documentation of pertinent information for removal of the JP drain of patient P8.

Based on document review and interview, the hospital failed to ensure emergency services (ES) were provided in accordance with ES policy for Medical Staff Coverage and Obligations by 1 of 3 ES medical staff (MS) members (MD2).

Findings include:

1. Review of MS Bylaws, Approved 4/6/17, indicated the following: Article 7: Part C: Section 2. The following undertaking shall be applicable to every MS Appointee and Applicant for MS appointment as a condition of consideration of such application and as a condition of continued MS appointment if granted. b) an agreement to abide by all Bylaws and policies of the Hospital...

2. Review of the policy titled Medical Staff Coverage and Obligations, Last Revised 04/2016, indicated the following: E. When a patient presents to the Emergency Department (ED) with an attending physician on the (Hospital) MS, that physician or covering physician will be notified...

3. Review of medical records (MR) indicated the following for patient P3:
A. On 8/15/17 patient P3 underwent robotic-assisted laparoscopic radical prostatectomy with bilateral pelvic lymph node dissection with MDA. During the operation a vesicourethral anastomosis was performed and a drain was placed. Discharge instructions indicated the following: Call your doctor (MDA) if...or you develop complications... If you think you have an emergency, call for emergency medical services right away.
B. On 8/20/17 patient P3 presented to the ED with chief complaint as follows: patient with prostate surgery 3 days ago. Foley in place, no urine since last night. Pain level 10/10. The MR indicated catheter was irrigated 2x by nursing and 1x by MD2. The patient was discharged to home with instructions for self-irrigation of the catheter. The MR lacked documentation of MDA having been notified.
C. On 8/21/17 the patient, P3, presented again to the ED with catheter complications. The History and Physical documentation dated 8/21/17 by MDA indicated the following: Saturday morning he/she woke up with some difficulty with the catheter draining and went to the emergency room (ER) directly. The patient did not contact me nor did the ER contact me...He/she was sent home...Again, all of this was without my awareness.

4. On 9/28/17 at approximately 3:00pm A5, Clinical Manger Post Surgical, verified that the MR for P3 lacked documentation of notification to the attending physician during the ED visit 8/20/17.