HospitalInspections.org

Based on a review of the clinical record and an interview with staff, the facility failed to ensure that the clinical record for patient #2 was accurately written.

Findings were:

A review of the clinical record for patient #2 revealed the following physician's orders:

* An order written on 2-26-19 at 10:42 am read as follows:
"CPM application; apply in PACU [post-anesthesia care unit], at least 6 hours per day. Day 0 is 0-30 degrees. Pt can do this as much as can tolerate. Pt can sleep in CPM."

* An order written on 2-27-19 at 6:37 am read as follows:
"CPM application; at least 6 hours daily; 30-60 [degrees] today. Increase by increments of 5 to 10 degrees to goal of 60 [degrees]. Pt can be in the CPM longer than 6 hours for as long as they can tolerate. Pt can sleep in the CPM."

A review of documentation in the clinical record for patient #2 revealed no consistent evidence that the CPM machine had been worn 6 hours per day per physician's orders and there was no evidence that the device had been applied until 8:31 pm on 2-26-19.

In an interview with staff #1, staff #1 confirmed that documentation in patient #2's clinical record was inconsistent and did not provide evidence that the CPM machine had been work 6 hours per day per physician's orders.

The above was confirmed in an interview with the Director of Quality and other administrative staff the afternoon of 6-12-19.