HospitalInspections.org

Based on record review and interview the hospital failed to keep current 1 of 1 (Patient #1) care plan when Patient #1 was diagnosed with a fracture of the 5th metacarpal of the right hand.

Findings included:

on 03/28/24 Patient #1 received a medical evaluation for a complaint of right hand pain. The radiology report dated 03/28/24 reflected the patient had a fracture of the 5th metacarpal of the right hand. Patient #1's treatment plan did not reflect the fracture had been added to the treatment plan.

During an interview on 04/03/24 at 10:40 AM Personnel #1 reflected the treatment plan had not been updated to include the metacarpal fracture.

The policy titled Treatment Plan: Interdisciplinary Master Treatment Plan reviewed 04/07/22 reflected..."8. The treatment plan shall be revised, if necessary, based on the findings of any assessment, reassessment, evaluation, or re-evaluation, or as otherwise clinically indicated..."

Based on record review and interview the hospital failed to maintain a medical record for 1 of 1 (Patient #1) patients that supported the diagnosis of a right 5th metacarpal fracture. The nursing record did not contain an assessment of the patient's right hand.

Findings included:

On 03/28/24 Patient #1 received a medical consultation for right hand pain. The Shift Progress notes for 03/28/24 did not reflect an assessment of Patient #1's right hand nor a reason for a medical consultation. The medical record did not reflect a follow-up medical progress note evidencing the x-ray had reflected the patient had a fracture of the right 5th metacarpal; nor a plan for treatment of the fracture. The Shift Progress Note dated 03/30/24 at 09:00 AM reflected the patient complained of pain to the right hand. The note reflected the nurse had wrapped the right hand, but no assessment of the hand was evidenced. On 03/30/24 at 04:14 PM The Physician's Order reflected..."Tramadol 50mg PO ( by mouth) once a day PRN (as needed) for breakthrough pain. The chart did not evidence a medical progress note that justified a need for pain medication.

During an interview on 04/03/24 at 10:40 AM Personnel #1 verified the above findings.

During an interview on 04/03/24 at 11:30 AM Personnel #3 stated Patient #1 had approached them on 03/29/24 and asked to have their right hand bandaged. Personnel #3 stated Patient #1's hand was swollen approximately half way up the hand and their was bruising present to the fingers.

The policy titled Documentation Requirements revised 05/02/22 reflected...15. The medical record must contain documentation of complications...20. Pertinent progress notes shall be recorded at the time of observation, sufficient to permit continuity of care and transferability of care...Whenever possible each of the patient's clinical problems shall be clearly identified in the progress notes and correlated with specific orders with reasons for instituting various tests or treatment given and results of test..."