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Based on interviews and document review, the facility failed to ensure fluid balance levels were accurately evaluated and documented on in 2 of 10 medical records reviewed (Patient #2 and #8).

This failure created the potential for negative patient outcomes by missing treatment opportunities for patients experiencing fluid imbalances.

FINDINGS

POLICY

According to the policy, Multi-Disciplinary Patient Assessment and Reassessment of Patients, patients are reassessed throughout the day or shift based on patient needs. Reassessment is defined as ongoing monitoring which in part also evaluates the effectiveness of the nursing diagnosis, plan of care, and interventions carried out. Any member may consult the medical staff at any time should an issue need to be addressed outside of the daily meeting.

REFERENCE

According to Lippincott Procedures, Intake and Output Assessment, many patients require fluid intake and output monitoring. Intake and output assessment is also essential in monitoring a patient's response to treatment.

1. The facility failed to ensure fluid intake and output measurements were accurately assessed, documented and addressed when abnormal in accordance with facility expectations.

a) A review of Patient #2's medical record revealed the patient presented to the facility on 09/17/17 with a chief complaint of shortness of breath. According to the History and Physical, Patient #2 had a history of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) and was being treated for possible sepsis (infection in the bloodstream). A review of Patient #2's Intakes and Outputs report revealed inconsistencies of fluid intake and output documentation and instances where the patient's fluid output was significantly less than the intake recorded in a certain time frame. For example:

During the time frame of 3:00 a.m. until 2:59 p.m. on 09/18/17, Patient #2's total intake was documented at 1,656 milliliters (ml) and the total output was documented at 350 ml, resulting in a net fluid gain of 1,306 ml.

During the time frame of 3:00 p.m. on 09/18/17 until 2:59 a.m. on 09/19/17, Patient #2 was documented with a total of 750 ml oral intake and zero intravenous (IV) intake although the patient was documented on the Medical Administration Record as receiving 0.9% Normal Saline at 65 mls per hour and 150 mls of Levaquin (an antibiotic) during this time. The patient's output was documented at 50 ml for the duration of the time 12 hour time frame. There was no further documentation regarding the notification of a provider of the low urine output level.

During the time frame of 3:00 a.m. until 2:59 p.m. on 09/19/17, Patient #2's total intake was documented at 1,794 milliliters (ml) with an output of 250 ml, resulting in a net fluid gain of 1,544 ml.

b) A review of Patient #8's medical record revealed the patient presented to the facility on 11/18/17 with a chief complaint of urinary retention, blood in the urine and a history of having a urinary catheter at home. According to the Orders Report, an order for nursing staff to document fluid intake and output every shift was entered on 11/18/17. An additional order was entered on 11/18/17 at 4:40 a.m. which stated to irrigate the urinary bladder with a 3 way Foley catheter at 500 ml of normal saline per hour and to make sure the output is equal and or greater than the input.

A review of Patient #8's Intakes and Outputs report revealed instances where the output was less than the intake and there was no documentation of addressing the imbalance or notifying a provider of the resulting fluid gain. For example:

During the time frame of 3:00 a.m. until 2:59 p.m. on 11/19/17, Patient #8's total intake was documented at 13,507 ml with an output of 3,425 ml, resulting in a net fluid gain of 10,082 ml.

During the time frame of 3:00 p.m. on 11/19/17 to 2:59 a.m. on 11/20/17, Patient #8's intake was documented at 640 ml with an output of 450 ml, resulting in a net fluid gain of 190 ml.

c) On 01/03/18 at 3:49 p.m., an interview with a Registered Nurse (RN #1) was conducted. RN #1 revealed s/he worked in the Emergency Department and the Inpatient Unit at the facility. RN #1 explained that all staff were responsible for documenting fluid intakes and outputs on patients when providing care. After reviewing Patient #2's Intakes and Outputs report, RN #1 verified the patient had a total of 50 ml of urine output during the 12 hour time frame between 3:00 a.m. until 2:59 p.m. on 09/18/17. RN #1 identified Patient #2 experienced a trend of having an output less than the intake throughout the patient's visit and stated it was a concerning finding because it could have indicated kidney failure.

d) On 01/04/18 at 11:39 a.m., an interview with the Director of Nursing (DON #2) was conducted. DON #2 reported the importance of measuring fluid intakes and outputs was to be able to assess patients' how patients were progressing with their diagnoses and to help determine if patients were experiencing possible fluid imbalances. If a patient demonstrated a change in urine output, DON #2 stated the nurse was expected to notify the provider.

Upon reviewing Patient #2's Intakes and Outputs report DON #2 verified the patient had a poor urine output during the overnight shift on 09/18/17. DON #2 stated s/he would have expected the nurse to speak with the provider about the low urine output finding, pass the information to the staff working the next shift and document the notification in the medical record. After further review of the medical record, DON #2 stated s/he was unable to locate any documentation regarding communication about the low urine output.

DON #2 then reviewed Patient #8's medical record and identified an intake amount of 9,999 on 11/19/17 at 6:15 a.m. DON #2 stated s/he would not assume that intake was an accurate measurement and that there was no way to tell what Patient #8's true Intake and Output measurement was from the documentation in the medical record.

Based on document review and interviews, the facility failed to implement and monitor preventative interventions after a medication transcription error was identified in order to prevent a similar error from occurring in 1 of 10 medical records reviewed (Patient #2).

The failure created the potential for patients to not continue receiving medications taken prior to being admitted.

FINDINGS

POLICY

According to Medication Reconciliation, medication reconciliation is an interdisciplinary process between providers and nursing designed to decrease medication adverse drug events and potential adverse drug event. Medication reconciliation will be performed to clarify any discrepancies between the patient's actual medication regime and the most recent record of prescribed medications. This will allow the physician to review the information and order the appropriate medications and dosages for patients upon admission, transfer within and discharge from the facility.

1. The facility failed to ensure patients' home medications were reconciled and addressed for possible ordering during hospital visits.

a) A review of Patient #2's medical record revealed the patient presented to the facility on 09/17/17 with a chief complaint of shortness of breath. According to the History and Physical, Patient #2 had a history of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) and was being treated for possible sepsis (infection in the blood stream). According to a copy of a handwritten medication list, Patient #8 was taking several medications including Furosemide (a diuretic used to treat fluid retention) and DuoNeb (an inhaled medication used to treat respiratory diseases) at home.

A Review of the Home Medications section of the History of Present Illness (HPI) did not include Furosemide and DuoNeb on the list, which was documented as being reviewed by Physician #3 on 09/17/17 at 9:16 p.m.

A Review of the Admission Assessment Report listed the Home Medications were verified on 09/18/17 at 1:31 p.m. by RN #1; however, Furosemide and DuoNeb were not included on the list.

A review of the History and Physical also did not include Furosemide and DuoNeb on the list of home medications the patient took prior to admission.

According to the Medication Administration History Report (MAR), Patient #8 did not receive Furosemide until 09/20/17 at 1:18 p.m.

b) On 01/03/18 at 5:27 p.m., an interview with RN #4 was conducted who explained the home medication reconciliation process. RN #4 stated the process began when patients reported to the nurse which medications they were taking at home. This was communicated to the nurse by providing a list of home medications, bringing in pill bottles used at home or by verbally telling the nurse which medications the patient was currently taking. The nurse would then document the information in the computer. RN #4 then explained the provider and the nurse assigned to the patient on the inpatient unit were expected to verify that the home medications were accurately included in the patient's medical record. The home medication list in the medical record was then used by the physician to order medications for administration during the hospital visit.

RN #4 then stated s/he recalled providing care for Patient #2 in the Emergency Room and entering the home medications into the medical record. RN #4 stated after entering the medications into the computer s/he placed a copy of the handwritten list on Physician #3's desk for further review. RN #4 acknowledged the Furosemide and DuoNeb were not entered into the medical record and stated the patient's physician and inpatient admitting nurse were also responsible for double checking the documentation. After the omission was identified, RN #4 stated DON #2 spoke with him/her about the importance of ensuring all home medications were included in patients' medical records.

c) On 01/03/18 at 3:49 p.m., an interview with RN #1 was conducted who revealed s/he had provided care to Patient #2 on the inpatient unit the day the patient was admitted to the facility. RN #1 stated s/he did not recall if the the patient was on Furosemide or DuoNeb prior to the admission, nor did s/he recall seeing the handwritten list of home medications provided by the patient. RN #1 stated if s/he had known the patient was on Furosemide or DuoNeb s/he would have added it to the patient's medical record. RN #1 stated the implication of not having accurate home medications listed in the medical record was that the provider might not have known all of the medications the patient was on prior to being admitted in order to decide which medications the patient should have received while at the facility.

d) On 01/04/18 at 10:47 a.m., an interview with Physician #3 was conducted, who revealed s/he recalled caring for Patient #2 in the Emergency Room. Physician #3 stated s/he could not recall if s/he had seen the handwritten home medication list provided by the patient. Physician #3 further stated his/her practice was to look at the home medication list in the medical record then ask the patient further questions to clarify home medications. Physician #3 stated that even if Furosemide was listed as a home medication s/he would not have ordered Furosemide to be continued anyway due to the patient's presentation with sepsis. Physician #3 further stated s/he still would have expected the Furosemide and DuoNeb to be transcribed to the patient's medical record as a home medication even if it was not continued during the visit in order for there to be complete documentation of home medications for the patient.

e) On 01/04/18 at 11:39 a.m., an interview with the director of nursing (DON #2) was conducted. DON #2 explained the process of documenting home medications was the responsibility of the admitting nurse and the nurse in the inpatient unit was expected to verify that the list was complete and accurate. DON #2 stated this process was important because accurate information gathered on patients resulted in a better clinical picture in order to be able to treat patients.

DON #2 then stated after reviewing Patient #2's medical record the facility determined staff had followed the expected process but had missed transcribing some of the patient's home medications to the medical record. DON #2 reported s/he had spoken to the nurses involved with the error but s/he did not document those conversations. Furthermore, DON #2 stated there had been no further interventions or auditing put in place to ensure the process for transcribing home medications was successful throughout the facility or if the omission with Patient #2's medications was an isolated incident.

f) On 01/04/18 at 11:12 a.m., an interview with RN #5 was conducted who revealed his/her responsibilities included managing the quality program at the facility. RN #5 stated s/he was involved in reviewing the incident regarding the omission of Furosemide in Patient #2's home medication list in the medical record. RN #5 then stated there were plans to change the process of entering home medications into the medical record, however, there had been nothing implemented at the present time. RN #5 further stated there had not been any further investigation to see if the medication omission for Patient #2 was an isolated event or a recurring pattern at the facility.