HospitalInspections.org

Based on interview and record review the hospital failed to ensure that nursing documentation was complete in identifying the course and results of care and treatment for one for applicable patient (Patient #2). Findings include:

Per record review Patient #2 had a history of hypertension (high blood pressure), peripheral vascular disease (narrowing of blood vessels), deep venous thrombosis (clot in the vein), anxiety, and a prior umbilical hernia (intestine protrudes through the abdominal wall at the belly button) repair. S/he presented to the emergency department (ED) on 5/1/19 with abdominal pain and nausea. S/he was found to have a small bowel obstruction (blockage in the small intestine) related to a ventral hernia (bulge of tissue through an opening of weakness within the abdominal wall muscles) and was admitted to the hospital. On 5/2/19 s/he was evaluated by a surgeon; and on 5/4/19 s/he was taken to the operating room to repair the hernia. There was no evidence in the medical record that identified that the patient had an abdominal incision and/or that the incision was monitored until 5/7/19 at 8:00 PM, three days after the surgery. Per interview on 7/2/19 at 2:05 PM with the Clinical Education Manager, s/he confirmed that there was no documentation which identified and monitored a post-surgical wound until 5/7/19. S/he stated that the expectation was that all wounds were identified and monitored; and that the nurses were to document their findings in the medical record.