HospitalInspections.org

Based on a review of the patient's medical record (MR), facility documentation, and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to provide care in a safe setting in one of one medical record.

Findings include:

Review of Observation: Suicidal, Homicidal Patient 1:1 (One to one), policy and procedure dated July 2013, revealed, "... Statement of Policy: 1:1 Observation is a safety measure to provide a 1:1 staff/patient ratio for the patient found by clinical assessment to be exhibiting behavior that may be harmful/risky to self or others. A physician order is required. The Nursing suicidal risk assessment may also identify a patient who is at risk for suicide. The patient's rights, safety, dignity, and well-being are preserved. ... Discontinuation of 1:1 Observation is ordered by the Physician. Observation Staff: ... Document q 15 minutes on the 1:1 Observation Record. Documentation on the 1:1 observation handoff to enhance hand off communication. Points of Emphasis ... 4) The patient(s) must be supervised at all times until relief is obtained. ... Desired Patient Outcome: The primary outcome is to prevent a patient from injuring him/herself utilizing the least restrictive method that is effective, while maintaining the patient's dignity, rights and well-being. Specifically: ... Patient's safety, hydration, nutrition, and elimination needs will be met. ... ."

1) Review of MR1 revealed that there was no documented evidence of a Physician Order to discontinue the 1:1 observation status of the patient.

2) An interview was conducted with EMP2 on April 10, 2015, at approximately 10:15 AM. EMP2 revealed, "I know there wasn't an order to D/C the one to one. ... I felt that we removed all of the threats so we discontinued the one to one observation. ... ."

Based on a review of the patient's medical record (MR), facility documents, and interview with facility staff (EMP) it was determined that Conemaugh Memorial Medical Center failed to follow their adopted policies in relation to RN supervision and evaluation of the nursing care of the patient in one of one medical record (MR1).

Findings include:

Review of Database/Admission and M/S Assessment Care Manager Documentation, policy and procedure dated May 2013, revealed, "... Daily M/S Assessment: Assess your patient daily per shift requirement: ... b. On 7a-7p, a 12 hour shift, chart in the classes represented below as 1 through 15 during the hours of 7-3. ... Classes to chart on: 1. Pt problem should reflect the reason for admission, nursing diagnosis, or some new problem that has occurred. For example-chest pain or shortness of breath. ... 18. Other systems-When a problem, or abnormality, occurs in the remaining systems, please assess and chart your problems. When a change in the patient's condition occurs during your shift-you must chart what change occurred but only in the system/s affected-even if you have already charted on that shift. ... ."

1) MR1 Assessment/Interventions, nursing documentation dated December 29, 2014, revealed, "... 03:35 Pt problm [sic] ... Under 1:1 observation due to history of PICA. Non-verbal. ... Skin Alterations ... skin intact ... 08:47 ... Pt admitted syncope, from ... Residential Services 1:1 2nd to PICA ... ADLs Grooming ... 10:03 complete ... Oral care complete ... Feeding complete assist ... Elimination ... incontinent ... 17:04 High risk equipm [sic] ... 1:1 PICA ... 12/30/14 10:27 ... pt does not cooperate with eating, po intake is poor, Pt receiving IV fluids until po is greater than 300. ... 16:59 ... pt resting today, did not exhibit any signs of pain. Pt had increased PO intake. Cardiac monitor and IV fluids discontinued. ... IVs/Lines/Blocks ...Peripheral Lines Location #1 Right 2 ... Interventions ... removd/protocol ... no IV access ... pt removed ... 20:00 Skin Alterations Skin Alteratn [sic] 1 ... Alteratn [sic] Type 1 ... tear ... Location 1 ... right arm ... Appearance ... pink unapproximated crusted ... Care/Dressing ... open to air cleaned ... Drainage ... none ... 12/31/14 17:32 ... Pt po intake increased, eating all meals. Pt is scheduled to go for EGD tomorrow to remove bezeoa [sic]. ... 01/01/14 17:00 Patient went to GI lab today for EGD. foreign object was removed. ... ."

MR1 Progress Note, physician documentation revealed, "... 3:36:34 PM, Tuesday, December 30, 2014 ... Plan: possible ingestion of cardiac monitor leads check cxr and abd film for eval for foreign bodies ... ."

2) An interview was conducted with EMP3 on April 15, 2015, at 3:05 PM. EMP3 revealed, "... I guess I didn't document that the leads were missing."

Review of Remote Cardiac Monitoring: Medical/Surgical Nursing Procedure and Responsibilities, policy and procedure dated October 30, 2014, revealed, "... Policy-All staff caring for patients requiring remote cardiac monitoring will follow established procedures, guidelines and responsibilities to provide a safe environment for our patients. ... Responsibilities: ... Rhythm strips and a brief report on the monitored patients are sent to the nurses stations every 8 hours (Nursing Work Sheet attached-Attachment B). The RN signs his/her patients strips every 8 hours. RN signs first initial, last name on the printed telemetry strip print-out indicating she/he has reviewed the strips before placing the monitor strips on the chart. The RN signature acknowledges that the nurse has reviewed the rhythm strips. ... ."

1) MR1 EKG Rhythm Strips, documentation revealed that telemetry rhythm strips were completed on December 29, 2014, at 3:32 AM, 7:12 AM, 7:22 AM, 8:46 AM, 3:05 PM, 5:03 PM, 10:22 PM, 11:13 PM, and on December 30, 2014, at 1:41 AM. The patient's cardiac monitor was discontinued on December 30, 2014, at 12:00 PM. The EKG Rhythm Strips documentation revealed that the Monitor Technician (M. T.) signed each document with a first initial and last name, however, failed to reveal the RN's signature (first initial and last name) in the space provided.

2) An interview was conducted with EMP2 on April 10, 2015, at 10:30 AM. EMP2 confirmed the above findings and revealed, "... The whole paper is tubed to the Unit and the nurse caring for the patient is responsible for reviewing and signing off the strips.