HospitalInspections.org

Based on document review, medical record review and staff interview, it was determined the hospital failed to ensure the nursing staff followed hospital policy by documenting patient care provided in six (6) of ten (10) medical records (Patient #2, 3, 4, 5, 7, 10) reviewed. This has the potential to negatively impact all patient care by not providing necessary information to all caregivers/providers to determine effectiveness of care. Findings include:

1. Beckley Appalachian Regional Hospital (BARH) policy Patient Care Flow Record, F-II-06, adopted 10/1/05, states in part "...The data gathered during the nursing reassessment may be utilized by various disciplines to assist with the reassessment process/plan of care...PURPOSE: To document the daily assessment and interventions of adult and pediatric patients admitted to ARH. The findings are used to review and evaluate patient outcomes and plan of care...PROCEDURE: The ARH Patient Care Flow Sheet contains the following elements: ...Diet...A key to record the amount and method of consumption should be used to record intake at breakfast, lunch, afternoon snack, dinner and evening snack...Completion of oral care...is recorded in the row labeled as such...Completion of AM care...is recorded in the row labeled as such...Completion of bath, and level of assistance patient required, is recorded in the row labeled such...Patient's skin should be cleansed whenever soiled and patient should have complete bath at least every other day while hospitalized. In the event patient or family refuse complete bath, this should be noted...Linen change is recorded in the row labeled such...Linens should be changed anytime they are soiled and at least every other day. In the event patient or family refuses linen changes, this should be noted...Position change should be recorded every two (2) hours using key provided to note position...In the event patient or family refuses position change, this should be noted along with education provided regarding the importance of position changes...Oral intake should be totaled every eight (8) hours and documented in the designated box..."

2. Review of the medical record for Patient #2 revealed the patient was admitted 2/20/10 and discharged 3/9/10. During the admission, there was inconsistent documented evidence on the flowsheet of personal hygiene and linen change provided and of diet and oral intake.

3. During an interview with the Community Chief Nursing Officer (CCNO) in the afternoon of 12/1/10, the above policy and the record were reviewed and the CCNO agreed with the findings.

4. Review of the medical record, in the morning of 11/30/10, for Patient #3 revealed the patient was admitted on 11/22/10. During the admission, there was inconsistent documented evidence on the flowsheet of personal hygiene and linen change provided and of diet and oral intake. Also, daily weights were ordered on admission with no documented evidence of occurrence until 11/28/10.

5. Review of the medical record, in the morning of 11/30/10, for Patient #4 revealed the patient was admitted on 11/25/10. During the admission, there was inconsistent documented evidence on the flowsheet of personal hygiene and linen change provided.

6. Review of the medical record, in the morning of 11/30/10, for Patient #5 revealed the patient was admitted on 11/25/10. During the admission, there was inconsistent documented evidence on the flowsheet of personal hygiene and linen change provided. Also, daily weights were ordered on admission with no documented evidence of a weight on 11/27/10, 11/28/10 or 11/29/10.

7. During an interview with the 3rd Floor UM in the morning of 11/30/10, medical records #3, #4 and #5 were reviewed and the UM agreed with the findings.

8. Review of the medical record, in the morning of 12/1/10, for Patient #7 revealed the patient was admitted on 11/26/10. During the admission, there was inconsistent documented evidence on the flowsheet of personal hygiene and linen change provided.

9. Review of the medical record, in the morning of 12/1/10, for Patient #10 revealed the patient was admitted on 11/27/10. During the admission, there was inconsistent documented evidence on the flowsheet of personal hygiene and linen change provided.

10. During an interview with the 2nd Floor UM in the morning of 12/1/10, medical records #7 and #10 were reviewed and the UM agreed with the findings.