HospitalInspections.org

Based on interview, record review and policy and procedure review the facility failed to ensure the medical records of patients discharged from the outpatient surgery department were complete and had documentation of physician discharge orders and patient discharge instructions (Patients #6, #7, #9, #10). The facility failed to document the amount of bleeding for four of four patients reviewed with a laceration (Patient #11, #17, #18 and #20).


Findings include:

A review of the facility's Outpatient Department Guidelines of Care last reviewed 09/28/09 included the following:

Purpose:"The Outpatient Services department provides care for stable patients. Expectation of the staff is patient-focused care to promote continuity, consistency and high quality nursing care."

Policy:"The following guidelines have been established to guide staff in care of the outpatient. All patients, family members, and significant others can expect consistent and efficient nursing care during their outpatient visit."

Procedure:

1 "The patient will be assessed by a registered nurse with regard to physical, psychosocial, functional and spiritual status during the admission process. This will be performed within 2 hours of admission to the Outpatient Services Department."

2. "The patient can expect immediate intervention for life threatening events and timely intervention for significant change in status."

3. "A Physician's order is required for discharge."

3 "The patient can expect to receive written discharge instructions prior to discharge. Verbal and written instructions will be given to patients and/or a responsible adult. Instructions must include activity, diet, treatments, exercise, follow-up appointment, medication, wound care and dressing care as appropriate."

4 "The patient, family, and significant other(s) can expect to be informed and instructed regarding his/her health care needs. Patient-focused learning needs will be assessed and evaluated so that the patient and his/her support systems will understand the health care education necessary to promote wellness."

The facility's Hospital wide Discharge Criteria last reviewed 09/28/09 included the following:

1. Discharge instructions are provided to the patient and responsible adult. The discharge instructions will be documented. The patient or responsible adult should acknowledge understanding of the instructions by signing the discharge sheet. A copy of the discharge instructions will be provided to the patient and responsible adult. The instructions will include:

a. How to contact physicians with any questions.

b. Instructions to seek emergency care if needed.

c. Care of the patient at home.

The facility's Assessment/Reassessment Plan Policy and procedure last reviewed 05/2011 included the following:

Policy Statement: "Each patient need for care is assessed by qualified individuals of appropriate disciplines throughout the organization. This assessment begins at the time of admission and continues throughout the patients contact with the (Hospital)."

Purpose: "The goal of patient assessment/reassessment is to determine what kind of care is required to meet the patients initial needs as well as his or her needs as they change in response to care. The facility will then coordinate the care treatment and services provided to the patient as part of the plan of care, treatment and services consistent with the deemed scope of care, treatment and services offered by the organization."

Surgical Invasive Procedures :

1. "A pre-operative checklist will be utilized in both the inpatient and ambulatory surgery areas to assess the patients educational needs, preparation and condition during the pre-operative stage."

2 "Preoperative checklist - The R.N. in the holding area of the OR and in all invasive settings, or Out-patient Surgery area is responsible for the final review of the pre-operative checklist., for variations identified during this pre-operative nursing assessment and noting interventions taken as identified on the peri-operative form."

3. "Plan of Care is initiated by the R.N. pre-operatively/pre-procedurally after completion of the initial admission assessment. "

Patient #6

On 09/13/11 at 9:30 AM, a review of the patients medical record revealed the patient was admitted to out patient surgery on 06/06/11 at 10:51 AM for a scheduled right second toe amputation surgery. A Physical and History dated 05/17/11 indicated the patient had a history of hypertension, diabetes, peripheral artery disease and dyslipidemia

A review of the Nursing Invasive Procedure Patient Safety Checklist dated 06/06/11 at 10:51 AM documented the patients blood pressure was 185/99. On 06/06/11 at 11:30 AM the patients blood sugar, accucheck level was documented as 372 (Normal 80-100). On 06/06/11 at 11:52 AM the patients blood pressure was documented as 180/88. (Normal 90/60 to 119/79)

A Physician Order dated 06/06/11 at 11:55 AM documented the patients surgery was canceled due to elevated blood pressure and elevated blood sugar.

A review of the patients medical record revealed no documented evidence of a physician discharge order, discharge summary, physician progress note, nursing progress assessment note or discharge instructions form.

On 09/13/11, the Risk Manager Director confirmed there was no documented evidence in the medical record of physician progress notes, nursing assessment or progress notes, documentation of nursing interventions to address the patients elevated blood pressure and blood sugar levels, and no discharge instructions provided to the patient.

On 09/13/11 at 2:00 PM, the Surgery Charge Nurse (Employee #8) acknowledged the patients nurse failed to inform the physician the patient had not been taking his blood pressure medication for six days prior to the patients surgery. The Surgery Charge Nurse reported the patients nurse failed to follow the nursing process and document nursing assessments, plan of care and nursing interventions in the medical record in regards to the patients hypertension and hyperglycemia. The Surgery Charge Nurse reported the patients nurse failed follow discharge policy and procedure by not providing the patient with discharge instructions regarding medications and physician follow-up or medical referral for evaluation and treatment of the patients hypertension and hyperglycemia prior to the patients discharge from the hospital. The Surgery Charge Nurse acknowledged follow-up care and treatment should have been provided to the patient to treat his hypertension and hyperglycemia prior to discharge from the facility.

Patient #7

On 09/13/11 a review of the medical record revealed Patient #7 was admitted to the outpatient surgery department on 08/09/11 with diagnoses that included allergic rhinitis, hypertrophy of nasal turbinates and deviated nasal septum. The patient was scheduled for endoscopic sinus surgery, septoplasty, turbinate modification and nasal valve repair. The patient medical record included post operative orders dated 08/09/11 at 5:00 PM that included intravenous normal saline to run at 100 cc (cubic centimeter) an hour, clear liquid diet, intravenous Demerol pain medication orders and Tylenol with Codeine oral pain medication orders. The post operative orders were signed by the surgeon.

A post operative description of procedure dated 08/09/11 at 5:00 PM,, documented the patient had endoscopic sinus surgery and the finding included a polyp. The patients condition was documented as stable with a estimated 30 cc blood loss. The post operative description of the procedure was signed by the surgeon on 09/09/11 at 5:00 PM. There was no documented evidence of a physician discharge order or discharge instructions located in the patients medical record.

On 09/13/11 at 4:00 PM, the Director of Surgery reported Patient #7's surgery had been canceled and the patient never had endoscopic sinus surgery. The Director of Surgery reported she could not account for or explain why there were post operative orders and a post operative description of a procedure that never took place documented in the patients medical record. The Director of Surgery acknowledged there was no documented evidence of a physician discharge order or patient discharge instructions located in the medical record.

Patient #9

On 09/13/11 a review of the medical record revealed Patient #9 was admitted to the outpatient surgery department on 08/26/11 with diagnoses that included diabetes and right great toe osteomyelitis. The patient was scheduled for a right hallux amputation surgery.

A Physicians Order dated 08/26/11 at 9:10 AM, documented the surgery was canceled and to discharge the patient home. There was no documented nursing note or physician progress note that indicated why the patients surgery had been canceled. There was no documented evidence patient discharge instructions that included medication instructions or follow-up care was provided to the patient prior to discharge.

Patient # 10

On 09/13/11 a review of the medical record revealed Patient #9 was admitted to the outpatient surgery department on 05/20/11 with diagnoses that included status post left knee arthroplasty and infected left knee. The patient was scheduled for a needle aspiration and debridement of the left knee. A physician order dated 05/20/11 at 2:45 PM, included performing a cell count, gram stain, aerobic, anaerobic, fungus and AFB (acid fast bacillus) on the left knee aspirate.

There was no documented evidence of a physician discharge order, surgeon operative report of findings, anesthesia record, physician progress notes or nursing notes located in the patients medical medical record.


27469


Patient #11

Patient #11 arrived at the Emergency Department (ED) on 7/30/11 at 7:00 PM. The patient was triaged at 7:20 PM. The patient was examined by the physician assistant (PA) at 8:36 PM.

The chief complaint on the Emergency Nursing Record was documented as scrotal laceration. Additional findings documented "scrotal sac chunk out from clippers - bleeding ". There was no documented evidence of the number of wounds, size, depth or amount of bleeding from the wounds.

The Emergency Physician Record documented the patient had one scrotal laceration on the left side. There was no documented evidence of the size, depth or amount of bleeding from the wounds. The PA ordered sutures and a tetanus injection. The record documented the patient refused the tetanus injection.

Patient #17

Patient #17 arrived at the Emergency Department on 8/16/11 with a chief complaint of a left forearm laceration. There was no documented evidence on the Emergency Nursing Record of the size, depth or amount of bleeding from the wounds.

Patient #18

Patient #18 arrived at the Emergency Department on 8/16/11 with a chief complaint of a laceration on the chin. There was no documented evidence on the Emergency Nursing Record of the size, depth or amount of bleeding from the wounds.

Patient #20

Patient #20 arrived at the Emergency Department on 9/3/11 with a chief complaint of a laceration to the forehead. There was no documented evidence on the Emergency Nursing Record of the size, depth or amount of bleeding from the wounds.

On 9/13/11, at 1:55 PM, the Medical Director of the Emergency Department was interviewed. The physician confirmed the PA should have charted the amount of bleeding seen from Patient #11.

On 9/13/11, at 2:05 PM, Employee #9, RN in ED, was interviewed. The employee explained if a patient arrives in the ED with a laceration, the staff should document the appearance, length, width, and amount of bleeding. The RN reviewed the nursing documentation for Patient's #11, #17, #18 and #20. The RN acknowledged there was no documented evidence of the amount of bleeding from the wounds.

On 9/13/11, at 2:30 PM, Employee #10, RN in ED, was interviewed. The employee explained if a patient arrives in the ED with a laceration, the staff should document the appearance, length, width, depth, pain scale and amount of bleeding. The RN reviewed the nursing documentation for Patient ' s #11, #17, #18 and #20. The RN acknowledged there was no documented evidence of the amount of bleeding from the wounds.

On 9/13/11, at 2:45 PM, Employee #11, agency RN in ED, was interviewed via telephone. The RN explained there was approximately 1" by ?" by ?" clot noted on Patient #11's towel he had brought from home. The RN did not note any other bleeding. The RN acknowledged he did not document the clot or bleeding on the nursing record.

The Skin Integrity Management policy, effective 10/10 was reviewed. The scope of the policy was the nursing division. The purpose documented to provide guidelines for maintaining patient skin integrity and to promote patient care and patient safety regarding skin integrity.

Attachment E: Wound Documentation Guidelines listed location, measurements, wound bed appearance, condition of surrounding skin, wound pain and exudates.

The Triage-Emergency Department policy, reviewed 8/11 was reviewed. The policy documented the Triage Nurse would complete a visual and verbal assessment of all patients and complete the portion of the ED record designed for triage notes.

Complaint #NV00028776
Complaint #NV00029041

Based on interview, record review and the facility's discharge policy and procedure review, the facility failed to identify a patient was likely to suffer adverse consequences due to untreated hypertension and hyperglycemia upon discharge without an adequate discharge plan. (Patient #6)

Findings include:

Patient #6

On 09/13/11 at 9:30 AM, a review of the patients medical record revealed the patient was admitted to out patient surgery on 06/06/11 at 10:51 AM for a scheduled right second toe amputation surgery. A Physical and History dated 05/17/11 indicated the patient had a history of hypertension, diabetes, peripheral artery disease and dyslipidemia

A review of of Nursing Invasive Procedure Patient Safety Checklist dated 06/06/11 at 10:51 AM documented the patients blood pressure was 185/99. On 06/06/11 at 11:30 AM the patients blood sugar, accucheck level was documented as 372 (Normal 80-100). On 06/06/11 at 11:52 AM the patients blood pressure was documented as 180/88 (Normal 90/60 to 119/79).

A review of the patients Medication Reconciliation Form dated 06/06/11, completed by the patients nurse documented the patient had not taken prescribed blood pressure medication Hydralazine and Enapramil for the past six days preceding the day of surgery. There was no documented evidence the patients physician was notified the patient had not been taking prescribed blood pressure medication for six days.

A Physician Order dated 06/06/11 at 11:55 AM documented the patients surgery was canceled due to elevated blood pressure and elevated blood sugar.

A review of the patients medical record revealed no documented evidence of a physician discharge summary, physician progress note, nursing progress assessment note or discharge instructions form.

On 09/13/11, the Risk Manager Director confirmed there was no documented evidence in the medical record of physician progress notes, nursing assessment or progress notes, documentation of nursing interventions to address the patients elevated blood pressure and blood sugar levels, and no discharge instructions provided to the patient.

A review of the facility's Outpatient Department Guidelines of Care last reviewed 09/28/09 included the following:

Purpose:"The Outpatient Services department provides care for stable patients. Expectation of the staff is patient-focused care to promote continuity, consistency and high quality nursing care."

Policy:"The following guidelines have been established to guide staff in care of the outpatient. All patients, family members, and significant others can expect consistent and efficient nursing care during their outpatient visit."

Procedure:

1 "The patient will be assessed by a registered nurse with regard to physical, psychosocial, functional and spiritual status during the admission process. This will be performed within 2 hours of admission to the Outpatient Services Department."

2 "The patient can expect immediate intervention for life threatening events and timely intervention for significant change in status."

3 "The patient can expect to receive written discharge instructions prior to discharge. Verbal and written instructions will be given to patients and/or a responsible adult. Instructions must include activity, diet, treatments, exercise, follow-up appointment, medication, wound care and dressing care as appropriate."

4 "The patient, family, and significant other(s) can expect to be informed and instructed regarding his/her health care needs. Patient-focused learning needs will be assessed and evaluated so that the patient and his/her support systems will understand the health care education necessary to promote wellness."

The facility's Hospital wide Discharge Criteria last reviewed 09/28/09 included the following:

1. Discharge instructions are provided to the patient and responsible adult. The discharge instructions will be documented. The patient or responsible adult should acknowledge understanding of the instructions by signing the discharge sheet. A copy of the discharge instructions will be provided to the patient and responsible adult. The instructions will include:

a. How to contact physicians with any questions.

b. Instructions to seek emergency care if needed.

c. Care of the patient at home.

The facility's Assessment/Reassessment Plan Policy and procedure last reviewed 05/2011 included the following:

Policy Statement: "Each patient need for care is assessed by qualified individuals of appropriate disciplines throughout the organization. This assessment begins at the time of admission and continues throughout the patients contact with the (Hospital)."

Purpose: "The goal of patient assessment/reassessment is to determine what kind of care is required to meet the patients initial needs as well as his or her needs as they change in response to care. The facility will then coordinate the care treatment and services provided to the patient as part of the plan of care, treatment and services consistent with the deemed scope of care, treatment and services offered by the organization."

Surgical Invasive Procedures :

1. "A pre-operative checklist will be utilized in both the inpatient and ambulatory surgery areas to assess the patients educational needs, preparation and condition during the pre-operative stage."

2 "Preoperative checklist - The R.N. in the holding area of the OR and in all invasive settings, or Out-patient Surgery area is responsible for the final review of the pre-operative checklist., for variations identified during this pre-operative nursing assessment and noting interventions taken as identified on the peri-operative form."

3. "Plan of Care is initiated by the R.N. pre-operatively/pre-procedurally after completion of the initial admission assessment. "


On 09/13/11 at 12:10 PM, the Director of Surgery reported the patients nurse failed to complete and document in the medical record a progress note that documented the patients assessment of elevated blood pressure and blood sugar levels, nursing interventions, plan of care, follow-up, notification of the physician and discharge instructions. The Director of Surgery reported the physician order to cancel the patients surgery due to elevated blood pressure readings and elevated blood sugar readings was not a discharge order. The Director of Surgery reported the patients nurse failed to complete a discharge instruction form that included diet instructions, medication instructions and physician follow-up instructions. The Director of Surgery acknowledged given the patients elevated blood pressure and blood sugar levels a referral to the hospital emergency department for evaluation and treatment would have been more appropriate than discharging the patient home with no follow-up care and treatment.

On 09/13/11 at 12:40 PM, the patients nurse (Employee #7) reported assessing the patient in the pre-operative phase and finding the patients blood pressure was elevated at 185/99 and 180/88 and the patients blood sugar was elevated at 372. Employee #7 did not remember completing a progress note on the patient or implementing any nursing interventions to deal with the patients elevated blood pressure and elevated blood sugar levels. Employee #7 reported the patients physician was called and notified of the patients elevated blood sugar and blood pressure by the charge nurse and the patients surgery was then canceled. Employee #7 acknowledged no discharge instruction form that included instructions regarding resumption of blood pressure and diabetes medications was filled out or given to the patient upon discharge. Employee #7 was not aware of any discharge instructions given to the patient regarding recommendations or referral for follow-up for evaluation and treatment of the patients hypertension and hyperglycemia prior to discharge.

On 09/13/11 at 2:00 PM, the Surgery Charge Nurse who acknowledged the patients nurse failed to inform the physician the patient had not been taking his blood pressure medication for six days prior to the patients surgery. The Surgery Charge Nurse reported the patients nurse failed to follow the nursing process and document nursing assessments, plan of care and nursing interventions in the medical record in regards to the patients hypertension and hyperglycemia. Employee #8 reported the patients nurse failed follow discharge policy and procedure by not providing the patient with discharge instructions regarding medications and physician follow-up or medical referral for evaluation and treatment of the patients hypertension and hyperglycemia prior to the patients discharge from the hospital. The Surgery Charge Nurse acknowledged follow-up care and treatment should have been provided to the patient to treat his hypertension and hyperglycemia prior to discharge from the facility.

Complaint #NV00028776

Based on interview, record review and discharge policy and procedure review the facility failed to complete a discharge planning evaluation that included the likelihood of the patient needing immediate care and treatment for hypertension and hyperglycemia prior to discharge from the hospital surgery center. (Patient #6)

Findings inlcude:

A review of the facility's Outpatient Department Guidelines of Care last reviewed 09/28/09 included the following:

Purpose:"The Outpatient Services department provides care for stable patients. Expectation of the staff is patient-focused care to promote continuity, consistency and high quality nursing care."

Policy:"The following guidelines have been established to guide staff in care of the outpatient. All patients, family members, and significant others can expect consistent and efficient nursing care during their outpatient visit."

Procedure:

1 "The patient will be assessed by a registered nurse with regard to physical, psychosocial, functional and spiritual status during the admission process. This will be performed within 2 hours of admission to the Outpatient Services Department."

2 "The patient can expect immediate intervention for life threatening events and timely intervention for significant change in status."

3 "The patient can expect to receive written discharge instructions prior to discharge. Verbal and written instructions will be given to patients and/or a responsible adult. Instructions must include activity, diet, treatments, exercise, follow-up appointment, medication, wound care and dressing care as appropriate."

4 "The patient, family, and significant other(s) can expect to be informed and instructed regarding his/her health care needs. Patient-focused learning needs will be assessed and evaluated so that the patient and his/her support systems will understand the health care education necessary to promote wellness."

The facility's Hospital wide Discharge Criteria last reviewed 09/28/09 included the following:

1. Discharge instructions are provided to the patient and responsible adult. The discharge instructions will be documented. The patient or responsible adult should acknowledge understanding of the instructions by signing the discharge sheet. A copy of the discharge instructions will be provided to the patient and responsible adult. The instructions will include:

a. How to contact physicians with any questions.

b. Instructions to seek emergency care if needed.

c. Care of the patient at home.

The facility's Assessment/Reassessment Plan Policy and procedure last reviewed 05/2011 included the following:

Policy Statement: "Each patient need for care is assessed by qualified individuals of appropriate disciplines throughout the organization. This assessment begins at the time of admission and continues throughout the patients contact with the (Hospital)."

Purpose: "The goal of patient assessment/reassessment is to determine what kind of care is required to meet the patients initial needs as well as his or her needs as they change in response to care. The facility will then coordinate the care treatment and services provided to the patient as part of the plan of care, treatment and services consistent with the deemed scope of care, treatment and services offered by the organization."

Surgical Invasive Procedures :

1. "A pre-operative checklist will be utilized in both the inpatient and ambulatory surgery areas to assess the patients educational needs, preparation and condition during the pre-operative stage."

2 "Preoperative checklist - The R.N. in the holding area of the OR and in all invasive settings, or Out-patient Surgery area is responsible for the final review of the pre-operative checklist., for variations identified during this pre-operative nursing assessment and noting interventions taken as identified on the peri-operative form."

3. "Plan of Care is initiated by the R.N. pre-operatively/pre-procedurally after completion of the initial admission assessment. "

Patient #6

On 09/13/11 at 9:30 AM a review of the Patient #6's medical record revealed the patient was admitted to out patient surgery on 06/06/11 at 10:51 AM for a scheduled right second toe amputation surgery. A Physical and History dated 05/17/11 indicated the patient had a history of hypertension, diabetes, peripheral artery disease and dyslipidemia

A review of of Nursing Invasive Procedure Patient Safety Checklist dated 06/06/11 at 10:51 AM documented the patients blood pressure was 185/99. On 06/06/11 at 11:30 AM the patients blood sugar, accucheck level was documented as 372 (Normal 80-100). On 06/06/11 at 11:52 AM the patients blood pressure was documented as 180/88 (Normal 90/60 to 119/79).

A review of the patients Medication Reconciliation Form dated 06/06/11, completed by the patients nurse documented the patient had not taken prescribed blood pressure medication Hydralazine and Enapramil for the past six days preceding the day of surgery. There was no documented evidence the patients physician was notified the patient had not been taking prescribed blood pressure medication for six days.

A Physician Order dated 06/06/11 at 11:55 AM documented the patients surgery was canceled due to elevated blood pressure and elevated blood sugar.

A review of the patients medical record revealed no documented evidence of a physician discharge summary, physician progress note, nursing progress assessment note or discharge instructions form that included medication information or instructions for a referral for follow-up care for evaluation and treatment for hypertension and hyperglycemia.

On 09/13/11, the Risk Manager Director confirmed there was no documented evidence in the medical record of physician progress notes, nursing assessment or progress notes, documentation of nursing interventions to address the patients elevated blood pressure and blood sugar levels, and no discharge instructions provided to the patient.

On 09/13/11 at 12:10 PM, the Director of Surgery reported the patients nurse failed to complete and document in the medical record a progress note that documented the patients assessment of elevated blood pressure and blood sugar levels, nursing interventions, plan of care, follow-up, notification of the physician and discharge instructions. The Director of Surgery reported the physician order to cancel the patients surgery due to elevated blood pressure readings and elevated blood sugar readings was not a discharge order. The Director of Surgery reported the patients nurse failed to complete a discharge instruction form that included diet instructions, medication instructions and physician follow-up instructions. The Director of Surgery acknowledged given the patients elevated blood pressure and blood sugar levels a referral to the hospital emergency department for evaluation and treatment would have been more appropriate than discharging the patient home with no follow-up care and treatment.

On 09/13/11 at 12:40 PM an interview with Employee #7, the patients nurse was conducted. Employee #7 reported assessing the patient in the pre-operative phase and finding the patients blood pressure was elevated at 185/99 and 180/88 and the patients blood sugar was elevated at 372. Employee #7 did not remember completing a discharge planning evaluation on the patient or implementing any nursing interventions to deal with the patients elevated blood pressure and elevated blood sugar levels. Employee #7 reported the patients physician was called and notified of the patients elevated blood sugar and blood pressure by the charge nurse and the patients surgery was then canceled. Employee #7 acknowledged no discharge instruction form that included instructions regarding resumption of blood pressure and diabetes medications was filled out or given to the patient upon discharge. Employee #7 was not aware of any discharge instructions given to the patient regarding recommendations or referral for follow-up for evaluation and treatment of the patients hypertension and hyperglycemia prior to discharge.

On 09/13/11 at 2:00 PM, the Surgery Charge Nurse acknowledged the patients nurse failed to inform the patient physician the patient had not been taking his blood pressure medication for six days prior to the patients surgery. The Surgery Charge Nurse reported the patients nurse failed to follow the nursing process and document nursing assessments, plan of care and nursing interventions in the medical record in regards to the patients hypertension and hyperglycemia. Employee #8 reported the patients nurse failed follow discharge policy and procedure by not providing the patient with discharge instructions regarding medications and physician follow-up or medical referral for evaluation and treatment of the patients hypertension and hyperglycemia prior to the patients discharge from the hospital. The Surgery Charge Nurse acknowledged follow-up care and treatment should have been provided to the patient to treat his hypertension and hyperglycemia prior to discharge from the facility.

Complaint #NV00028776