HospitalInspections.org

Based on review of documentation and interview it was determined that the facility failed to ensure that services furnished in the facility were provided in accordance with the facility's own policies.

Findings were:
The facility did not follow it's own policy. Review of medical records for patients #1 and #2 revealed that nursing staff failed to obtain physician orders when these patients were place on 1:1 precautions as required by facility policy. Review of the medical record for patient #1 and #2 revealed that both of these patients had been placed on 1:1 observation. Review of the medical record for patient #1 revealed two each orange colored "Patient Observation/Rounds Form 1:1". These forms documented that on 6/09/2016 patient #1 was on 1:1 from 8:45pm until 7:00am on 6/10/2016 (a total of 10 hours and 15 minutes). Review of the physician order section of the medical record for patient #1 revealed no physician order for 1:1 precautions.

Review of the medical record for patient #2 revealed three each orange colored "Patient Observation/Rounds Form 1:1". Patient #2 was placed on 1:1 observation on 5/9/2016 (sic) from 1:30am until 7:15am (a total of 5 hours and 45 minutes). Patient #2 was again placed on 1:1 observation on 6/12/2016 from 9:15pm until 6:45am on 6/13/2016 (a total of 8 hours and 30 minutes). Also found in the medical record of patient #2 was a "Multidisciplinary Progress Note" which documented that patient #2 was on 1:1 from 6/12/16 at 21:15 until 6/13/2016 at 07:00. Review of the physician order section of the medical record for patient #2 revealed no physician order for 1:1 precautions.

Review of facility policy entitled: "Special Precautions Guidelines" with revised date of 4/13 stated under the procedure section: "2.0 An order for the appropriate level of precautions should be demonstrated in the physicians's order section of the medical record, and the appropriate Precaution Record should be initiated by the charge nurse or designee. When special precautions are initiated by nursing order, the nurse will contact the physician as soon as possible and notify him/her of the need for the precaution. Initiation of precautions should be documented in the physician orders specifying date, time and level of observation. Any special precautions that impinge on the Patient's rights such as 1:1 observation must have clinical justification. the physician should be contacted within 1 hour to obtain verbal order for special precaution. A licensed nurse or designee should ensure that all patient orders for special precautions are recorded and posted per facility policies and procedures." Additionally a review of facility policy entitled: "Physician Orders" with issue date of 11/2008 stated under the policy section: "The communication of medical orders must be executed in manner designed to ensure patient safety and eliminate misunderstanding. Orders shall be in writing by the physician, signed and dated. Orders that have been dictated verbally or by telephone must be co-signed within 72 hours."

In an interview on 6/27/2016 with the facility's Director of Risk Management and the Director of Process Improvement it was confirmed that there were no physician orders for 1:1 observation found in the medical records of patients #1 and #2.

Based on review of documentation and interview it was determined that the facility failed to ensure that patient treatment plans were updated as required by facility policy.

Findings were:
The treatment plans for 2 of 2 patients were not updated to reflect the need for special observation as required by facility policy. Review of the medical record for patient #1 and #2 revealed that both of these patients had been placed on 1:1 observation. Review of the medical record for patient #1 revealed two each orange colored "Patient Observation/Rounds Form 1:1". These forms documented that on 6/09/2016 patient #1 was on 1:1 from 8:45pm until 7:00am on 6/10/2016 (a total of 10 hours and 15 minutes). Review of "Multidisciplinary Treatment Plan" dated 6/8/2016 for patient #1 was found to contain no documentation regarding the need to place patient #1 on 1:1 observation during this time period.

Review of the medical record for patient #2 revealed three each orange colored "Patient Observation/Rounds Form 1:1". Patient #2 was placed on 1:1 observation on 5/9/2016 (sic) from 1:30am until 7:15am (a total of 5 hours and 45 minutes). Patient #2 was again placed on 1:1 observation on 6/12/2016 from 9:15pm until 6:45am on 6/13/2016 (a total of 8 hours and 30 minutes). Also found in the medical record of patient #2 was a "Multidisciplinary Progress Note" which documented that patient #2 was on 1:1 from 6/12/16 at 21:15 until 6/13/2016 at 07:00. Review of the "Multidisciplinary Treatment Plan" for patient #2 contained no documentation regarding the need to place patient #2 on 1:1 observation during these time periods.

Review of facility policy entitled: "Special Precautions Guidelines" with revised date of 4/13 stated on page 5 of 6: "11.0 The need for special observation must be addressed in the patient's treatment plan."
In an interview on 6/28/2016 with the facility's Director of Risk Management and the Director of Process Improvement it was confirmed that the treatment plans for patient #1 and #2 did not contain documentation regarding the need for any special precautions.