HospitalInspections.org

On the days of the Complaint Investigation based on record review and interview with staff, staff failed to provide documentation of timely nursing assessment and reassessment related to documented clinical symptoms for 1 of 15 patient records reviewed for care and services. (Patient #1)


The findings are:


On 06/26/12 at 0900, a review of Patient #1's chart showed the patient presented to the Hospital's Emergency Department (ED) on 01/05/2012 at 1218 with a complaint of increased low back pain that resulted in an inpatient admission by the physician.

On 06/26/12 at 0930, a review of nursing documentation revealed Registered Nurse (RN) #5 documented on 1/6/12 at 0630, "PT (Patient) called for pain medication. reports that he has difficulty taking deeper breaths due to pain and spasms. OS[sic] SAT (oxygen saturation) at 89%. Paged Dr.(Doctor) .... Received new orders. NC (nasal canula) inplace at 2 liters (L), O2 (oxygen saturation) up to 94%. Call bell in reach, encouraged to call for needs. Oral care provided. Foley in place. Total output 1050 CC (cubic centimeters) clear yellow urine".

Review of the next nursing documentation entry dated 01/06/2012 at 0735 revealed Registered Nurse (RN) #21 documented, "Patient resting comfortably in bed at this time, VSS (vital signs stable), continuous IVF (intravenous fluid) infusing at this time, patient denies any pain or discomfort at this time, Foley patent draining clear yellow urine, safety precautions maintained, call light within reach, will continue to assess". There was no documentation related to the patient's pulmonary system to include but not limited to oxygen saturation level, Oxygen infusion rate and device, or the patient's breathing pattern although the previous nursing entry by the night shift indicated changes in the patient's medical condition.

Review of the next nursing documentation entry on 01/06/2012 at 1716 by Registered Nurse (RN) #21 revealed, "Patient resting comfortably in bed at this time, Patient tolerating diet fair, patient medicated once for pain and muscles spasms with good effect, wife in room with patient this time, patient denies any pain or discomfort at this time, no change in initial assessment at this time, safety precautions maintained, call light within reach". There was no documentation related to the patient's pulmonary system to include but not limited to oxygen saturation level, Oxygen infusion rate and device, or the patient's breathing pattern.

Review of the next nursing documentation entry dated 01/06/2012 at 1935 by the night shift nurse, Registered Nurse (RN ) 5, revealed"Patient in bed eyes closed, not easily arousable with verbal cues. Rubbed sternum, patient opened eyes but non verbal. Checked oxygen saturation (O2) SAT at 59% on 2 liters (L) nasal canula (nc). Heart rate at 126. Called charge nurse (CN) to room and Rapid response team (RRT) paged". On 01/06/2012 at 1936, Registered Nurse (RN) #5 documented, "Non rebreather (NR) mask applied at 10 liters (L). Patient eyes open, still non verbal but able to squeeze RN (Registered Nurse) finger when told to do so. Blood pressure (BP) 115/70, Heart rate (HR) 135, oxygen saturation (O2) SAT 99%, respirations 30". On 01/06/2012 at 1940, Registered Nurse (RN ) #5 documented, "Nursing supervisor and Rapid Response Team (RRT) in room. Oxygen saturation (O2) SAT 91% on non rebreather (NR) mask. Removed Fentanyl patch from R (Right) upper back. MD (Medical Doctor) paged".

On 06/26/12 at 1400, the findings were reviewed with the Administrator of Patient Care who reported that the Hospital is working on Communication.