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ADVENTHEALTH OCALA
CONTENT OF RECORD
Tag No.: A0449
Based on record review and interview the facility failed to ensure the nursing assessment record was complete for 1 (#2) of 6 patients.
Findings:
The record review for Patient #2 revealed on 06/13/2014 the patient had an ultrasound guided right thoracentesis by the Physician's Assistant. 1200 ml of fluid was obtained and sent to lab for analysis. A follow up chest x-ray showed no evidence of a pneumothorax. Discharge instructions were signed at 1530.
An interview with the Risk Manager on 09/25/2014 at 4:00 PM revealed she was unable to locate the nursing notes following the thoracentesis on 06/13/2014. There was no record located of the vital signs taken, or the condition of the patient on discharge.
Review of the policy titled: Patient Assessment Radiology reviewed 06/27/2013 revealed:
Reassessment and Documentation:
2. After procedure, patient will be monitored for at least 1-2 hours with vital signs and reassessment being done every 15 minutes with documentation being done on radiology nursing procedure sheet.