HospitalInspections.org

Based on review of documentation and interviews with facility staff, the facility failed to provide a safe setting for the patient to receive care as an order for a Foley urinary catheter was not carried out in a timely manner.

The findings were:
Review of the medical record of patient #1 revealed that on the "Post-Operative Laninectomy/Discectomy/Fusion Orders" the order for "Foley if no void by___" was checked. The order sheet was signed by the physician ' s assistant on 8/25/10 at 1219 hours. The order sheet was noted by the "CA" at 2000 hours on 8/25/10 and by the nurse at 1000 hours on 8/26/10. The patient was discharged from the post anesthesia care unit (PACU) at 1800 hours on 8/25/10. The patient complaint stated that when the patient was admitted to the floor, his bladder was distended, he was experiencing discomfort, and was unable to urinate. A telephone order was obtained by the nurse at 1915 hours 8/25/10 to insert Foley catheter now. It was documented in the medical record that a urinary catheter was inserted on 8/25/10 at 1845 hours. These findings were confirmed by the chief nursing officer in an interview on 2/1/11.


Additional findings determined that the facility failed to provide a safe setting for the patient to receive care as effective pain management was not provided patient #1 as evidenced by:

Medical records indicate that patient #1 had unmanaged pain during his hospitalization. The hospital uses a pain scale of 0-10 with 0 being no pain and 10 being maximum, severe pain.

Review of medical records of patient #1 shows that the patient rarely achieved an acceptable pain intensity level of 4/10 as defined in the Pain Assessment document.
(8-25-10) Pre and Post Operative Progress Notes: "Pt with very difficult pain control in PACU"; "Pain 9-10/10"
(8-26-10) Progress Notes: "Lots of incisional pain, slow to mobilize. Pain control a big issue." Orthotic Note - "Patient expressed feeling pain the minute we walked in." "aching, sharp, shooting", "Security was called to the patient's room because he was in pain and yelling at staff.", "Pain 5-6-7-8-9-10/10"
(8-27-10) Progress Notes: "Pain remains severe." Medication Response Summary: "still in pain, pt states that he is unable to become comfortable". "pt complaining of sharp, shooting, tingling pain from back down left leg", Critical Response Team was called because patient was in crisis: hyperventillating and diaphoretic because of pain. "Pain 4-5-7-8-9/10"
(8-28-10) Medication Response Summary: "feels like it's getting worse", "Still hurts", "MD aware of pt's unrelieved pain", "pt still has ridiculous amounts of pain despite all his pain meds. MDs aware. Pt has not slept in days and can get ambien tonight. Pt had revision of his fusion today but still with tingling/shooting pain to leg." "Give PRN pain meds when he can have them, instead of waiting for him to request them" "Pain 5-6-7-8/10"
(8-29-10)Patient Information: " Pt requesting to see physician to address nerve pain." "Pain and anxiety" "Pain 5-6-7-8/10"
(8-30-10) "Pain, anxiety", "Shooting pain in LLE from hip to foot", "Aching, radiating","Pain 4-5-7-8-10/10"
(8-31-10) "Have prn pain and anxiety meds ready when he can have them.", "Sharp, shooting pain in left leg from hip to foot", "Pain chronic", "Pain 5-6-7-8/10"
(9-1-10)"Pt states that pain radiates from back to left lower posterior leg down to foot", "He has continued to have significant pain, although he was a chronic pain patient, and we have consulted with Dr. Thai multiple times who is his pain management physician on an outpatient basis. He is currently complaining of mild incision pain with the exception of with movement, increases to moderate pain, and he has intermittent left leg pain, more so with movement. He continues to have slight numbness and tingling in the left leg.", "Pain 4-6/10"

Based on review of documentation and interviews with facility staff, the facility failed to assure that all patient medical record entries were legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided as a number of forms in the medical record of patient #1 were incomplete or unauthenticated.

The findings were:
Review of the medical record of patient #1 revealed the following forms were incomplete or unauthenticated.
1. Adult Patient Profile-Part A, Patient History Information; not signed. The form has a signature block for the express admit nurse and stated "for nursing must be signature of RN" and there was no RN signature.
2. Adult Patient Profile-Part B. Patient Screening; form not completed and not signed. The form has a signature block for "RN Signature" and there was no RN signature.
3. Pre and Post Operative Progress Notes dated 8/25/10 and dated 8/28/10; The section to document that " There are no changes or discrepancies from the attached H&P OR The attached H&P is valid with the following changes." was not completed and signed by the physician.
4. Preoperative Checklist dated 8/28/20 was incomplete, vital signs and physical assessment not done.
These findings were confirmed by the facility chief nursing officer in an interview on 2/1/11.

Based on review of documentation and interviews with facility staff the facility failed to authenticate verbal orders based on Federal and State law which requires that verbal orders must be authenticated within 48 hours.

The findings were:
Review of the medical record of patient #1 revealed that 9 out of 17 telephone orders were not authenticated within 48 hours. This finding was confirmed by the facility chief nursing officer in an interview on 2/1/11.